Sepsis — Adjuvant Therapies — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Adjuvant Therapies

The following additional therapies may be considered in specific case scenarios. For additional details and considerations, please reference the Surviving Sepsis Campaign Guidelines  

IVIG

Routine use of IVIG in septic pediatric patients is NOT recommended.

IVIG could be considered for patients with primary humoral immunodeficiency and/or immunocompromised with documented low IgG.

  • Administer IV or SC
  • Refer to formulary for further information on dosing
  • Immunology approval required for administration of IVIG

IVIG could also be considered for patients with toxic shock. Data are mixed, but some data from largely retrospective studies show benefit in mortality particularly in streptococcal toxic shock syndrome.

Thiamine

Routine use of thiamine for children with sepsis is NOT recommended. Off-label use of thiamine for patients with persistent lactatemia despite other therapies may be considered.

A dose of 2 mg/kg/dose (max 200 mg/dose) intravenously BID for 5-7 days has been utilized.

Plasma Exchange

If plasma exchange is considered, it has been shown the most benefit occurs when performed early (within 30 hours) after sepsis and organ dysfunction onset.

May be considered for patients with:

  • Thrombocytopenia associated multisystem organ failure (≥ 3 organ system failures) and thrombocytopenia (platelet count < 100,000)
  • Septic shock with estimated mortality > 35%
    • Mortality rates > 35% have been reported in pediatric patients with septic shock requiring:
      • > 1 vasoactive infusion
      • Invasive mechanical ventilation
      • AND at least one additional severe organ dysfunction (e.g., renal, hepatic, hematologic, neurologic)
    • Thrombocytopenia alone should not constitute the one additional severe organ dysfunction.

Oncology patients who have undergone bone marrow transplant appear to be at increased risk of mortality compared to oncology patients without bone marrow transplant. Neutropenia alone does not appear to increase the risk of mortality from septic shock. Plasma exchange should be discussed with the primary consulting service (e.g., Oncology or Immunology or Solid Organ Transplant team) for immunosuppressed patients.

Consider Diuretics or Dialysis if Fluid Overload > 10-15%

Diuresis

Evaluate % fluid overload (FO) daily:

  • % FO=(Current weight-Admission weight)/Admission weight x 100
  • Consider a trial of fluid restriction using a total fluid limit prior to diuresis, while still maximizing nutrition.

Hemodynamically stable patients with > 10-15% fluid overload, consider diuretic use:

Consult Nephrology if:

  • Patient’s creatinine doubles
  • Urine output is < 0.5 mL/kg/hour for greater than 12 hours
    (KDIGO Stage 2 AKI)
  • If no baseline creatinine available, consider twice the upper limit of normal for age as doubled creatinine.

Renal Replacement Therapies

Consider use in hemodynamically stable patients with oliguria/anuria and fluid overload unresponsive to diuretic therapy.