PICU Clinical Pathway for the Evaluation/Treatment of Infants
> 28 Days and Children with Severe Sepsis/Septic Shock
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- Evaluate for Signs and Symptoms Concerning for Sepsis or Infection
- Fever (temperature ≥ 38.5°C)
- Hypothermia (temperature < 36°C)
- Elevated heart rate
- Altered mental status
- Poor perfusion
- Sepsis Best Practice Alert
No Evidence of Organ Dysfunction
- Consider alternative diagnoses including viral infection or non-infectious conditions
- Consider need for screening labs
- Monitor for Signs of Infection with or without Organ Dysfunction
- Clinical Pathway for Blood Culture Acquisition in PICU/PCU Patient with Fever (Non-Oncology/Non-Neutropenic)
- Evaluate patient for clinical, laboratory, and radiographic signs suggestive of bacterial/fungal infection.
- If after this evaluation, a specific bacterial source is suspected, use the corresponding clinical pathway:
- If after this evaluation a bacterial infection is suspected but no specific source is apparent, use critical care yellow zone: suspected bacterial infection without organ dysfunction order set, and consider the need for the following:
- Obtain IV Access if Not Already Present
- Obtain labs and cultures
- Order antibiotics if indicated
- If antibiotics are ordered, they should be administered within 1 hour of the order
- NS or LR 20-30 ml/kg bolus
- Monitor for Signs of Organ Dysfunction
- Antibiotic Recommendations
- Recommended Laboratory Studies
Evidence of Organ Dysfunction
- Use critical care Red Zone order set (Sepsis, suspected infection with organ dysfunction)
- Begin supplemental O2 regardless of SpO2
- Immediate IV Access, IV Escalation Plan
- NS or LR 20-30 mL/kg Boluses
- Order antibiotics immediately upon recognition of organ dysfunction and administer within 1 hour
- Correct hypoglycemia, hypocalcemia
- Antibiotic Recommendations
- Recommended Laboratory Studies
FLUID REFRACTORY SHOCK
Consider CVL, arterial line, Foley
Consider CVL, arterial line, Foley
20 min
45-60 min
1-6 hrs
PICU Discharge
- Titrate norepinephrine
- Consider epinephrine, dopamine, vasopressin
- PRBC if Hgb < 8 - 10 g/dL
- Titrate epinephrine
- Consider norepinephrine, dopamine, dobutamine
- PRBC if Hgb < 8 - 10 g/dL
- Titrate epinephrine
- Consider dopamine
- Consider milrinone or dobutamine if
ScvO2 < 70% or lactate elevated - PRBC if Hgb < 8 - 10 g/dL
Consider Stress Dose Hydrocortisone
Evaluate for:
- Pericardial effusion
- Pneumothorax
- Intra-abdominal hypertension
- Primary cardiac dysfunction
Consider ECMO
Adjuvant Therapies
IVIG, Plasma Exchange, Diuresis, RRT
IVIG, Plasma Exchange, Diuresis, RRT
Continue to Monitor Clinical Goals Following Resolution of Shock
- Wean FiO2 to keep SpO2 92-97%
- Continue Lung Protective Strategies
- Consider Diuretics or Dialysis if Fluid Overload > 10-15%
- PRBCs if Hgb < 7 g/dL
- Wean hydrocortisone when vasoactive infusions no longer required
- Monitor culture results and reassess antibiotic coverage
- Consult ID if culture negative sepsis to determine antibiotic duration
- PT/OT consult, consider PM&R consult
- Refer patient to Sepsis Survivors Follow-up Program
Posted: August 2012
Revised: February 2016, August 2019
Authors: K. Chiotos, MD; J. Fitzgerald, MD; S. Weiss, MD; L. Marsillio, MD; C. Watson, RN; S. Warrington, PharmD; R. Giordano, RT; T. Metjian, PharmD; J. Verger, RN; B. Laskin, MD; J. Rossano, MD; K. Roberts, CNS; V. Srinivasan, MD; J. Gerber, MD; G. Bird, MD; C. Woods-Hill MD; M. Hayes PharmD
Revised: February 2016, August 2019
Authors: K. Chiotos, MD; J. Fitzgerald, MD; S. Weiss, MD; L. Marsillio, MD; C. Watson, RN; S. Warrington, PharmD; R. Giordano, RT; T. Metjian, PharmD; J. Verger, RN; B. Laskin, MD; J. Rossano, MD; K. Roberts, CNS; V. Srinivasan, MD; J. Gerber, MD; G. Bird, MD; C. Woods-Hill MD; M. Hayes PharmD
Evidence
- International Pediatric Sepsis Consensus Conference: Definitions for Sepsis and Organ Dysfunction in Pediatrics
- Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock: 2017 Update from the American College of Critical Care Medicine
- Sepsis References
- Nutrition References
- Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2017
- Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2017
- World Federation of Pediatric Intensive & Critical Care Societies website
- Sepsis Alliance