TABLE 2

Preprinted Order Set for Shock Protocol

CategoryInterventionExpected Time Frame From Protocol InitiationNotes
Nursing
    Vital-sign measurementSupplemental oxygen; pulse oximetry; cardiopulmonary monitoring5 minMeasure vital signs every 15 min
    Vascular accessNo anesthetic creams used; freezing sprays can be used5–10 minPhysician notified if no access after 5 min
    Strict monitoring of UOP, fluids administeredFoley catheter if not neutropenicFrom onsetVital-sign flow sheet (Fig 1)
Blood pressure support
    Fluid resuscitation20 mL/kg (maximum: 1 L) IV up to 3 boluses; all boluses were given push-pull or via rapid infuser15 min (to start of first bolus)10 mL/kg boluses for patients with cardiac conditions, BMT patients, and patients immediately after lung transplant
    Vasoactive agentsWarm shock: norepinephrine; cold shock: dopamine ± epinephrineOrder with completion of third bolusLow doses given via peripheral IV line
Antibiotic therapy
    High risk (except asplenia)Piperacillin-tazobactam, aminoglycoside, vancomycin30 minPiperacillin-tazobactam and aminoglycoside given first, at same time via the same line
    Asplenia and immunologically normal hostsCeftriaxone, vancomycin, nafcillin30 minCeftriaxone given first over 3 min, then vancomycin
Other medications
    Stress-dose steroidsHydrocortisone 100 mg/m230 minNo ACTH-stimulation testing performed
Laboratory, radiographic evaluation
    Screening laboratory testsCBC; chemistries; liver panel; DIC panel; CRP; VBG with lactate; consider type and screen10 min after received by laboratorySent via life-threatening laboratory system
    MicrobiologyBlood culture: peripheral and central (if applicable); urine culture, rapid RSV and influenza assaysAll lumens of central lines cultured
    RadiologyPortable chest radiographAble to be viewed in resuscitation room
Other
    Page primary services; page ICUAt time of protocol initiation; with completion of third bolusICU charge nurse receives page with each shock-protocol initiation
  • UOP indicates urine output; IV, intravenous; BMT, bone marrow transplant; ACTH, adrenocorticotropic hormone; CBC, complete blood count; DIC, disseminated intravascular coagulation; CRP, C-reactive protein; VBG, venous blood gas; RSV, respiratory syncytial virus.