Logo Elsevier

Careplan

Sepsis or Septic Shock (Pediatric ED)

Sep.11.2020

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

  • 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:
        • health literacy
        • cultural and spiritual preferences
      • 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
    • endocarditis
    • 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 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 abnormal
    • CRP (C-reactive protein)
    • cultures and gram stain
    • lipase
    • liver function tests
    • procalcitonin level
    • serum creatinine
    • serum electrolytes
    • serum lactate
    • urinalysis

    Diagnostics

    • CT (computed tomography) scan
    • ECG (electrocardiogram)
    • lumbar puncture
    • ultrasound (abdomen, chest)
    • x-ray (abdomen, chest)

    Potential Additional Testing

    • pregnancy test (females of childbearing age)

    Problem Intervention

    Provide Respiratory Support

    • Assess and monitor airway, breathing and circulation; 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.
    • Consider noninvasive or invasive positive pressure ventilation to enhance oxygenation and ventilation, as well as reduce work of breathing.
    • Facilitate lung-protection measures, such as limited ventilator tidal volume and plateau pressure; implement positive end-expiratory pressure.

    Problem Intervention

    Provide Hemodynamic Support

    • Provide prompt fluid therapy to improve blood flow, perfusion and tissue oxygenation.
    • Evaluate and address responsiveness to fluid resuscitation during and following each bolus; include blood pressure, peripheral perfusion, breath sounds, mentation and level of consciousness.
    • Anticipate use of vasoactive agent to support microperfusion and oxygen delivery; titrate to response.
    • Anticipate corticosteroid administration for refractory shock or for suspected or proven absolute adrenal insufficiency.
    • Monitor cardiovascular status; observe for, and address, cardiac dysrhythmia.
    • Monitor and manage electrolyte imbalances, especially hypocalcemia and hyperkalemia.
    • Monitor and address end-organ dysfunction; consider using a standardized tool to assess for organ failure.

    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; evaluate pain and treatment response at regular intervals.
    • Involve patient and family in the management plan.
    • Provide nonpharmacologic strategies, such as positioning, quiet and calm environment and minimal stimulation.
    • Consider pharmacologic measures, such as an analgesic, antipyretic or antianxiety agent.
    • Evaluate risk for opioid use and dependence.

    Problem Intervention

    Facilitate Procedures

    • Initiate and maintain 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.
    • 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.

    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

    • Infants are particularly prone to hypothermia. Hypothermia may indicate serious infection.
    • Information from parents or primary caregiver is very important, as they know the child’s baseline status.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • Maternal stabilization and resuscitation are the primary priorities.
    • Assessment of fetal status, a secondary assessment, should include fetal heart rate, contraction activity and presence of maternal-fetal hemorrhage.
    • 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 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
    • 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

    References

    • American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement—Guidelines for care of children in the Emergency Department. Journal of Emergency Nursing. 2013;39(2), 116. doi:10.1016/j.jen.2013.01.003 [Quality Measures,Clinical Practice Guidelines]
    • American Heart Association; The American Academy of Pediatrics. (2016). Pediatric advanced life support provider manual. United States: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Armstrong, B. A.; Betzold, R. D.; May, A. K.. Sepsis and septic shock strategies. Surgical Clinics of North America. 2017;97(6), 1339-1379. doi:10.1016/j.suc.2017.07.003 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Bader, M. K.; Littlejohns, L. R.; Olson, D. M. (2016). AANN Core curriculum for neuroscience nursing. Chicago: American Association of Neuroscience Nurses. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • College of Respiratory Therapists of Ontario. (2013). Oxygen therapy clinical best practice guideline. Source[Quality Measures,Clinical Practice Guidelines]
    • Davis, A. L.; Carcillo, J. A.; Aneja, R. K.; Deymann, A. J.; Lin, J. C.; Nguyen, T. C.; Okhuysen-Cawley, R. S.; Relvas, M. S.; Rozenfeld, R. A.; Skippen, P. W.; Stojadinovic, B. J.; Williams, E. A.; Yeh, T. S.; Balamuth, F.; Brierley, J.; de Caen, A. R.; Cheifetz, I. M.; Choong, K.; Conway Jr., E.; Cornell, T.; Doctor, A.; Dugas, M. A.; Feldman, J. D.; Fitzgerald, J. C.; Flori, H. R.; Fortenberry, J. D.; Graciano, A. L.; Greenwald, B. M.; Hall, M. W.; Han, Y. Y.; Hernan, L. J.; Irazuzta, J. E.; Iselin, E.; van der Jagt, É. W.; Jeffries, H. E.; Kache, S.; Katyal, C.; Kissoon, N.; Kon, A. A.; Kutko, M. C.; MacLaren, G.; Maul, T.; Mehta, R.; Odetola, F.; Parbuoni, K.; Paul, R.; Peters, M. J.; Ranjit, S.; Reuter-Rice, K. E.; Schnitzler, E. J.; Scott, H. F.; Torres Jr., A.; Weingarten-Abrams, J.; Weiss, S. L.; Zimmerman, J. J.; Zuckerberg, A. L. American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Critical Care Medicine. 2017;45(6), 1061-1093. doi:10.1097/CCM.0000000000002425 [Quality Measures,Clinical Practice Guidelines]
    • Davis, M. D.; Walsh, B. K.; Sittig, S. E.;Restrepo, R. D.. AARC clinical practice guideline: Blood gas analysis and hemoximetry. Respiratory Care. 2013;58(10), 1694-1703. [Quality Measures,Clinical Practice Guidelines]
    • de Caen, A. R.; Berg, M. D.; Chameides, L.; Gooden, C. K.; Hickey, R. W.; Scott, H. F.; Sutton, R. M.; Tijssen, J. A.; Topjian, A.; van der Jagt, É. W.; Schexnayder, S. M.; Samson, R. A. Part 12: Pediatric advanced life support: 2015 american heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2), S526-542. doi:10.1161/CIR.0000000000000266 [Quality Measures,Clinical Practice Guidelines]
    • Dellinger, R. P.; Levy, M. M.; Rhodes, A.; Annane, D.; Gerlach, H.; Opal, S. M.; Sevransky, J. E.; Sprung, C. L.; Douglas, I. S.; Jaeschke, R.; Osborn, T. M.; Nunnally, M. E.; Townsend, S. R.; Reinhart, K.; Kleinpell, R. M.; Angus, D. C.; Deutschman, C. S.; Machado, F. R.; Rubenfeld, G. D.; Webb, S. A.; Beale, R. J.; Vincent, J. L.; Moreno, R. Surviving sepsis campaign:  International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 2013;41(2), 580-637. doi:10.1097/CCM.0b013e31827e83af [Quality Measures,Clinical Practice Guidelines]
    • Dudley, N.; Ackerman, A.; Brown, K. M.; Snow, S. K.; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Emergency Nurses Association Pediatric Committee. Patient- and family-centered care of children in the emergency department. Pediatrics. 2015;135(1), e255-e272. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Gibbison, B.; López-López, J. A.; Higgins, J. P.; Miller, T.; Angelini, G. D.; Lightman, S. L.; Annane, D. Corticosteroids in septic shock: A systematic review and network meta-analysis. Critical Care. 2017;21(1), 78. [Metasynthesis,Meta-analysis,Systematic Review]
    • Gulanick, M.; Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions and outcomes. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hooten, M.; Thorson, D.; Bianco, J.; Bonte, B.; Clavel Jr., A.; Hora, J.; Johnson, C.; Kirksson, E.; Noonan, M. P.; Reznikoff, C.; Schweim, K.; Wainio, J.; Walker, N.. (2016 [updated 2017, Aug]). Pain: Assessment, non-opioid treatment approaches and opioid management. (pp.160). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Source[Quality Measures,Clinical Practice Guidelines]
    • Johnston, A. N. B.; Park, J.; Doi, S. A.; Sharman, V.; Clark, J.; Robinson, J.; Crilly, J.. Effect of immediate administration of antibiotics in patients with sepsis in tertiary care: A systematic review and meta-analysis. Clinical Therapeutics. 2017;39(1), 190-202.e6. doi:10.1016/j.clinthera.2016.12.003 Source[Metasynthesis,Meta-analysis,Systematic Review]
    • Liang, S. Y.; Theodoro, D. L.; Schuur, J. D.; Marschall, J.;. Infection prevention in the emergency department. Annals of Emergency Medicine. 2014;64(3), 299-313. doi:10.1016/j.annemergmed.2014.02.024 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Long, B.; Koyfman, A.. Best clinical practice: Blood culture utility in the emergency department. Journal of Emergency Medicine. 2016;51(5), 529-539. doi:10.1016/j.jemermed.2016.07.003 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Marsac, M. L.; Kassam-Adams, N.; Hildenbrand, A. K.; Nicholls, E.; Winston, F. K.; Leff, S. S.; Feinn, J.. Implementing a trauma-informed approach in pediatric health care networks. JAMA Pediatrics. 2016;170(1), 70-77. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Martin, K.; Weiss, S. L. Initial resuscitation and management of pediatric sepsis shock. Minerva Pediatrica. 2015;67(2), 141-158. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Moritz, M. L.; Ayus, J. C. Maintenance intravenous fluids in acutely ill patients. New England Journal of Medicine. 2015;373(14), 1350-1360. doi:10.1056/NEJMra1412877 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • National Collaborating Centre for Women's and Children's Health. (2007, May). Feverish illness in children: Assessment and initial management in children younger than 5 years. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • National Institute for Health and Care Excellence. (2015). Intravenous fluid therapy in children and young people in hospital. (NICE guideline [NG29]). Source[Quality Measures,Clinical Practice Guidelines]
    • National Institute for Health and Care Excellence. (2016). Sepsis: Recognition, diagnosis and early management. (NICE guideline [NG51]). Source[Quality Measures,Clinical Practice Guidelines]
    • Pulia, M. S.; Redwood, R.; Sharp, B.. Antimicrobial stewardship in the management of sepsis. Emergency Medicine Clinics of North America. 2017;35(1), 199-217. doi:10.1016/j.emc.2016.09.007 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Registered Nurses' Association of Ontario. (2013). Assessment and management of pain. Source[Quality Measures,Clinical Practice Guidelines]
    • Registered Nurses' Association of Ontario. (2015). Person- and family-centred care. Source[Quality Measures,Clinical Practice Guidelines]
    • Saugel, B.; Huber, W.; Nierhaus, A.; Kluge, S.; Reuter, D. A.; Wagner, J. Y.. Advanced hemodynamic management in patients with septic shock. BioMed Research International. 2016;2016 doi:10.1155/2016/8268569 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Silversides, J. A.; Major, E.; Ferguson, A. J.; Mann, E. E.; McAuley, D. F.; Marshall, J. C.; Blackwood, B.; Fan, E. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: A systematic review and meta-analysis. Intensive Care Medicine. 2017, February;43(2), 155-170. doi:10.1007/s00134-016-4573-3 [Metasynthesis,Meta-analysis,Systematic Review]
    • Singer, M.; Deutschman, C. S.; Seymour, C. W.; Shankar-Hari, M.; Annane, D.; Bauer, M.; Bellomo, R.; Bernard, G. R.; Chiche, J. D.; Coopersmith, C. M.; Hotchkiss, R. S.; Levy, M. M.; Marshall, J. C.; Martin, G. S.; Opal, S. M.; Rubenfeld, G. D.; van der Poll, T.; Vincent, J. L.; Angus, D. C.. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8), 801-810. doi:10.1001/jama.2016.0287 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Sterling, S. A.; Miller, R.; Pryor, J.; Puskarich, M. A.; Jones, A. E. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock:  A systematic review and meta-analysis. Critical Care Medicine. 2015;43(9), 1907-1915. [Metasynthesis,Meta-analysis,Systematic Review]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Wang, D. H.. Beyond code status: Palliative care begins in the emergency department. Annals of Emergency Medicine. 2017;69(4), 437-443. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Wente, S. J. K. Nonpharmacologic Pediatric Pain Management in Emergency Departments: A Systematic Review of the Literature. Journal of Emergency Nursing. 2013;39(2), 140. doi:10.1016/j.jen.2012.09.011 [Metasynthesis,Meta-analysis,Systematic Review]
    • Wolf, L.; Storer, A.; Barnason, S.; Brim, C.; Halpern, J.; Leviner, S.; Lindauer, C.; Patrick, V. C.; Proehl, J. A.; Williams, J.; Bradford, J. Y. (2012). Clinical practice guideline: Family presence during invasive procedures and resuscitation. United States: Emergency Nurses Association. [Quality Measures,Clinical Practice Guidelines]
    • World Health Organization. (2016). Paediatric emergency triage, assessment and treatment: Care of critically-ill children. Geneva: World Health Organization (WHO). [Quality Measures,Clinical Practice Guidelines]
    • Young, V. B.. Effective management of pain and anxiety for the pediatric patient in the emergency department. Critical Care Nursing Clinics. 2017;29(2), 205-216. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

    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.

    ;