Monitor the patient for trend available vital signs, urine output, capillary refill, and adjuncts (ultrasound and/or labs if available).

GOAL: Establish a baseline and measure response to interventions.

- Minimum: Serial vital signs measurement, mental status assessment, and urine output. Vital signs trends and interventions recorded on flowsheet.
- Better: Add point-of-care lactate every 6 hours until normal.
- Best: Add ultrasound monitoring to assess and trend inferior vena cava (IVC) and left ventricular (LV) filling, decrease in “hyperdynamic” cardiac physiology.

Employing focused, goal-oriented interventions as early as possible has shown to decrease mortality. The following goals will direct treatment initiatives. Medical providers should develop and prioritize a problem list with an accompanying treatment-solutions plan to meet the below therapy goals.

- Systolic blood pressure (SBP) > 90 mmHg and/or palpable radial pulse (if blood pressure monitoring is not available). SBP is the most appropriate and feasible modality for monitoring a patient’s perfusion status.
- Mean Arterial Pressure (MAP) > 65. MAP is manually calculated using the formula (Systolic BP + (2 x Diastolic BP))/3. Most electronic monitors will automatically calculate the MAP. At times, the MAP may be adequate even when the SBP is low, however, SBP may be used when it is easier to monitor.
- Capillary refill is an easy physical exam skill and important indicator of adequate perfusion as a high-fidelity marker for effective resuscitation. It should be performed and recorded as a trend at least every 30 minutes for the unstable septic patient. The proper way to measure capillary refill is to apply pressure down on the fingernail until it blanches (turns white), and after the removal of the pressure, time the nail’s return to normal color as compared to the other nails. Normal values are a return to baseline color in three seconds or less. Longer times indicate normal perfusion has not been restored.
- If a soft tissue infection is suspected, inspect and monitor the identified site (e.g., cellulitis) for improvement. Use a marker to outline any redness; time and date it. Monitor for any progression beyond the marked lines. If redness worsens after 24 hours or failure to improve within 48 hours, consider changing antibiotics or the need for surgical debridement after consulting telemedicine.
- Urine output (UOP) should be maintained at an average of 0.3-0.5mL/kg/hr.
- Perform and repeat available labs as indicated. Diagnostics: urine dipstick, malaria tests. Trend: i-STAT, lactate.
- Initiate telemedicine early and often and report trends.
- Monitor overall respiratory status. Many patients who are critically ill with sepsis will need ventilatory support at some point in their management – see the Airway Management - PFC CPG,21 as well as the PFC reference paper: “MSMAID” Applying an Anesthesia Checklist to SOF Medicine.22 Always be prepared to manage a complex airway with septic patients. Also, see the CCAT Mechanical Ventilation CPG. 23