WHEN DO I GIVE FLUIDS?

CMS BUNDLE
SAYS………………
TMC follows CMS BUNDLE
THIS IS WHEN YOU MUST GIVE FLUIDS

These values indicate tissue HYPO perfusion

• Lactic > 4 • 2 readings of

SBP< 90mmHg or
MAP <65 mmHg
(ortho static BP does not count)
EMS vitals COUNT, unless
patient is not hypotensive once
they arrive to the ER.
 “Trigger Time”
• These values create something called,
“Trigger Time”
• Not the same as “Time Zero”

This means fluids MUST be administered within 3 hrs.

30mL/Kg for crystalloid fluids

Vital Signs every 15 minutes must be initiated

 Exceptions to Hypotension & Lactic
(These MUST be documented to be accepted)

• Blood Pressure values are Normal for patient and Baseline is documented
• Example: Pt baseline is 89/54 this is not a new onset hypotension r/t ……
• Acute condition NOT r/t sepsis
• Hypotension d/t blood loss; or N/V r/t SBO
• Due to a Chronic condition
• Example: Pt on Midorine for intermittent hypotension
• Medication induced
• Example: Pt received metoprolol for HTN. Pt given morphine. Etc.
• Documentation of BP is erroneous
• Seizure, DKA, trauma, pancreatitis and other conditions that cause elevated lactic acid when
documented appropriately
***At any point “Sepsis” is mentioned with in 24 hours after severe sepsis presentations the
“Exceptions” DO NOT apply.
 What do I have to give?
• 30mL/Kg of crystalloids fluids
• 3hrs from Trigger Time
• EMS fluids DO count as long
• All these fluids MUST BE completed within 3 hrs. of as there is an amount given
trigger time
with a START/STOP time
• START/STOP time must be documented. documented.
• There is 10% margin given for these fluids, if they are NOT • IBW can be used ONLY if BMI
ordered in the 30mL/Kg format.
>30
• Crystalloids fluids from antibiotics DO count if completed
with in 3 hours of trigger time and the 30mL/Kg format was • FYI maintance fluids @
not used. <125mL/hr. DO NOT count
towards bolus.
 Exceptions
THERE IS ONLY 2
**** If there is documentation the patient
has an implanted Ventricular Assist Device

**** Documentation of the patient/POA

refusal of IV fluids then patient is
excluded from fluid bolus

****CMS does not give wiggle room for the bolus

fluids r/t pulmonary edema, renal failure or CHF. The
patient will die from tissue HYPO perfusion causing
multiple organ dysfunction syndrome (MODS)
regardless. You might want to consider BIPAP,
intubation, and specialty consult for patients with these
 REASSESSMENT APPLIES WHEN FLUID
RESUSCITATION IS NECESSARY
• 1 hr. Post volume infusion a set of vital signs needs to be documented
• 3hrs. From fluid stop time the reassessment must be completed by a provider(any time in 3 hrs.)
• Any one of the 3 options below count for the reassessment
1. Simply stating, “Sepsis reassessment completed post bolus” in your documentation
2. Documenting 5 of the 8 listed below will count as a reassessment:
3. Any one of these below can be
• Physical Cardiopulmonary Exam
document by other medical
• Peripheral Pulses professionals, however the provider
• Shock Index must attest to reviewing it. It will count
as a reassessment.
• Capillary refill
• Reference Urine output  Passive Leg Raise
• Skin Condition  CVP
• Vital Signs  Echo
• POC IVC
 Scv02
 If you hand this patient off and it is not time to complete the reassessment, ensure this
information is WELL communicated to the receiving provider they will need to
complete it.
 Initiation OF Vasopressors
•Must BE started within 6 hours of Trigger
time, if persistent hypotension is present.

Persistent
hypotension
Crystalloids New Onset of
given at hypotension within
30mL/Kg given one hour after the
within 3hrs of
initial
hypotension
OR target ordered
volume of
crystalloid fluids
and patient is was completely
still infused.
hypotension
 INITIATION OF VASOPRESSORS
•Must BE started within 6 hours of Trigger
time, if persistent hypotension is present.
TMC POLICY :
If hypotension MAP (less than 65 mmHg or <90 mmHg) persists after fluid
resuscitation, start:
(a) Norepinephrine - start at 2 mcg/min and titrate to a MAP of 65 mmHg (maximum
dose 30 mcg/min) or

(b) Epinephrine – start at 0.1 mcg/kg/min and titrate to a MAP

of 65 mmHg (maximum dose 1 mcg/kg/min)

(c) Vasopressin may be added to norepinephrine to increase MAP or reduce dose of

norepinephrine
What Does the Surviving Sepsis Campaign(SSC)
SAY………
What Does the Surviving Sepsis Campaign(SSC)
SAY………
 THAT’S A WRAP
• CMS BUNDLE is our GUIDLEINES(rules)

• SSC provide recommendations