(+)Marianne Gausche-Hill, MD,

FACEP
Professor of Medicine, David Geffen
School of Medicine at UCLA; Director of
EMS and Pediatric Emergency Medicine
Fellowships, Harbor-UCLA Medical
Center, Department of Emergency
Medicine, Torrance, California

Pediatric Septic Shock Recognition

and Management: State of the Art
Early recognition and aggressive management
of septic shock in children is necessary to
reverse the traditionally bad outcomes of this
disease. The speaker will provide an in-depth
examination of the recognition and critical
initial management of these patients. The most
recent approaches in diagnostics and cuttingedge therapeutics including early goal-directed
therapy and rapid response protocols will be
explored. Evidence-based differences in
management of children compared to adults
also will be highlighted.
Define the early clinical manifestations of
septic shock.
Recognize the importance of early and
aggressive fluid therapy.
Review the current base of evidence supporting
EGDT for pediatric shock.
Differentiate between pediatric and adult shock
treatment algorithms.

SA-07
10/15/2011
8:00 AM - 8:50 AM
Moscone Convention Center

(+)No significant financial relationships to disclose

Pediatric Septic Shock Recognition and

Management: State of the Art

Marianne Gausche-Hill, MD, FACEP, FAAP

Professor of Medicine
David Geffen School of Medicine at UCLA
Vice Chair and Chief of the Division of Pediatric Emergency
Medicine
Director, EMS and Pediatric Emergency Medicine Fellowships
Harbor-UCLA Medical Center
Department of Emergency Medicine

Disclosures
In the past 12 months, I have not had a
significant financial interest or other
relationship with the manufacturer(s) of the
products or provider(s) of the services that
will be discussed in my presentation.
This presentation will not include include
discussion of pharmaceuticals or devices
that have not been approved by the FDA.

Objectives
Define the early manifestations of septic
shock.
Recognize the importance of early
aggressive fluid therapy.
Review the current base of evidence for
EGDT for pediatric shock.
Differentiate between pediatric and adult
treatment algorithms.

Early Goal-Directed Therapy in the

Treatment of Severe Sepsis and Septic
Shock
Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne
Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S.,
Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael
Tomlanovich, M.D., for the Early Goal-Directed Therapy
Collaborative Group

Showed reduced mortality 46% .to 30%

Pediatric Age Group Definitions

2007 American College of
Critical Care Medicine
clinical practice parameters
for hemodynamic support of
pediatric and neonatal
septic shock*
Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A,
et al. Clinical Practice Parameters for Hemodynamic
Support of Pediatric and Neonatal Septic Shock: 2007
Update from the American College of Critical Care
Medicine. Critical Care Medicine 2009;37:666-688.

Newborn
Neonate
Infant
Toddler
School age child
Adolescent and
young adult

0 days to 1 wk
1 wk to 1 mo
1 mo to 1 yr
25 yrs
612 yrs
13 to 18 yrs

Pediatr Crit Care Med 2005;6:2-8

Systemic Inflammatory Response

Syndrome (SIRS)
Nonspecific inflammatory process
Originally described in adults with trauma,
infection, burns, pancreatitis and other
diseases

Sepsis is defined as SIRS + infection

Pediatric modifications were made in
definition based on an international
consensus conference
Pediatr Crit Care Med 2005;6:2-8

SIRS Definition for Children

The presence of at least two of the following four criteria,
one of which must be abnormal temperature or
leukocyte count:
Core temperature of >38.5C or <36C.
Tachycardia, defined as a mean heart rate >2 SD above normal
for age OR for children <1 yr old: bradycardia (unexplained
by other factors and which persists >30 min)
Mean respiratory rate >2 SD above normal for age or
mechanical ventilation for an acute process not related to
underlying neuromuscular disease or the receipt of general
anesthesia.
Leukocyte count elevated or depressed for age (not secondary
to chemotherapy-induced leukopenia) or >10% immature
neutrophils.

SIRS and Temperature

Fever defined as 38C
38.5C has improved specificity

Core temperature is considered gold

standard
Rectal, bladder, oral, or central catheter probe
Fever may also be documented at home by a
reliable source within 4 hrs of presentation
to the ED

SIRS: Age-specific vital signs and

laboratory variables
Age Group

Tachycardia Bradycardia

Respiratory
Rate

WBC
X103/mm3

Systolic
BP mmHg

Newborn

>180

<100

>50

>34

<65

Neonate

>180

<100

>40

>19.5 or
<5

<75

Infant

>180

<90

>34

>17.5 or
<5

<100

Toddler

>140

NA

>22

>15.5 or
<6

<94

Child

>130

NA

>18

>13.5 or
<4.5

<105

Adolescent >110

NA

>14

>11 or
<4.5

<117

Pediatric SIRS
Diagnosis of pediatrics SIRS requires that
temperature and leukocyte abnormalities
be present
SIRS should not be diagnosed in
pediatrics with just an elevated heart rate
or respiratory rate

Biochemical Markers of
Inflammation
Elevations in biomarkers not part of the
definition to date
Sedimentation rate
C reactive protein
Base deficit
Interleukin -6
Procalcitonin

Infection
A suspected or proven (by positive culture, tissue
stain, or polymerase chain reaction test) infection
caused by any pathogen
OR
A clinical syndrome associated with a high
probability of infection.

Pediatr Crit Care Med 2005;6:2-8

Infection
Evidence of infection includes positive
findings on clinical exam, imaging, or
laboratory tests
white blood cells in a normally sterile body
fluid
perforated viscus
chest radiograph consistent with pneumonia
petechial or purpuric rash, or purpura
fulminans
Pediatr Crit Care Med 2005;6:2-8

Sepsis Definitions
Sepsis = SIRS in the presence of or as a result
of suspected or proven infection
Severe sepsis = Sepsis plus one of the
following:
cardiovascular organ dysfunction OR
acute respiratory distress syndrome OR
two or more other organ dysfunctions
(respiratory, renal, hepatic, neurologic,
hematologic).

Modifications from the adult definitions are in bold

Septic Shock

Cardiovascular Dysfunction

Septic shock = Sepsis and cardiovascular

organ dysfunction
There is no requirement for hypotension as
there is in the adult population
Tachycardia (may be absent if hypothermic)
with signs of decreased perfusion)
Decreased peripheral pulses, altered
alertness, capillary refill >2 seconds, mottled
or cool extremities, or decreased urine output

Despite administration of isotonic intravenous fluid bolus

>40 mL/kg in 1 hr
Decrease in BP (hypotension) <5th percentile for age or systolic
BP <2 SD below normal for age OR

Need for vasoactive drug to maintain BP in normal range

(dopamine >5 g/kg/min or dobutamine, epinephrine, or
norepinephrine at any dose) OR
Two of the following:

Unexplained metabolic acidosis: base deficit >5.0 mEq/L

Increased arterial lactate >2 times upper limit of normal
Oliguria: urine output <0.5 mL/kg/hr
Prolonged capillary refill: >5 secs
Core to peripheral temperature gap >3C

Carcillo JA, et al: Crit Care Med 2002

Cold or Warm Shock

Decreased perfusion manifested by
altered/decreased mental status
Capillary refill >2 secs (cold shock) or
flash capillary refill (warm shock)
Diminished (cold shock) or bounding
(warm shock) peripheral pulses
Mottled cool extremities (cold shock), or
decreased urine output 1 mL/kg/h

Refractory Shock
Shock persists despite goal-directed use
of inotropic agents, vasopressors,
vasodilators, and maintenance of
metabolic (glucose and calcium) and hormonal
(thyroid, hydrocortisone, insulin) homeostasis

Fluid refractory and Catecholamine

Resistant Shock
Fluid-refractory/dopamine-resistant shock
Shock persists despite 60 mL/kg fluid
resuscitation (when appropriate) and dopamine
infusion to 10 g/kg/min

Catecholamine-resistant shock
Shock persists despite use of the direct-acting
catecholamines; epinephrine or
norepinephrine

Sepsis Associated Mortality

Predominant cause of death in adult septic
shock is (vasomotor paralysis) inability to
maintain cardiac output through
tachycardia and increases in SVR
Pediatric septic shock is associated with
severe hypovolemialow CO (not low SVR)
and a reduction in oxygen delivery

Cardiac Index

Brierley J, Peters MJ: Pediatrics 2010

Reported on 30 children with fluid
refractory [>40 ml/kg in first hour]
Assessed using non-invasive cardiac output
device
Community acquired [12/14 (86%) normal
or low cardiac index; high SVR (cold shock)]
Central line related sepsis [15/16 (94%)
elevated cardiac index with low SVR (warm
shock)]

The index is usually calculated using the

following formula:
where
CI=Cardiac index
BSA=Body surface area
SV=Stroke volume
HR=Heart rate
CO=Cardiac output

GDT for CI
3.3-6.0 L/min/m2
<2.0 bad

No difference in BP: CI predicts death

from cardiogenic shock

(Parr et al, Circulation, 1975)

Case: 4 day-old boy with fast breathing

Mother states baby was fine until she noted
choking and fast breathing after breast feeding
Baby appeared to have labored breathing and
short spells of apnea followed by being limp
Pediatric Assessment Triangle
Appearance: Poor tone
Work of breathing: Tachypneic
Circulation: Pale/mottled

=Shock

VSS: HR 202; RR 60;

BP 68 mmHg; T 38.2C

ALOC: AEIOU TIPS

Alcohol/Ammonia/
Abuse
Electrolytes/
Encephalopathy
Infection
Overdose/Oxygen
Uremia

Trauma/Tumor
Insulin/intussusception/
Inborn errors of
metabolism
Psychiatric/psychogenic/
Poisoning
Shock/Stroke/ Seizure/
Shunt/Subarachnoid
hemorrhage

Ill appearing neonate

Infection sepsis/meningitis/respiratory
infection/myocarditis/septic arthritis
Congenital congenital heart disease if
cyanotic ductal dependent lesion
Metabolic low sodium, low glucose, in
born error
Trauma child maltreatment
Toxic unlikely but should not be
forgotten
What if the baby was irritable/crying?

Adapted from APLS: The Pediatric Emergency Medicine Resource

The Crying Game

Obviously the same players as the ill
appearing neonate
Other considerations:
Corneal abrasion
Hair tourniquet
Colic
Testicular torsion
New parent
Back to our patient

Fever + SIRS
Age Group

Tachycardia Bradycardia

Respiratory
Rate

WBC
X103/mm3

Systolic
BP mmHg

Newborn

>180

<100

>50

>34

<65

Neonate

>180

<100

>40

>19.5 or
<5

<75

Infant

>180

<90

>34

>17.5 or
<5

<100

Toddler

>140

NA

>22

>15.5 or
<6

<94

Examine the whole baby top

to bottomeverytime.

Child

>130

NA

>18

>13.5 or
<4.5

<105

I mean it!

Adolescent >110

NA

>14

>11 or
<4.5

<117

Newborn Considerations
In utero 85% of
fetal circulation
bypasses the
lungs through the
ductus arterious
and foramen ovale

Newborn Considerations
Oxygen in the lungs triggers a lowering of
pulmonic vascular resistance
Sepsis induced acidosis and hypoxia can
increase pulmonary vascular resistance
and thus arterial pressure causing the
ductus to remain open

Persistent Pulmonary Hypertension of the

Newborn (PPHN)
This results in
PPHN this leads
to right ventricular
work right heart
failure
Therapy directed at
reducing pulmonary
artery pressures
Inhaled Nitric oxide
Inhaled prostacyclin
and IV adenosine
may treat refractory
PPHN

Newborn Considerations
Other issues include relative deficiencies in
thyroid and parathyroid hormones [replenish
thyroid hormone, calcium]

Hydrocortisone given on day 1 reduces risk of

hypotension
Poor glycogen stores monitor glucose
Immature thermogensis external warming
Pentoxyfilline - vasodilator and antiinflammatory

Newborn: GDT Sepsis

Newborns
< 7 days
Brierley J, et al
Critical Care
Medicine
2009;37:666-688

Monitor/Oxygen/Intubate
IV accessmay be a challenge
Fluid resuscitation with Normal Saline
Check rapid glucose and calcium
Give antibiotics

Laboratories for Critical Neonate

Electrolytes, calcium, renal and liver
function tests
Glucose, ketones, lactate, and ammonia
CBC and blood culture, INR
Cath UA and culture
CXR

Newborn GDT Sepsis

Prostaglandin E1 (Alprostadil)
Dose 0.05-0.1 g/kg/min
If see increase in PaO2
can decrease immediately
to lowest effective dose
Side effects apnea, fever,
seizures, flushing,
bradycardia

Newborn GDT Sepsis

If no PICU initiate transfer

If baby remains in shock begin dopamine
Establish central access

Case: 4 day-old boy with fast breathing

Patient was intubated with atropine, ketamine
Patient was given 60 ml/kg NS and
prostaglandin E1
Stat Echocardiogram to rule out ductal
dependent lesion Prostaglandin stopped
Glucose noted to be 30 mg/DL and 4 mL/kg of
D10W infused; Calcium was normal
Antibiotics cefotaxime and ampicillin [acyclovir]
Patient transferred to pediatric critical care
center by transport team

Case: 5 year-old girl with vomiting

5 year old BIB parents to ED with history
of 3 days of fever and vomiting
Child appears listless, is tachypneic, skin
is pale
Pediatric Assessment Triangle
Appearance: Poor interactiveness
Work of breathing: Tachypneic
Circulation: Pale

=Shock

VSS: HR 160; RR 28; T 39.5C; BP 70 mmHg

Fever + SIRS
Age Group

Tachycardia Bradycardia

Respiratory
Rate

WBC
X103/mm3

Systolic
BP mmHg

New born

>180

<100

>50

>34

<65

Neonate

>180

<100

>40

>19.5 or
<5

<75

Infant

>180

<90

>34

>17.5 or
<5

<100

Toddler

>140

NA

>22

>15.5 or
<6

<94

Child

>130

NA

>18

>13.5 or
<4.5

<105

Adolescent >110

NA

>14

>11 or
<4.5

<117

Infants and
Children
Brierley J, et al
Critical Care
Medicine
2009;37:666-688

First minutes

Laboratories
Electrolytes, calcium, renal and
liver function tests
Glucose, lactate
Consider adding ketones and
lactate

Patient placed on 100% oxygen

IV access obtained and 20 mL/kg bolus initiated
Blood sent for Antibiotics begun ceftriaxone 100 mg/kg
Rapid glucose 80 mg/dL; calcium normal

Fluid Resuscitation
Critical to adequately fluid resuscitate in the ED
Orr et al reported that specific hemodynamic
abnormalities in the ED were associated with
progressive mortality

Eucardia (1%)
Tachycardia/ bradycardia (3%)
Hypotension with capillary refill 3 secs (5%)
Normotension with capillary refill greater than 3 secs
(7%)
Hypotension with capillary refill greater than 3 secs
(33%)

CBC and blood culture, INR

Cath UA and culture
Consider tox screen

CXR

Fluid Resuscitation
Large volumes of fluid for acute
stabilization of children has NOT been
shown to increase incidence of RDS or
cerebral edema
Reversal of these hemodynamic abnormalities was
associated with a 40% reduction in mortality odds
ratio regardless of the stage of hemodynamic
abnormality at the time of presentation

Other Goals

What about fluid boluses?

PALS recommends to begin with 20 mL/kg and
then monitor

HR
Quality of peripheral pulses
Capillary refill
Level of consciousness
Urine output

Practically- fluid resuscitation volumes

commonly exceed 40- 60 mL/kg
Can be as high as 200 mL/kg

Normal Saline or Lactated Ringers

Fluid Refractory Shock

Fresh frozen plasma may be infused to correct

abnormal prothrombin time and partial
thromboplastin time values
Do not use routinelymay cause hypotension caused
by vasoactive kinins and high citrate concentration

Use of blood as volume expanders not well

studied in children
Some evidence for improved outcomes

Goal is to transfuse to hemoglobin >10 g/dL to

achieve a Scvo2 >70%

Mechanical Ventilation
Indications:

Intubation may be performed hereor earlier

Child requiring invasive monitoring and central
line should be intubated

Mechanical Ventilation
Benefits:
Up to 40% of CO may be required to support the work
of breathing, and this can be unloaded by ventilation,
diverting flow to vital organs
Increased intrathoracic pressure also reduces left
ventricular afterload that may be beneficial in patients
with low CO and high SVR
Mild hyperventilation may also be used to
compensate for metabolic acidosis by altering the
respiratory component of acid-base balance
Facilitates temperature control and reduces oxygen
consumption

Caution: Excessive ventilation may impair CO,

especially if patient is hypovolemic

Need to establish invasive hemodynamic

monitoring
Should be considered in any patient who is
not rapidly stabilized with fluid resuscitation
and peripherally administered inotropes
Evidence of respiratory failure
Moribund condition

Etomidate (0.3 mg/kg)

Onset: Less than 1 min [my experience <30 s]
Duration: 5 to 20 min
Advantage: Minimal respiratory depression, lowers ICP
and cerebral metabolic rate, few cardiovascular effects
Disadvantage: Myoclonic excitation (might resemble
seizures); causes adrenal insufficiency some concerns
over affect on outcome in patients with septic shock not
recommended
Etomidate inhibits 11 -hydroxylase [enzyme in final step
of cortisol production]

Ketamine (2 mg/kg)
Onset: 1- 2 min Duration: 30-60 min
Advantage: Bronchodilator, limited respiratory
depression sympathomimetic, less likely to
cause myocardial depression.
Disadvantage: Inject slowly to avoid vomiting;
increases oral secretions (use atropine as an
adjunctive agent), increases ICP (but recent
data shows increases CPP), might cause
emergence reactions

Ketamine
Ketamine is a central NMDA receptor
blocker
Blocks nuclear factor-kappa B transcription
Reduces systemic interleukin-6 production
Maintains an intact adrenal axis and
maintains cardiovascular stability
Prefered over etomidate at this point

Sedative of choice for patients in septic shock

RSI in Septic Shock

Caution with propofol, thiopental, and
benzodiazepines as can cause
hypotension
Use neuromuscular blocker
succinylcholine or rocuronium
Pretreatment with atropine is
controversial...would consider if
succinylcholine used

Central Venous Access

Minimal invasive monitoring needed if child
responds to fluid resuscitation
Central venous access and arterial monitoring
required in fluid refractory shock
Goal: Scvo2 saturation >70%

To gain accurate measures of ScvO2, the tip of

the catheter must be at or close to the SVC-right
atrial or inferior vena cava-right atrial junction

Ultrasound
Echocardiography may assist in determining CO
and SVC flow
Goals:
CO >3.3 L/min/m2 and <6.0 L/min/m2
SVC flow >40 mL/kg/min

Ultrasound may be used to assess volume

status using aortic to IVC ratio [data suggested from
dehydration studies]

Ultrasound may be very useful in establishing

vascular access

10

Cardiovascular Drug Therapy

Balance pharmacologic agent and patient
response
Target:
Effect on SVR or pulmonic vascular
resistance (vasodilator or vasopressor
Contractility (inotropes)
HR (chronotropes)

Cardiovascular Drug Therapy

First line inotropic support
Dopamine (59 g/kg/min)
Dobutamine
Used if low CO state with adequate or increased
SVR

Epinephrine (0.05 0.3 g/kg/min)

Cardiovascular Drug Therapy

Epinephrine

Adult data favors use of norepinephrine as

first-line agent in fluid refractory shock

Stimulates gluconeogenesis and

glycogenolysis, and inhibits the action of
insulin, leading to increased blood glucose
concentrations

Adults with fluid-refractory, dopamine

resistant shock have high CO and low SVR

Children with this condition predominantly

have low CO
Dobutamine- or dopamine-refractory low CO
shock may be reversed with epinephrine
infusion

Epinephrine
Preferred route of administration central line
Emergency situation - peripheral IV route or
through an intraosseous needle while attaining
central access.
The American Heart Association/PALS guidelines for
children recommends the initial use of epinephrine by
peripheral IV or intraosseous for cardiopulmonary
resuscitation or postcardiopulmonary resuscitation
shock, and by the intramuscular route for anaphylaxis

Also increases the shuttle of lactate to the

liver as a substrate for glucose production
(the Cori cycle) thus may not be helpful
monitoring lactate in children receiving
epinephrine

Vasopressin
Safety and efficacy of low-dose arginine
vasopressin have yet to be demonstrated
in children with septic shock, and await the
results of an ongoing randomized
controlled trial

11

Vasodilators
Vasodilators:

Nitroprusside
Nitroglycerin
Prostacyclin
Pentoxifylline
Dopexamine
Fenoldopam

Inamrinone (Inocor) and milrinone are

rarely used in adults with septic shock
because catecholamine refractory low
CO and high vascular resistance is
uncommon; this is a major proportion
of children with fluid-refractory,
dopamine-resistant shock

Type III Phosphdiesterase Inhibitors

Stimulate intracelluar cAMP by blocking hydrolysis
Milrinone
Inamrinone

Case: 5 year-old girl with vomiting

Hydrocortisone
Give if child at risk for adrenal insufficiency or
adrenal pituitary axis failure
Purpura fulminans
Congenital adrenal hyperplasia
Prior recent steroid exposure, hypothalamic/pituitary
abnormality)

AND
Remains in shock despite epinephrine or
norepinephrine infusion
Stress dose 12 mg/kg/day [may require up to
50 mg/kg/day]
Unclear benefit? Risk

Therapies adults and children with septic shock

Therapy

Patient received 100 mL/kg of NS in ED

Urine + for infection
Patient received Ceftriaxone and gentamicin
Patient intubated
Patient initially placed on dopamine
Admitted to PICU
Required central line and IV epinephrine
Hospitalized for 2 weeks

The First Hour: The Job of the ED

Physician
Maintain or restore airway, oxygenation and
ventilation; maintain perfusion
Therapeutic endpoints:
Capillary refill <2 secs
Normal pulses with no differential between the quality
of peripheral and central pulses
Warm extremities
Urine output 1 mL/kg/h
Normal mental status
Normal blood pressure for age
Normal glucose concentration
Normal ionized calcium concentration

Children

Adults

Volume

Usually need more fluid: may need up to and

over 60 cc/kg

Fluid resuscitation till CVP 12

Antibiotics

Early initiation of appropriate antibiotics

recommended within 1 h

Early initiation of appropriate antibiotics

recommended within 2 h

Inotropes and vasopressors

First line peripheral Epinephrine for cold

shock
Transition to central when able
Central norepinephrine for warm shock

First line Nor-epinephrine

dobututamine
Vasopressin for warm shock

Vasodilators

Used for pulmonary hypertension; Low cardiac

output high SVR shock

No role

Tight glycemic control

Unresolved

Harmful

ECMO

Survival 80% in neonates and 50% in children

Evolving-H1N1 is popularizing its use

Inhaled NO

Neonates with right ventricle failure

No role for NO

Plasma exchange

Used for patients with TAMOF including

DIC/purpura fulminans

Effective in adults but rarely used

Activated Protein C

Not recommended

Recommended

Hydrocortisone

Absolute Adrenal Insufficiency only Post

ACTH cortisol level <18 g/download or
baseline <5 g/dL

Use if continue to be on vasopressors

regardless of adrenal status

Primary HLH protocolEtoposide/cyclosporine A,

dexamethasone,
chemotherapy

Used for primary HLH with familial history,

consanguineous parents, or peforin
mutations

Not indicated

Han, et al: Pediatrics 2003

9 year study of 91 infants and children
presenting in shock at community hospitals
Shock reversal defined as return of normal SBP and
cap refill
26 (29%) mortality overall
24 patients with shock reversal at 75 min [96%
survival]
If achieved reversal >9 fold increase in odds of
survival
Each additional hour of persistent shock with >2 times
odds of mortality
The bottom line: Survivorsreceived more fluids 40 ml/kg

12

Carcillo J, et al: Mortality and functional morbidity

after use of PALS/APLS by community physicians
Pediatrics 2009
4856 children transported to 5 childrens
hospitals. PALS/APLS resuscitation performed
by community physicians reduced mortality rates
in trauma patients and mortality and neurological
morbidity rates in nontrauma patients alike
Early use of PALS/APLS-recommended
interventions was associated with reduced
mortality (9% vs 15%) and functional morbidity
(1.24% vs 4.23%) rates (OR 0.66[95% CI 0.47-0.92])

Septic Shock Care Guideline: Individual

Care Elements
Attending ED physician
notified

Attending ED physician at bedside within 15 min of triage designation of resuscitation

Monitoring

Patient placed on continuous pulse oximetry and cardiac monitoring; obtain a full set of VSs,
including manual blood pressure

Oxygenation

Patient placed on oxygen regardless of O2 saturation level

Intravenous access and

laboratory studies

Start peripheral intravenous line; order the following laboratory work: capillary blood gas,
ionized calcium, lactate, and glucose levels, a complete blood count, and a blood culture
Within the first 5 min in the ED: administer a rapid fluid bolus of 20 mL/kg NS by push method; if
there are no signs of rales, gallop rhythm, or increased work of breathing or increased
oxygen need, reassess the patient's clinical status and prepare for second bolus

Intravenous fluids

Within the first 15 min in the ED: administer a second rapid fluid bolus of 20 mL/kg NS by push
method (total of 40 mL/kg); if there are no signs of rales, gallop rhythm, or increased work
of breathing or increased oxygen need, reassess the patient's clinical status and prepare
for third bolus

Larsen GY, Mecham N, Greenberg R:

Pediatrics 2011; 127:e1585-1992
An emergency department septic shock protocol
and care guideline for children initiated at triage
2006 multidisciplinary team reviewed national
guidelines developed a care guideline for patients
with suspected septic shock in the ED
2007 staff educated on protocol and protocol posted
at triage monthly case reviews once protocol
initiated
2007 point of care lactate testing approved
Patients outcomes studied pre- and post-protocol
implementation

Larsen GY, Mecham N, Greenberg R:

Pediatrics 2011; 127:e1585-1992
Outcomes:
Improved compliance
with septic shock
guidelines
Median LOS declined
181-140 hours p<0.05
No change in
mortality rate 7.1% vs
6.4%, p=0.93

Within the first 30 min in the ED: administer a third rapid fluid bolus of 20 mL/kg NS by push
method (total of 60 mL/kg); fluid should be pushed with the goal of attaining normal
perfusion and blood pressure, so the patient must be reassessed between each bolus, and
the reassessment must be documented on the ED nursing flow sheet
Antibiotics

Within 3 h of identification, administer antibiotics if septic shock is suspected (eg, ceftriaxone)

Data sources: Brierley J, Carcillo JA, Choong K, et al. Crit Care Med. 2009;37(2):666688; and
Carcillo JA, Fields AI. Crit Care Med. 2002;30(6):13651378.

Cruz AT, et al: Pediatrics 2011;127:e758e766

Implementation of Goal-Directed Therapy for
Children with Suspected Sepsis in the
Emergency Department
Utilized a computerized traige tool which corrected
heart rate for pyrexia and children falling outside the
norms were identified nurse given electronic alert
at this point nurse to consider activating the protocol
If patient appeared ill (AMS or prolonged cap refill) or
at high risk for sepsis (T>38C or <35.5C, history of
malignancy, bone marrow transplant, asplenia,
immunodeficiency or central venous catheter) the
protocol was initiated

Clinical Task

% Before
After
Implementation Implementation
(2005-2007)
(2008-2009)

MD at bedside
within 15 min

33%

63%

Antibiotics within
3h

53%

81%

Measured
lactate

10%

81%

20 ml/kg within
15 min

10%

47%

20 ml/kg within
60 min

43%

79%

P<0.05

Cruz AT, et al: Pediatrics 2011;127:e758e766

Implementation of Goal-Directed Therapy for Children
with Suspected Sepsis in the Emergency Department
Activation of protocol:
Transport team and PICU notified of potential admission
Pediatric transport team nurse, respiratory therapist, EMT could
be asked to assist in resuscitation
Patient taken to designated resuscitation area
Attending physician notified to see the patient
Graphical flow sheet documented progress of resuscitation
Preprinted order sets were created for labs and x-rays
Change in nursing culture from NS delivered via infusion pump over
an hour to rapid infuser system or manual syringe delivery

Texas Childrens Hospital, Houston TX

13

Preprinted order sets

Shock flow sheet.

Intervention

Expected Time Frame

From Protocol
Initiation

Notes

Vital-sign measurement

Supplemental oxygen; pulse oximetry;

cardiopulmonary monitoring

5 min

Measure vital signs every 15 min

Vascular ccess

No anesthetic creams used; freezing sprays can be

used

510 min

Physician notified if no access after 5 min

Strict monitoring of UOP,

fluids administered

Foley catheter if not neutropenic

From onset

Vital-sign flow sheet (Fig 1)

Fluid resuscitation

20 mL/kg (maximum: 1 L) IV up to 3 boluses; all

boluses were given push-pull or via rapid
infuser

15 min (to start of first bolus)

10 mL/kg boluses for patients with cardiac conditions, BMT

patients, and patients immediately after lung transplant

Vasoactive agents

Warm shock: norepinephrine; cold shock: dopamine

epinephrine

Order with completion of third

bolus

Low doses given via peripheral IV line

Piperacillin-tazobactam, aminoglycoside,
vancomycin

30 min

Piperacillin-tazobactam and aminoglycoside given first, at

same time via the same line

Category
Nursing

Blood pressure support

Antibiotic therapy
High risk (except asplenia)
Asplenia and
immunologically
normal hosts

Ceftriaxone, vancomycin, nafcillin

30 min

Ceftriaxone given first over 3 min, then vancomycin

Hydrocortisone 100 mg/m 2

30 min

No ACTH-stimulation testing performed

Screening aboratory tests

CBC; chemistries; liver panel; DIC panel; CRP; VBG

with lactate; consider type and screen

10 min after received by

laboratory

Sent via life-threatening laboratory system

Microbiology

Blood culture: peripheral and central (if applicable);

urine culture, rapid RSV and influenza
assays

All lumens of central lines cultured

Radiology

Portable chest radiograph

Able to be viewed in resuscitation room

At time of protocol initiation;

with completion of third
bolus

ICU charge nurse receives page with each shock-protocol

initiation

Other medications
Stress-dose steroids
Laboratory, adiographic
evaluation

Cruz A T et al. Pediatrics 2011;127:e758-e766

Page primary services; page

ICU

2011 by American Academy of Pediatrics

Cruz AT, et al: Pediatrics 2011;127:e758e766

Implementation of Goal-Directed Therapy for
Children with Suspected Sepsis in the
Emergency Department

Summary
In the ED.
Recognition use of ED protocols for septic
shock can improve compliance with
guidelines
Aggressive fluid resuscitation 60 mL/kg
Early antibiotic therapy
Caution in using etomidate ketamine may
be a better sedative
Early use of inotrope (Dopamine IV)
Monitor glucose, calcium, temperature
Early initiation of transfer of critical children

Outcomes
Time of triage to first 20 ml/kg bolus decreased from 56 to 22
minutes , p<0.001
Triage to first antibiotic decreased from 130 to 38 minutes,
p<0.001

Questions???

References

Aneja RK, Carcillo JA. Dirreferences between adult and pediatric septic
shock. Minerva Anestesiologica 2011;77:1-7.
Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, et al. Clinical
Practice Parameters for Hemodynamic Support of Pediatric and Neonatal
Septic Shock: 2007 Update from the American College of Critical Care
Medicine. Critical Care Medicine 2009;37:666-688.
Carcillo JA, et al: Mortality and functional morbidity after use of
PALS/APLS by community physicians. Pediatrics 2009;124(2):500-8.
Carvalho WB, Carlotti AP, Carmona F, Troster EJ, Bousso A, et al.
Comment on the 2007 American College of Critical Care Medicine
Clinical Guidelines for Management of Pediatric and Neonatal Septic
Shock. Critical Care Medicine 2009; 37:2324-2325.
Cruz AT, et al: Implementation of Goal-Directed Therapy for Children with
Suspected Sepsis in the Emergency Department Pediatrics
2011;127:e758-e766
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, et al. Surviving
Sepsis Campaign: International Guidelines for Management of Severe
Sepsis and Septic Shock: 2008. Critical Care Medicine 2008;36:296327.

14

References

Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS. Early Reversal
of Pediatric-neonatal Septic Shock by Community Physicians is
Associated with Improved Outcomes. Pediatrics 2003;112:793-799.
Ferrer R, Artigas A, Levy MM, Blanco J, Gonzlez-Diaz G, et al.
Improvement in Process of Care and Outcome after a Multicenter Severe
Sepsis Educational Program in Spain. JAMA 2008;299:2294-2303.
Kisson N, Orr RA, Carcillo JA: Updated American College of Critical Care
Medicine Pediatric Advanced Life Support Guidelines for Management
of Pediatric and Neonatal Septic Shock. Relevance to the Emergency
Care Clinician. Pediatric Emergency Care 2010;26;867869.
Larsen GY, Mecham N, Greenberg R: An emergency department septic
shock protocol and care guideline for children initiated at triage.
Pediatrics 2011; 127:e1585-1992
Oliveira CF, Nogueria de S FR, Oliveira DS, Gottschald AF, et al. Time
and Fluid-sensitive Resuscitation for Hemodynamic Support of Children
in Septic Shock: Barriers to the Implementation of the American College
of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a
Pediatric Intensive Care Unit in a Developing World.

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