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Patient's infectious symptoms have not stabilized, and the patient is at risk of rapid decompensation. The patient will be admitted for careful hydration, antibiotic therapy, and infectious source control. Severe Sepsis criteria: Infectious source: [***] Emergent Medical Associates 2019 Taking Care to the Next Level End organ damage indicated by: [***] Lactate > 2.0 mmol/L Hypotension (SBP < 90 or >40 mmHG drop or MAP < 65) Acute Resp Failure (sat < 92% w/o oxygen) Crt > 2.0 INR > 1.5 Plt < 100 Bili > 2 Sepsis Management: Time of recognition of severe sepsis: [***] Within 3 hours of recognition: Blood cultures x 2 before broad-spectrum antibiotics: [***]Yes 30 ml/kg NS bolus [***]Completed Initial lactate [***] Repeat lactate [***]Not indicated as initial lactate < 2.0 Septic Shock Assessment: Any lactic acid > 4.0 [***]No Persistent hypotension (SBP < 90 or 40 mmHg drop, MAP < 65) despite 30 mL/kg IV fluid bolus [***]No A focused sepsis perfusion/reperfusion reassessment examination was performed post 30ml/kg bolus @ [***]: Temp [***], BP [***], HR [***], RR[***], Pox [***] Persistent Hypotension Treatment: Comfort care [***]No Hypotension caused by: pt. baseline, med-induced, erroneous value, condition other than infection [***]No Refusal by patient/decision maker for: blood draw, IVF, Antibiotics, Pressors [***]No Central line [***] Vasopressor started [***]Norepinephrine I considered further perfusion assessment with CVP measurement, SCVO2, bedside ultrasound volume assessment, passive leg raise, trial of further fluid bolus and proceeded with [***]. Accepting Care Team Current data and ongoing care discussed. Time: [***] Admitting Physician: [***] Consultant(s): Outstanding Data: [***]None Critical Care Time: [***] minutes Treatments/Evaluations: Close monitoring and treatment of unstable vital signs, cardiorespiratory, and neurologic status, while maintaining tight balance of fluid, respiratory, and cardiac interventions. This includes the administration of emergency fluid management while maintaining close respiratory support as well as the provision of immediate and broad-spectrum antibiotic therapy, while performing a simultaneous assessment for possible sources in order to direct targeted therapy. This time includes discussing the case with the patient and the patient’s family. This time also includes the consideration for invasive and chemical support to prevent cardiopulmonary collapse. This time does not include all procedures stated elsewhere in this record. This time also includes reviewing old records, labs and radiological studies. This time includes examining and re-examining the patient. Additionally, this time also includes arranging care with admitting and consulting physicians. Admit MDM: Patient’s infectious symptoms have not stabilized and the patient is at risk of rapid decompensation. The patient will be admitted for careful hydration, antibiotic therapy, and infectious source control. Severe Sepsis Criteria: Infectious Source: [XOXO] End organ damage indicated by: Lactate > 2.0 mmol/L Hypotension (SBP < 90 or > 40 mmHG drop or MAP < 65) Acute Resp Failure (sat < 92% w/o oxygen) Crt > 2.0 INR > 1.5 Plt < 100 Bili > 2 Severe Sepsis Management and Critical Care: Critical Care Time: [XOXO] minutes Emergent fluid management, while maintaining close respiratory support. Immediate broad spectrum antibiotic therapy. Simultaneous assessment for possible sources in order to direct therapy. Consideration for invasive and chemical support to prevent respiratory or cardiac collapse. Blood Cultures X 2 before broad spectrum antibiotics initiated within 3 hours of recognition. 30 ml/kg NS bolus Completed Initial Lactate [XOXO] Repeat Lactate [XOXO] not indicated as initial < 2.0. Severe Sepsis Shock Assessment (1 hour post 30 ml/kg fluid bolus): Hypotension (SBP < 90 or > 40 mmHg drop, MAP < 65): [XOXO] No Lactic acid ≥ 4 [XOXO] No Shock Lactic Acid ≥ 4.0 OR Hypotension Perfusion Reassessment: Temp [XOXO], Pulse [XOXO], RR [XOXO], BP [XOXO]/[XOXO] Heart Exam: [XOXO] Tachycardic Lung Exam: [XOXO] No Crackling Capillary Refill: [XOXO] Delayed Peripheral Pulses: [XOXO]Radially present Skin:[XOXO] Mottled, pale Hypotension Treatment: Comfort Care: [XOXO] No Central Line: [XOXO] Vasopressor started: [XOXO] Norepinephrine I considered further perfusion assessment with CVP measurement, SCVO2, bedside ultrasound volume assessment, passive leg raise, trial of further fluid bolus. And preceded with [XOXO] Accepting Care Team: Current data and ongoing care discussed. Time: [XOXO] Primary Provider: [XOXO] Consulting: [XOXO] Outstanding Data: [XOXO]



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