DisclaimerThese guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. Show
Read the full CAHS clinical disclaimer AimThis guideline aims to describe the key steps required to enable prompt recognition and rapid initial and ongoing management of paediatric sepsis and septic shock, for children presenting, or already admitted to, Perth Children’s Hospital. RiskSepsis is a major cause of morbidity and mortality in the paediatric population and can be very challenging to diagnose and manage. For every hour a child remains in septic shock the mortality risk doubles.1 Care delivered in the first hour after sepsis identification is crucial in ensuring the optimum outcome for the patient.2 Oncology patients with suspected sepsis or septic shock are to be managed according to this guideline with early input from the Oncology Fellow. Refer to the Fever in the Oncology Patient - Emergency Department Guideline for key additional information, including a pathway for the initial management of Fever in the Oncology Patient. DefinitionsSepsis can be defined as a dysregulated host response to infection leading to life threatening end organ dysfunction.3 Septic shock is defined as sepsis with evidence of cardiovascular dysfunction.2-5 Hypotension is generally a late sign and is not required to diagnose septic shock in children. However, the presence of hypotension is confirmatory of shock. Key Points for Managing Sepsis and Septic Shock 2,121.Early recognition and initiation of treatment. 2.Rapid vascular access, within 5 minutes of recognition of septic shock:
3. Empiric antibiotic therapy as soon as possible and within 60 minutes of septic shock recognition:
4. Rapid, judicious, fluid resuscitation of shocked patients: 10-20mL/kg sodium chloride 0.9% or balanced fluid boluses as a push aiming for shock reversal. 5.Early initiation of inotropes via peripheral access (if needed with early recourse to central venous access), for fluid refractory shock (≥40mL/kg fluid without shock reversal).
6. Source control (if possible). Figure 1: Sepsis flowchartClinical recognition of sepsis
Sepsis should be considered in a patient with suspected or proven infection AND/OR fever or hypothermia (temperature ≥ 38°C or < 36°C) AND any of the following:
A high level of family / carer or clinician concern including 'unwell' appearance should trigger review by a more senior clinician and escalation of care.High risk groupsThe following children have a higher risk of sepsis and the threshold for investigation / management of sepsis should be lower:
Management of Suspected Sepsis or Septic ShockInitial Emergency Management:
In Emergency Department
On the wards
Vascular Access
Blood tests
Blood lactate
Other investigations
Hypoglycaemia
Antibiotics
Empiric IV antibiotic choicesCommunity-acquired sepsisInfant <4 weeks corrected gestational age (Meningitis NOT excluded):
Infant / child ≥ 4 weeks old:
Antibiotic Administration
Healthcare-associated sepsisHealthcare-associated sepsis includes suspected sepsis / septic shock in oncology or immunocompromised patients and suspected sepsis / septic shock in the presence of a central venous access device (CVAD). Infant < 4 weeks old: contact Infectious DiseasesInfant / child ≥ 4 weeks old:
Fluid resuscitation
Inotropes
Adrenaline (epinephrine) infusion (via peripheral access)
Intubation
Steroids
References
What is the most important goal of nursing care for a client who is in shock?The nursing role in managing the patient with shock
Common interventions include adequate oxygen, fluid and/or drug therapy. In all cases the nurse needs to provide a safe environment for the patient who may be at risk due to a reducing level of consciousness and deteriorating vital signs.
Which tests would the nurse expect to be ordered for a patient experiencing shock?Tests might include: Blood pressure measurement. People in shock have very low blood pressure. Electrocardiogram (ECG or EKG).
Which medications does the nurse anticipate administering to the patient in septic shock?The recommended first-line agent for septic shock is norepinephrine, preferably administered through a central catheter. Norepinephrine has predominant alpha-receptor agonist effects and results in potent peripheral arterial vasoconstriction without significantly increasing heart rate or cardiac output.
What vital signs would you expect to find with a patient who is experiencing shock?Common signs and symptoms of shock include:. Low blood pressure.. Altered mental state, including reduced alertness and awareness, confusion, and sleepiness.. Cold, moist skin. Hands and feet may be blue or pale.. Weak or rapid pulse.. Rapid breathing and hyperventilation.. Decreased urine output.. |