ED Pathway for Evaluation/Treatment of Infants > 28 Days of Age and Children with Severe Sepsis

Monitor Response-MS, VS, Airway, Breathing, Perfusion

Clinical parameters to monitor response to fluid therapy

TARGETS

Age Tachycardia* RR* Systolic BP Hypotension Systolic BP 50th Percentile
1 mo to 1 yr >180 >34 <75 85-95
>1 yr - 5 yrs >140 >22 <74 88-95
>5 yrs - 12 yrs >130 >18 <83 96-106
>12 yrs - <18 yrs >110 >14 <90 108-118

* >95th percentile

Remember, heart rate is affected by pain, anxiety, medications and hydration status.

Clinical findings which suggest fluid overload

RN Documentation

q 15 minutes HR, RR, BP, oxygen saturation
q 30 minutes Mental status
Respiratory effort
Capillary refill
Quality of pulses
Skin temperature
q 60 minutes Temperature, I/O