HOUSE STAFF

MANUAL
NEPHROLOGY ROTATION

Department of Nephrology
SHARIF MEDICAL AND DENTAL COLLEGE | LAHORE
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CONTENTS

TOPICS PAGES
1. Must have Mobile Applications 2
2. Responsibilities of house physicians 3
3. Documentation 4
4. National Health Insurance Program 7
5. Recognize, evaluate and treat AKI 8
6. Recognize, evaluate and treat CKD 10
7. How to differentiate between AKI and CKD 12
8. Treat complications of CKD 13
9. Initiation of hemodialysis 17
10. Recognize, evaluate and treat sepsis 19
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MUST HAVE MOBILE APPLICATIONS

1. Qx calculate
a. Software with calculators for every discipline including nephrology. It contains
calculators to estimate GFR, free water deficit etc.
2. Pharmapedia
a. A Pakistani drug data base software which contains both brand and generic names
3. Epocrates
a. A US drug software program which contains detailed information on each drug
including drug dosing based on renal function
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RESPONSIBILITES OF HOUSE PHYSICIANS

o Serve as the main doctor of admitted patients.

o Obtain and document thorough history and examination of every admitted patient along with
comprehensive assessment and plan of care.
o Ensure that all investigations and procedures are carried out on patients.
o Follow up on results of investigations by actively calling or visiting lab or radiology department.
o Fill out consultation request and actively seek consultation from other departments including calling or
physically visiting relevant consultants to obtain consultations.
o Perform daily rounds on patients.
o Perform night duties as assigned and perform evening rounds on all patients while on call.
o Counsel patients and family members.
o Prepare discharge summaries with appropriate follow up instructions.
o Be punctual and don’t leave your work place without informing your senior.
o Don’t be absent from work without prior notification in what’s app group.
o Attend and participate in all codes.
o Visit ER, ICU, ward or dialysis units whenever instructed by senior or if there is an emergency.
o Be gentle with nurses, support staff, patients and their attendants.
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DOCUMENTATION

 Fill out history and physical form for each admitted patient
 Remember “investigations” section on top of last page is for results of prior investigations
and not for new orders
 Write progress notes in SOAP format
o Subjective – Write new complaint or any interval history i-e transferred to ICU,
surgery, any major test like CT scan done, patient developed hypotension or fever
etc.
o Objective
 Write vital signs. Check orthostatic hypotension if dizzy or lightheaded
 Document any fever over last 24 hours
 Intake and output
 O2 saturation and FiO2 if in ICU
 Examine and document cardiac, respiratory system and volume status
(edema, JVP)
 Examine and document GI and neurological system if clinically indicated
 Write all labs over last 24 hours
o Assessment
 Write either diagnosis or problem (if diagnosis not yet established)
 Examples of Diagnoses – CKD stage V, AKI on CKD, CHF
exacerbation
 Examples of Problem – Fever, Dyspnea, abdominal pain. Always
write differential diagnosis of each problem e.g. Fever secondary
to OR rule out UTI, pneumonia or meningitis etc.
 Write diagnoses or problems in following sequence:-
 Primary renal problem AKI, AKI on CKD, CKD (along with stage),
ESRD (for patients on hemodialysis)
 Major problem or diagnosis which is the reason for admission like
CHF, sepsis, FOL etc.
 All complication of CKD individually i-e anemia, metabolic acidosis,
hypervolemia, hyperkalemia (at least in first progress note or every
note if actively being treated)
 All co-morbidities i-e CLD, CHF, DM, HTN (at least in first progress
note or every note if actively treated)
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o Plan
 Includes either treatment (medications, intervention, surgery,
consultation to other services) or further investigations (CXR, US, CT
scan, cultures etc) for work up of a problem.
 Write disposition if indicated i-e transfer to ICU, out of ICU, discharge
 Counseling to patients or family members should be documented
 Always write next day’s labs like CBC, electrolytes, creatinine tomorrow.

 Discharge Summary
o Carbon paper must be used to make a duplicate copy.
o Fill out Demographic information, CNIC and dates of admission and discharge. Do not
leave any item blank.
o Hospital course must be described briefly. Only major events should be covered. E.g.
Patient was admitted with pneumonia and treated with antibiotics or patient was
admitted with fluid overload and was diuresed or patient was admitted with uremic
symptoms. Hemodialysis was initiated.
o Write all medications clearly with names, dosage form, frequency and route. For Sehat
insaaf card patients, only write 1 or 2 medications which are pertinent to patient’s
admission. Rest of all home medications must be written on back.
o Always write follow up in 1 week in Nephrology OPD with CBC, electrolytes and
creatinine or any additional tests as advised by seniors under follow up instructions.

 Consent Forms and Procedure notes

o Consent forms need to be signed for every procedure. Consent forms should be signed
by patient or patient’s representative in appropriate spaces. Signatures of witness must
be obtained. Date and time should be documented.
o For every procedure, generic hospital consent form should be filled.
o In addition, we have consent forms in urdu which must also be filled for following
procedures:-
 Renal biopsy
 Hemodialysis catheter placement
 Hemodialysis
o We have pre-printed procedure notes for following procedures:-
 Renal biopsy
 Temporary Hemodialysis catheter placement
 Permanent Hemodialysis catheter placement
o Top parts of these procedure forms must be filled prior to the procedures.

 Transfer Forms
o Transfer forms must be filled out for all patients who are referred to another facility or
transferred to ICU (applicable to Sehat Insaaf Card patients)
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 Death Certificate
o Death Certificate should be filled out thoroughly under supervision of senior.
o Examples of disease or condition directly leading to death
 Pneumonia
 Catheter related bacterial infection
 Myocardial infarction
 Hyperkalemia
 Stroke
o Examples of Antecedant causes
 Hypertension
 Diabetes Mellitus
 CKD
 ESRD
 Coronary artery Disease
o Examples of other Significant conditions contributing to death
 Hepatitis C
 Fractures
 Hypothyroidism

 All notes must be signed, dated and timed followed by name and designation of the note
writer.

 Medications Chart
o All medications must be entered correctly with full name, dosage form, frequency and
route of administration.
o Each entry must be signed, dated and stamped.
o Medication chart should be revised in case of prolonged stay and frequent stopping and
starting of new medications.

 Chart Maintenance
o All papers in patient’s files must be placed in chronological order and in appropriate
section.
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NATIONAL HEALTH INSURANCE PROGRAM (SEHAT INSAAF CARD PATIENTS)

o These patients now constitute majority of our in-patients and are represented by green colour of
the files
o Admission form provided by National Health insurance service must always be filled out thoroughly,
documenting all necessary anticipated investigations and procedures (like dialysis catheter
placement and hemodialysis) along with minimum 7 days of anticipated hospital stay.
o A transfer form must be filled out whenever a patient is transferred to MICU.
o Only minimum and absolute necessary investigations should be ordered for these patients.
o A CT scan or MRI or any special lab must be pre-approved by National Health insurance’s
representative by filling out special investigation proforma.
o Only minimum and absolutely necessary medications must be written for these patients. Examples
include
 Life-saving medications like antibiotics or diuretics
 Symptomatic treatment like analgesics, anti-emetics etc.
 Medications to prevent exacerbation of chronic health problems like insulin, anti -
hypertensive medications etc.
 Each medication must be reviewed daily to determine its need for continuity.
o Comprehensive medication list must be entered on discharge summary which include treatment
of all health problems. However, most of these medications which are not related to current
admission must be written on back of discharge summary.
o All such patients must be kept in hospital for minimum of three days. But any longer or unnecessary
stay must be discouraged.
o A voucher is built for all investigations and medications of these patients by nurses which must be
cross-checked and signed by house physicians.
o Medications and medical supplies of these patients are usually obtained from surgical store of the
hospital. Only if a medication or item is not available at surgical store, it is obtained from the
pharmacy.
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RECOGNIZE, EVALUATE AND TREAT ACUTE KIDNEY INJURY (AKI)

 Recognize AKI
o Increase in serum creatinine by 0.3 mg/dl OR increase in serum creatinine by 1.5
fold in <7 days in a patient with underlying chronic kidney disease OR decline in
urine output <0.5 ml/kg/hour for 6 or more hours

 Evaluate AKI
o Evaluate patient to identify underlying cause and complications of AKI.
Remember few important causes and look for them during H&P and initial labs
 Pre-renal – Vomiting, diarrhea, CHF, CLD and drugs including diuretics,
RAAS blocker, NSAIDs
 Renal –
 ATN - Sepsis, aminoglycosides, contrast exposure, prolonged
hypotension, rhabdomyolysis
 AIN – Drug induced – NSAIDs
 RPGN – SLE, vasculitis etc.
 Post renal – Obstruction
o H&P
 Inquire about preceding event (diarrhea, hypotension, contrast
exposure)
 Review medication list
 Ask about past medical history – CHF/CLD
 Assess volume status
 Hypovolemic – due to vomiting/diarrhea
 Hypervolemic – due to CHF/CLD/complication of oliguric or anuric
AKI
 Skin rash – AIN, RPGN
 Clinical features of SLE, vasculitis like skin rash, arthralgia, fever, edema -
RPGN
o Investigations
 CBC – Look for sepsis
 Electrolytes, ABG – Look for complications of AKI like hyperkalemia,
metabolic acidosis
 Urea, creatinine – Urea:Cr ratio >40:1 indicate pre-renal cause
 Urine complete +/- urine protein to creatinine ratio
 Proteinuria/hematuria – RPGN
 WBCs – UTI (sepsis), AIN
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 Bland (No cells, protein or blood) – Pre-renal, Post-renal, AIN

 US KUB – Look for obstruction

 Treat AKI
o Treat underlying cause
 Stop offending drug like diuretic, RAAS blocker, aminoglycosides, NSAIDs
 If hypotensive give 0.9% saline 500 ml bolus and repeat till BP is normal or
patient develops pulmonary edema
 If hypovolemic but not hypotensive give 0.9% saline 75-100 ml/hour till
improvement of volume status and kidney function or patient develops
pulmonary edema
 Treat CHF exacerbation
 Treat sepsis
 Pass foley catheter/Relieve obstruction after consultation with urologist
o Treat complications of AKI (see later)
o Do hemodialysis if clinically indicated (See later)
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RECOGNIZE, EVALUATE AND TREAT CKD

 Recognize CKD

o Kidney damage OR decline in kidney function for 3 or more months

 Kidney damage is recognized by proteinuria, hematuria or abnormal US
 Decline in kidney function – GFR < 60 ml/min (Use Qx calculate to estimate
GFR using age, sex and serum creatinine)
 3 or more months – Look at records (serum creatinine, urine complete,
US) over 3 or more months and/or documentation of CKD in prior records

 Evaluate CKD
o Evaluate patient to identify underlying cause and complications of CKD.
Remember few important causes and recognize them during H&P and initial labs.
 Hypertension
 Diabetes Mellitus
 Glomerular disease
 Anaglesic/Hakeem medication use
 Polycystic kidney disease
 Chronic obstruction
o H&P
 Review past medical history – HTN, Diabetes mellitus (inquire about
duration and evaluate for end organ damage elsewhere i-e diabetic
retinopathy, hypertensive retinopathy, LVH)
 Review medications
 Review family history of CKD
 Evaluate for complications of CKD
 Fatigue/Pallor – anemia
 Anorexia, nausea, vomiting- uremic gastritis
 SOB/Pulmonary edema/JVD/peripheral edema – Hypervolemia
 Altered mental status – uremic encephalopathy
 Pericardial rub – uremic pericarditis
 Scratch marks, itching – uremic pruritis
o Investigations
 CBC – Look for anemia
 Electrolytes, ABG – Look for complications of CKD like hyperkalemia,
metabolic acidosis
 Ca, phosphorus – Look for hyperphosphatemia, hypocalcemia (CKD-MBD)
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 Urea, creatinine – Assess GFR using Qx calculate (enter age, sex and serum
creatinine). Stage CKD based on GFR
 Stage I GFR > 90, Stage II, GFR 60-89, Stage III GFR 30-59, Stage IV
GFR 15-29 and stage V GFR <15. Label patients on dialysis as ESRD.
 Urine complete +/- urine protein to creatinine ratio – Look for
proteinuria/hematuria which may indicate glomerular cause
 US KUB – Look for obstruction, PCKD or confirmation of CKD (small
shrunken kidneys, poor corticomedullary differentiation, thin renal cortex,
increased echogenicity). US in diabetic CKD may look normal though.

 Treat CKD
o Treat underlying cause like treat glomerular disease or relieve obstruction after
consulting with urologist. Discuss with senior
o Slow progression of CKD
 Keep BP < 130/80
 Keep HbA1c < 7 if diabetic
 Use RAAS blocker to suppress proteinuria if potassium normal and serum
creatinine is stable and eGFR > 20 ml/min. Discuss with senior
 Zestril (Lisinopril) 5 mg OD (maximum 20 mg 2 tabs daily) OR
 Eziday (Losartan) 25 mg OD (Max. 100 mg daily)
 Use Sodium glucose co-transporter blocker if proteinuria and eGFR > 25
ml/min. Discuss with senior
 Dapa (Dapagliflozin) 5 mg OD (Maximum 10 mg daily)
 Avoid NSAIDs/Hakeem medications
o Treat complications of CKD (See later)
o Counsel patient for hemodialysis if GFR < 15 ml/min and no AKI on CKD
o Start hemodialysis if indicated (See later)
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HOW TO DIFFERENTIATE BETWEEN AKI AND CKD

 In a patient with elevated serum creatinine, possibilities include AKI, CKD or AKI on CKD.
 Review old records (serum creatinine, urine examinations, US) to determine acuity or
chronicity of the problem.
 If no old records are available then look for following tips:-
o Long standing history of nausea, vomiting (uremic gastritis) may suggest CKD
o Etiology of AKI if present (Like CHF exacerbation, diuretic, RAAS blocker, sepsis,
obstruction, constrast, NSAID) may suggest either AKI or AKI on CKD. Treat these
factors and see if creatinine improves even if patient is suspected to have CKD.
o Etiology of CKD (DM, HTN) if present for long time and presence of end organ
damage elsewhere like retinopathy, LVH may suggest diabetic or hypertensive
CKD.
o Presence of anemia is suggestive of CKD. However, AKI in setting of hemolysis
(HUS-TTP), RPGN (vasculitis, autoimmune disease) or bleeding may be seen along
with anemia.
o Presence of chronic changes on US like (small kidneys < 9 cm, poor
corticomedullary differentiation, thin renal cortex < 1.0 cm, increased
echogenicity) suggest CKD. Chronic changes on US may not be seen in diabetic CKD
(kidneys may appear normal)
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TREAT COMPLICATIONS OF KIDNEY DISEASE (CKD/AKI)

1. ANEMIA OF CKD (Usually seen in CKD)

a. Target Hb 10-11.5 g/dl
b. Check Iron, TIBC and Ferritin after consulting with senior
c. Treat anemia as follows
i. Cap Elezo 150 mg 1+0+0
ii. Inj. Epokine 4000 units subQ once or twice a week. Use Inj. Epokine or
EPIAO 10,000 units subQ once a week in hemodialysis patients.

2. CKD MINERAL BONE DISEASE (Mineral abnormalities are seen in AKI as well)
a. Target calcium and phosphorous – normal reference range of lab. Correct calcium
for albumin by adding correction factor to serum calcium value. Correction factor
= (4-albumin)*0.8)
b. Hyperphosphatemia
i. Low phosphorous diet
ii. Tab Lophos (calcium acetate) 667 mg 1-2 tabs TDS with meals if serum
calcium normal or low
iii. Tab Renavel (Sevelamer) 400-800 mg 1-2 tabs TDS with meals if serum
calcium high
c. Hypocalcemia
i. Correct hyperphosphatemia as mentioned above
ii. If still low then prescribe Tab Qalsan or Chewcal (calcium carbonate)1-2
tabs TDS on empty stomach

3. METABOLIC ACIDOSIS
a. Target serum bicarbonate > 22 meq/L
b. Prescribe tab sodamint 300 mg (sodium bicarbonate) 1-2 tabs TDS
c. If severe, pH <7.2 then discuss with senior regarding IV sodium bicarbonate
i. If pH <7.2 and/or serum HCO3 < 15 meq/L and PATIENT NOT
HYPERVOLEMIC, Add 150 Meq of sodium bicarbonate in 1 L of D5W and
infuse at 50-75 ml/hour. Discuss with senior.
ii. If pH < 7.1 and/or serum HCO3 < 10 meq/L and PATIENT NOT
HYPERVOLEMIC, then administer 4 amp of sodium bicarbonate in 100 ml
0.9% saline IV stat followed by sodium bicarbonate infusion as above.
Discuss with senior.
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4. HYPERKALEMIA
a. Check ECG

b. If Serum K >6.0 meq/L and/or ECG changes of hyperkalemia (peaked T waves,

broad QRS complexes, loss of p wave)
i. IV calcium gluconate 1 amp slow IV stat and repeat ECG to see whether
changes have reverted
ii. Nebulize with Ventolin 2 c.c TDS
iii. Humulin R 10 units plus 4 amp of 25% Dextrose water IV TDS
iv. Kayexalate 15 gram in 30 ml Duphulac TDS
v. Low potassium diet and stop medications which may cause hyperkalemia
(ACE-I/ARB, spironolactone etc.)
c. If serum K 5.0-6.0 meq/L and no ECG changes of hyperkalemia
i. Kayexalate 15 gram in 30 ml Duphulac TDS
ii. Low potassium diet and stop medications which may cause hyperkalemia

5. HYPERVOLEMIA
a. Peripheral edema only
i. Evaluate for other causes like CHF (order 2 D echo), CLD (order US
abdomen, LFTs especially if ascites present)
ii. Low salt diet, Fluid restriction <1.5 L/day, I/O recording if admitted
iii. Tab Lasix 40 mg 1-4 tabs po bd (depending upon serum creatinine) if in
OPD OR
iv. IV Lasix 40 -160 mg bd if admitted OR
v. IV Lasix infusion 20-40 mg/hour if admitted
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vi. Add Metenix (metolazone) 5-10 mg QD or BD if resistant to Lasix

vii. Add Aldactone (spironolactone) 25-50 mg OD or tab Neo K (potassium
chloride) 500 mg 2+2+2 if hypokalemia
b. Pulmonary edema
i. Check ECG, CK-MB, Trop I, CXR and 2 D echo (Rule out MI,arrythmia)
ii. Low salt diet, Fluid restriction <1.5 L/day, I/O recording
iii. IV Lasix +/- Metenix as mentioned above
iv. Add Aldactone (spironolactone) 25-50 mg OD or tab Neo K (potassium
chloride) 500 mg 2+2+2 if hypokalemia

6. HYPERTENSION
a. Low salt diet
b. Use diuretic, RAAS blocker and calcium channel blocker as 1st line drugs
i. Diuretics (Avoid if hypovolemic or creatinine increasing)
1. GFR > 30 ml/min – Diuza (HCTZ) 25 mg OD
2. GFR < 30 ml/min OR edema – Lasix 40-160 mg twice a day
3. Add Aldactone (spironolactone) 25-50 mg daily if already on
thiazide/loop diuretic, RAAS blocker and calcium channel blocker.
Avoid if hyperkalemia and/or late CKD IV/CKD V)
ii. RAAS blocker (Avoid if late CKD IV/CKDV, hyperkalemia or creatinine rising)
1. Valtec (Valsartan) 80-160 mg once or twice a day
2. Zestril (Lisinopril) 5-20 mg once or twice a day
iii. Calcium channel blocker
1. Masidipine SR (Nifedipine) 30 or 60 mg once or twice a day
2. Amodip (Amlodipine) 5-10 mg daily
c. Use beta blocker, alpha blocker, centrally acting alpha agonist or vasodilators as
second line drugs
i. Beta blocker
1. Carveda (Carvedilol) 6.25 mg – 25 mg BD
ii. Alpha blocker
1. Hytrin (Doxazosin) 2-5 mg OD or BD
iii. Centrally acting alpha agonist
1. Aldomet (methyldopa) 250-500 mg TDS
iv. Vasodilators
1. Hydralazine 25-100 mg TDS or QID
d. For patients on hemodialysis, remove extra fluid on hemodialysis even if patient
appears to be clinically euvolemic.
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7. HYPONATREMIA
a. If hypovolemic – Start 0.9% saline 75-100 ml/hour
b. If Euvolemic
i. Fluid restriction < 1.0 L/day
ii. Extra salt 1 tea spoon twice a day if BP <140/90 mm Hg
c. If hypervolemic
i. Fluid restriction < 1.0 L/day
ii. Treat hypervolemia with Lasix as above
d. Do not correct Na by > 8meq/L over 24 hours

8. UREMIC GASTRITIS
a. Anorexia
i. Syrup Hunger up or Syrup Tres Orix 2 TS 2-3 times a day
b. Nausea, vomiting
i. Tab Motilium (domepridone) OR Maxalon (metoclopramide) 10 mg TDS
ii. Inj. Maxalon 10 mg TDS OR Inj. Onset 8 mg TDS
c. Gastritis
i. Cap or Inj. Omezole (omeprazole) 40 mg daily or BD

9. UREMIC PRURITIS
a. Treat hyperphosphatemia
b. Apply topical treatment
i. Vaseline or petroleum jelly TDS OR
ii. Liquid paraffin plus clobetasol cream BD or TDS OR
iii. Physiogel TDS
c. Next add tab Atarax (hydroxyzine) 10 mg BD or TDS
d. If no response then Cap Neogab (Gabapentin) 100-300 mg qhs
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INITIATION OF HEMODIALYSIS

1. Identify indications of hemodialysis

a. GFR < 15 ml/min AND one of the following
i. Complications of uremia
1. Uremic encephalopathy
2. Uremic pericarditis
3. Uremic gastritis (anorexia, nausea, vomiting)
4. Uremic platelet dysfunction (prolonged bleeding)
ii. Hyperkalemia refractory to medical treatment
iii. Metabolic acidosis refractory to medical treatment
iv. Hypervolemia refractory to medical treatment
2. Obtain consent from patient and/or attendant. Handover informed consent forms to
them
3. Order CBC, PT, PTT, INR, Hepatitis BsAg, Hepatitis C Antibody if not done already
a. Transfuse 1 megakit of platelet if platelet count <100,000
b. Type and transfuse 2 units of FFP if INR>1.5 or APTT > 40
4. Obtain CXR after catheter placement to look for catheter tip position (Right atrium) and
for any lung complication (Pneumothorax)
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5. Write hemodialysis orders and notify dialysis technician in respective hemodialysis unit
(C positive and C negative unit – C negative unit also has a room for hep B positive
patients)
6. Hemodialysis orders has five components:- A) blood flow B) dialysate flow C) Time D)
Ultrafiltration E) Anticoagulation
a. Blood flow – 1st ever HD should have a blood flow of 200 ml/min. Increase blood
flow by 50 ml/min on each subsequent dialysis till a maximum blood flow of 300-
400 ml/min is reached.
b. Dialysate flow – Fixed at 500 ml/min
c. Time – 1st ever HD is of 2 hours duration. Increase dialysis time by ½ hour to 1 hour
on each subsequent dialysis till a maximum time of 4 hours is reached.
d. Ultrafiltration – Depends on volume status, blood pressure and dialysis time.
Check with senior. In general, remove at least 2 liters if peripheral edema. Remove
even more if pulmonary edema provided blood pressure is adequate.
e. Anticoagulation – In general, write “no heparin” or “saline flushes only” for all
admitted patients. Especially write “no heparin” if platelets < 50,000 or uremic
pericarditis or active bleeding. Check with senior. If heparin needed due to dialyzer
clotting, then write “low dose heparin”
st
7. 1 3 sessions of hemodialysis are done on 3 consecutive days and then twice a week.
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RECOGNIZE, EVALUATE AND TREAT SEPSIS

KNOW THE DEFINITIONS

 Infection – Invasion of sterile tissue by organism

 Bacteremia – Presence of bacteria in blood
 Sepsis – Life threatening organ dysfunction (SOFA score of 2 or more – Use Qx calculate
for SOFA) due to dysregulated host response to an infection
 Septic Shock – Patients with sepsis, who despite adequate fluid resuscitation require
vasopressors to keep MAP>65 mm Hg and have a serum lactate of > 2 mmol/L
 Multiple organ dysfunction syndrome – Progressive organ dysfunction in a septic patient
so that homeostasis cannot be maintained without an intervention

RECOGNIZE SEPSIS

 Suspect sepsis in a patient with

o Fever
o Tachycardia
o Tachypnea
o Hypotension
o Altered mental status
o Oliguria
o Warm flushed skin (early), cold skin (late)
o Leukocytosis
o Leukopenia
o Use qSOFA score (2 out of 3) to recognize patients at high risk of death. Transfer
such patient to ICU
 SBP < 100 mm Hg
 RR > 22/min
 Altered mental status
EVALUATE PATIENT WITH SUSPECTED SEPSIS

 Evaluate patient to identify source of infection and organ dysfunction.

 Perform H&P (a complete review of systems to identify source and organ dysfunction)
 Order investigations
o CBC, Electrolytes, RFT, LFTs, ABG, PT, PTT, INR
o CXR
o Urine complete, culture
o Blood cultures (from 2 different sites, one site should be catheter if present)
o Sputum culture
o Wound culture if present
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o Imaging of abdomen (US or CT if indicated)

o LP if indicated
TREAT SEPSIS

 Secure airway if altered mental status

 Correct hypoxemia with oxygen. Be ready for mechanical ventilation
 Establish IV access
 Administer IV fluids in FIRST 3 HOURS
o 0.9% saline 500 ml Bolus and repeat if no signs of FOL. Give 2-3 liters of 0.9% saline
in first 3 hours unless patient has pulmonary edema or anuric (ESRD). Continue IV
fluids 0.9% saline 75 ml/hour subsequently depending upon response to
treatment and volume status
 Administer IV antibiotics in FIRST HOUR
o Decide antibiotics based on source of infection.
o If no source or patient is in ICU then
 IV Penro (Meropenem) AND
 Normal GFR – 1-2 gram IV TDS
 GFR 25-50 – 1 gram IV BD/TDS
 GFR 10-25 – 0.5-1 gram IV BD
 GFR<10/HD – 0.5- 1 gram IV OD
 IV Vinject (Vancomycin)
 Loading dose 20-30 mg/Kg then
 Normal GFR – 15 mg/Kg IV BD
 GFR 30-60 – 15 mg/Kg IV OD
 GFR 15-30 – 15 mg/kg IV every 24-48 hours
 GFR <15/HD – 15 mg/kg IV every 48-72 hours (post HD on HD days).
Or re-dose when vancomycin level <20 mcg/ml
o Eliminate source of infection i-e drain abscess, wound debridement, removal of
HD catheter, drainage of empyema etc.
 Start Vasopressors/inotropic agents in following sequence if MAP<65 despite IVF
1. Norepinephrine – Usual dose – 10 mcg/min, Maximum dose – 100 mcg/min THEN
2. Dopamine – Usual dose – 5-20 mcg/kg/min, Maximum dose – 50 mcg/kg/min OR
3. Epinephrine– Usual dose – 0.5-2 mcg/kg/min
 Administer IV hydrocortisone 100 mg IV TDS if SBP < 90 mm Hg despite vasopressors
 Supportive Rx
a. IV Omezole 40 mg daily or IV Zantac 50 mg BD for stress ulcer prophylaxis
b. Heparin 5000 units subQ BD for DVT prophylaxis unless patient is bleeding or
at risk of bleeding
c. Ensure or Glucerna 10 scoops BD or TDS NG/PO if inadequate oral intake
d. Keep BSL b/w 140-180 mg/dl with sliding scale insulin or insulin infusion
e. Transfuse PRBC if Hb<7.0 g/dl or active bleeding or if Hb<10.0 g/dl with acute
MI.
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f. Transfuse 1 mega unit platelets, 2-4 units FFP if active bleeding or intervention
is planned in setting of platelets<100 K or INR>1.5/APTT>40 respectively.
4. Target
a. MAP > 65 mm Hg
b. Urine output > 0.5 ml/kg/hour
c. CVP 8-12 cm H20 if present