Careplan

Sepsis or Septic Shock (Pediatric ED)

Jan.25.2022

Sepsis or Septic Shock (Pediatric ED)

Clinical Description

Care of the Emergency Department pediatric patient seeking treatment for sepsis or associated septic shock.

Key Information

Signs of early sepsis include increased heart rate or temperature, as well as changes in mental state, respiratory pattern or peripheral perfusion; signs and symptoms may progress rapidly.

Outcomes are improved by early identification of sepsis and the immediate initiation of evidence-based therapy following sepsis recognition, including aggressive fluid resuscitation and antimicrobial therapy.

Infants and children may be septic without an elevated temperature; a complete history, physical examination and clinical judgement are important for early recognition and intervention.

Blood pressure alone is not a reliable indicator of successful resuscitation in infants and children. Other parameters, such as capillary refill and end-organ perfusion, should be evaluated; shock may occur long before hypotension occurs.

Elevated lactic acid levels may indicate tissue hypoxia and poorer outcomes.

ARDS (acute respiratory distress syndrome) is highly associated with sepsis, whether it is the cause or result of sepsis. Suspect ARDS (acute respiratory distress syndrome) if PFR (ratio of partial pressure of arterial oxygen to fractional inspired oxygen) is less than 300 mmHg.

Threats to Life, Limb or Function

acute renal failure

ARDS (acute respiratory distress syndrome)

DIC (disseminated intravascular coagulation)

failure to recognize sepsis

multiple-organ-dysfunction syndrome

sepsis-associated encephalopathy

septic shock

Clinical Goals

By transition of care

A. The patient will achieve the following goals:

Goal: Acute Signs/Symptoms are Managed
Goal: Acceptable Pain Level Achieved

Correlate Health Status

Correlate health status to:
- history, comorbidity, congenital anomaly
- age, developmental level
- sex, gender identity
- baseline assessment data
- physiologic status
- response to medication and interventions
- psychosocial status, social determinants of health
- barriers to accessing care and services
- child and family/caregiver:
- safety risks
- family interaction
- plan for transition of care

Sepsis or Septic Shock

Associated Documentation

Sepsis/Septic Shock Management

Presentation

chills, rigors
cry high-pitched (infant)
feeding pattern or tolerance altered (infant)
fontanel full or bulging (infant)
level of consciousness altered
mental status altered
muscle tone altered (infant)
peripheral perfusion altered
poor arousal or response to social cues
tachycardia
tachypnea
temperature variation (increased or decreased)

Associated Signs/Symptoms

abdominal distension
anorexia
arthralgia, myalgia
cough
cyanosis
diaphoresis
diarrhea
dysuria
edema
fatigue
hypotension
nuchal rigidity
pain
pallor
petechiae, purpura
rash
shortness of breath
urinary frequency
urine output decreased
vomiting
work of breathing increased

Potential Causes

bone or joint infection
chemotherapy-induced neutropenia
endocarditis
group B streptococcus infection (newborn/neonate)
implanted device infection
intra-abdominal infection
meningitis
respiratory infection, pneumonia
skin or soft tissue infection
urinary tract infection
wound infection

Initial Assessment

airway patency
cardiovascular status
fluid status
gastrointestinal status
musculoskeletal status
neurologic status
pain evaluation
respiratory status
skin and soft tissue status

History

allergies
comorbidities
immunization status
last menstrual period (females of childbearing age)
medications
feeding pattern and tolerance
hospitalizations
infant birth history (prolonged rupture of membranes, maternal infection or fever)
recent antimicrobial therapy
recent childbirth
recent infection or exposure
recent injury or trauma
recent procedure or surgery
recent travel
symptom onset

Laboratory Studies

albumin, pre-albumin
amylase
ABG (arterial blood gas)
blood glucose level
BUN (blood urea nitrogen)
CBC (complete blood count) with differential
cerebrospinal fluid analysis
coagulation studies
CRP (C-reactive protein)
cultures and gram stain
lipase
liver function tests
procalcitonin level
serum creatinine
serum electrolytes
serum lactate
urinalysis

Diagnostics

ECG (electrocardiogram)
x-ray (abdomen, chest)

Potential Additional Testing

CT (computed tomography) scan
lumbar puncture
MRI (magnetic resonance imaging)
pregnancy test (females of childbearing age)
radiographic studies for joint pain
ultrasound (abdomen, chest)

Problem Intervention

Provide Respiratory Support

Assess and monitor airway and breathing for effective oxygenation and ventilation; maintain close surveillance for deterioration.
Maintain open and patent airway with use of positioning, airway adjuncts and secretion clearance.
Position to minimize the risk of aspiration, ventilation-perfusion mismatch and breathlessness.
Minimize oxygen consumption and demand; limit activity, reduce fever and utilize breathing techniques.
Provide oxygen therapy judiciously; titrate to prevent hyperoxemia; adjust to achieve oxygenation goal.
Consider positive pressure ventilation to support oxygenation, ventilation and relieve respiratory distress.
Recognize the need for intubation for airway protection and respiratory support; utilize lung protective strategy.

Problem Intervention

Provide Hemodynamic Support

Provide prompt fluid therapy to improve blood flow, perfusion and tissue oxygenation.
Evaluate and address age-appropriate responsiveness to fluid resuscitation during, and following, each bolus.
Monitor for fluid overload.
Anticipate use of vasoactive agent to support microperfusion and oxygen delivery; titrate to response.
Monitor cardiovascular status; observe for, and address, cardiac dysrhythmia.
Monitor and manage electrolyte imbalances; monitor other laboratory value trends, such as lactate.
Monitor and address end-organ dysfunction; consider using a standardized tool to assess for organ failure.
Prepare for supportive therapy, such as corticosteroid therapy, coagulopathy management and urgent intervention in the presence of hemodynamic instability.

Problem Intervention

Minimize and Manage Infection

Anticipate antimicrobial therapy administration; do not delay in the presence of high suspicion or clinical indicators.
Obtain cultures prior to initiating antimicrobial therapy when possible.
Determine and address underlying source of infection aggressively; consider vascular access device, invasive devices, meningitis, pneumonia or wound.
Initiate precautions to prevent the spread of infection.
Monitor blood glucose level and maintain glycemic control.

Problem Intervention

Promote Comfort and Manage Pain

Use a consistent pain assessment tool; include assessment of functional ability.
Evaluate pain and treatment response at regular intervals.
Involve patient and family/caregiver in the management plan.
Provide nonpharmacologic strategies, such as positioning, quiet and calm environment, as well as minimal stimulation.
Consider multimodal pharmacologic measures, such as an analgesic, antipyretic or antianxiety agent.
Evaluate risk for opioid use and dependence.

Problem Intervention

Facilitate Procedures

Evaluate need for NPO (nothing by mouth) status.
Prepare for or assist with procedure, such as urinary catheter placement, gastric decompression, lumbar puncture, cultures, debridement, incision and drainage, thoracentesis or thoracostomy.
Anticipate and prepare for surgical intervention.

Problem Intervention

Provide Psychosocial Support

Proactively provide information; encourage questions and address concerns.
Provide calm, reassuring presence. Monitor for increasing anxiety.
Recognize, identify and allow expression of emotions.
Promote parent/caregiver presence at bedside.
Offer choices to enhance a sense of control.
Honor spiritual and cultural preferences.
Recognize and utilize personal coping strategies.
Consider conversation around goals of care; involve palliative care team, if available.

Problem Intervention

Initiate Consult or Referral

Facilitate contact, such as child life specialist, primary care provider, intensivist, infectious disease specialist or surgeon.
Coordinate transition, such as hospital admission.

Education

General Emergency Education

Teaching Focus

symptom/problem overview
risk factors/triggers
self-management
assistive device
diagnostic test
diet modification
medical device/equipment use
medication administration
opioid medication management
orthopaedic device
safe medication disposal
smoking cessation
wound care

Population-Specific Considerations

Forensics and Legal

Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

Human Trafficking

Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration and other vulnerable and minority populations, as well as children who are homeless, runaways or in foster care.

Age-Related

Information from parents or primary caregiver is very important, as they know the child’s baseline status.
Infants are particularly prone to hypothermia. Hypothermia may indicate serious infection.
Newborns and neonates may have additional symptoms that may include apnea, irritability, hypothermia or jaundice.

Pregnancy

Beyond 20 weeks gestation, supine position should be avoided. Patient position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
Patient stabilization is a priority, as fetal status is impacted by patient status.
A secondary assessment should include fetal heart rate, contraction activity, presence of vaginal bleeding and membrane status.
Normal physiologic changes during pregnancy should be considered when treating a pregnant patient with sepsis. Hemodynamic parameters should be carefully monitored.
Infection during pregnancy can result in the increased production of prostaglandins, which may lead to preterm labor.

Quality Measures

NQF 0495. Median Time from ED arrival to ED Departure for Admitted ED Patients
Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.
Steward: Centers for Medicare and Medicaid Services
Care Setting: ED, Hospital
National Quality Forum-endorsed measure
Last Edited: 10/11/2017
NQF 0496. Median Time from ED arrival to ED Departure for Discharged ED Patients
Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.
Steward: Centers for Medicare and Medicaid Services
Care Setting: ED, Hospital
National Quality Forum-endorsed measure
Last Edited: 10/11/2017

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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.