ED - Fever in pediatric short gut patients with a central venous line
Last Updated: 4/26/2016 3:36:29 PM
Order Set
  Associated Pathway(s)
 Fever in short gut patients with a central venous line (<18 years) - http://www.curbsideup.com/link/1315
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  Inclusion Criteria
Inclusion Criteria ( All criteria are present )
  • GI patient with indwelling central venous catheter (i.e. - Broviac, Hickman, port, PICC)
  • Fever (≥ 38.0 C (100.4 F) in the past 24 hours)
Exclusion Criteria
  • Positive blood culture that has not been fully treated
  Time to antibiotics

Patients in the population are at high risk of septic shock. In order to reduce mortality please administer empiric antibiotics via central venous catheter within 1 hour of presentation.

  GENERAL
  Monitoring
Weight
Once
Vitals signs
Per protocol and repeat 15 min before and after each antibiotic given.
  Nursing Care
Nursing Communication -- Do not delay medications
Do not delay labs more than 30 min for topical analgesia for patients who require antibiotics
  Does this patient need to be NPO?
Yes
Diet NPO
Continuous
No
Diet Regular
Nursing Communication
Make patient NPO for respiratory distress, mental status changes or expectation of pending surgical or other procedure requiring sedation
  Does this patient require isolation?
Yes
Contact Isolation
(eg. MRSA, VRE, etc.)
Contact/Droplet Isolation
(eg. RSV, Rinovirus, etc.)
Airborne Isolation
(eg. TB, VZV, Measles, etc.)
  Respiratory Therapy
  Supplemental Oxygen
Nursing communication
Begin supplemental oxygen therapy for persistent oxygen saturation below 90% awake, 88% asleep or severe respiratory distress.
Pulse Oximetry/O2 Sats
STAT, CONTINUOUS, Indication: When patient is on supplemental oxygen
  LABORATORY

Do not delay workup for topical anesthetics by more than 30 minutes.

  Labs
Blood Culture (Aerobic & Anaerobic Bottles)
LAB ONE TIME, From each lumen of each central line if present
CBC with Differential
LAB ONE TIME
Complete metabolic panel
LAB ONE TIME
Serum Magnesium
LAB ONE TIME
Serum Phosphorus
LAB ONE TIME
Serum Procalcitonin
LAB ONE TIME
Serum CRP
LAB ONE TIME
Serum PT
LAB ONE TIME
Serum PTT
LAB ONE TIME
VBG with lactate
LAB ONE TIME
Urinalysis With Microscopic
LAB ONE TIME
Urine Culture
LAB ONE TIME
  IV fluids
  Signs of severe dehydration or shock?
Yes
NS bolus
20 mL/kg, IV, Once
  TPN stopped or unavaliable
Yes
POC blood glucose
POC, One time
D10 NS
mL/hr, continious
No
Nursing Communication
Start TPN at home rate
  Antibiotics

Only skip this area if the patient DOES NOT meet SIRs criteria AND has viral URI symptoms AND has temp < 38.5.

  All patients
Vancomycin IV
15 mg/kg, IV, q8 HOURS, MAX 1 gram
  Does the patient have a cephalosporin allergy?
Yes
Meropenem IV
20 mg/kg, IV, q8 HOURS, MAX 1 gram
  Has the patient grown high risk bacterial isolates in the past 3 months? - NO CEPHALOSPORIN ALLERGY
      Enterobacter cloacae (specifically cloacae NOT aerogenes), Citrobacter species, Acinetobacter species, Pseudomonas species
Yes
Cefepime IV
50 mg/kg, IV, q12 HOURS, MAX 2 gram
No
Ceftriaxone IV
50 mg/kg, IV, q24HOURS, MAX 1 gram
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