Yes Unsure Ongoing resuscitation – Septic shock order set □ Need for ongoing resuscitation should be driven by perfusion or BP /MAP concerns □ 2nd and 3 rd boluses given rapidly , with reassessment in between to determine how many boluses are needed and how patient is responding □ If patient not responding to 1st and 2 nd bolus at all, consider other causes of tachycardia/shock □ Investigate/treat potential sources of infection (including surgical source control) □ Stress dose hydrocortisone in at risk populations □ Address electrolyte deficiencies (Na+, glucose, Ca++) □ Clinician reassessment and discussion of next steps within 15 minutes of each intervention □ Recommended additional labs and imaging (guided by clinical situation/population) □ Plan for disposition Evaluation □ Place on monitors □ Clinician assessment focused on perfusion □ Initial huddle: discuss whether there are signs of shock, initiation of sepsis pathway, plan for reassessment (and set MRT criteria for floor patients) Screen positive (ED) Usual care/ reassessment plan Yes 20-60 min No Probable septic shock? 0-10 min 0-20 min Initial diagnosis and management – Septic shock order set □ Establish IV access □ Administer O2 to improve 02 carrying capacity □ Place patient on monitors: vitals at least q15 minutes including BP □ Administer 20 ml/kg NS via rapid infuser or push/pull unless contraindicated □ All patients: CBC, blood culture, blood gas, lactic acid, BMP □ Order antibiotics (see recommended antibiotic list) □ Recommended additional labs and imaging (guided by clinical situation/population) □ Clinician reassessment/discussion of next steps within 15 min of intervention Modified pathway (ED) Frontline provider concern for septic shock Usual care/ reassessment and disposition Evidence-Based Care Algorithm for the Management of Septic Shock Watcher/SA concern for septic shock (inpatient) Ongoing signs of shock? No Recommended antibiotics Rapid fluid administration / contraindications Recommended labs/imaging MRT considerations MAP for age Stress dose steroid recommendations Disposition considerations Signs of altered perfusion
Unknown source Intra-Abdominal source Non-CBDI Patients on immune- suppressive meds (e.g. Rheum), or with a CVC BMT or Oncology patient GI patient (including CVC, liver, small bowel transplant) History of multi-drug resistant bacteria** or recent exposure to Cefepime or Zosyn Previously Healthy Patient Medically Complex Patient Ceftriaxone +/- Vancomycin* Zosyn +/- Vancomycin* Refer to CBDI Divisional Guidelines Refer to GI Central Line Fever Flowchart Meropenem + Vancomycin Cefepime + Vancomycin Initial Empiric Antibiotics for Severe Sepsis / Septic Shock Recommended Labs / Imaging in Severe Sepsis / Septic Shock Initial Care - First Hour(s) All patients – CBC, blood culture, lactic acid, blood gas, BMP Select patients based on clinician suspicion/underlying conditions: UA/Urine culture, LFTs, HCG, CXR, CSF/viral/wound/trach studies as needed Advanced/ICU Care Procalcitonin is helpful to trend when deciding whether to continue antibiotics PT/PTT, DIC panel, type if signs of coagulopathy ESR/CRP for suspicion of osteomyelitis Advanced imaging as needed to identify source Vancomycin indicated for any child with risk factors for MRSA or highly-resistant S. pneumoniae Risk factors for MRSA: Bone/joint/deep tissue infection; history or family history of MRSA infection or recurrent boils Risk factors for highly-resistant S. pneumoniae: recent B-lactam exposure, daycare attendance, non-vaccinated When vancomycin is ordered, it should be administered after the antibiotic listed above it
Rapid Bolus Administration / Contraindications At all team discussions, discuss criteria for calling MRT, and call MRT is needed Recommend calling MRT if patient has abnormal perfusion after 60 ml / kg fluid resuscitation (can also call earlier) MRT and Disposition Considerations If risk for adrenal insufficiency: Catecholamine resistant shock Chronic steroid use Home stress dose steroid use Known adrenal hyperplasia Stress Dose Hydrocortisone Recommendations Initial Care - First Hour(s) Boluses should be 20 ml / KG NS via push pull or rapid infuser; adjust volume for patients with contraindications Patients who may need smaller boluses include: neonates < 1 month, those with signs of heart failure, and sickle cell patients with risk of cardiomyopathy; cardiology patients should have an echo after the 2nd bolus Some patients need pressors after only 40 ml/KG fluids; consider earlier if signs of overload including rales, hepatomegaly or increasing respiratory distress with fluid administration Select patients based on clinician suspicion/underlying conditions: LFTs, HCG, CXR, CSF/viral/wound/trach studies as needed These may be subtle in early, compensated shock: Delayed (>2 sec) capillary refill Cool, pale skin Altered mental status – sleepy, drowsy, fussy, irritable Weaker peripheral pulses In warm shock: flash capillary refill, bounding pulses Signs of Altered Perfusion