Sepsis — Respiratory Support — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Respiratory Support

Begin age-appropriate oxygen therapy regardless of SpO2
Indications for intubation

  • Hypoxemia or inadequate oxygen delivery
  • Left heart failure or refractory shock
  • To facilitate safety during invasive catheter placement
Initial Respiratory Assessment
  Goals
Respiratory rate
Pulse oximetry		 Normal for age
SpO2 ≥ 90%,
Work of breathing Minimal, normal
Breath sounds Normal
Gas exchange:
   Monitor ABG or noninvasive TcPCO2
SpO2 < 90%
Increased WOB
Inadequate Gas Exchange
Consider:
  • High-flow nasal cannula
  • Noninvasive positive pressure ventilation
Respiratory Reassessment
  Goals
As above plus
Venous ScvO2		  
≥ 70%
Lactate < 4 mmol/L
SpO2 < 90%
Increased WOB
Arterial pH < 7.25 ScvO2 < 70%
Consider:
  • Intubation
  • Invasive mechanical ventilation
Mechanical Ventilation Goals
SpO2 92-97%
Consider lower target in cases of
severe PARDS as clinically indicated.
Arterial pH > 7.25
ScvO2 > 70%
Lactate < 4 mmol/L
Follow: O2 Index (OI)
PaO2 / FiO2
Lung-protective Strategy
Tidal volume ≤ 8 mL/kg
PIP < 35 cm H20
FiO2 ≤ 60%
Wean FiO2 if SpO2 > 98%
Goals Not Met
Alternative Ventilator Strategies
  • Airway Pressure Release Ventilation (APRV)
  • High-frequency Oscillator (HFOV)
  • High-frequency Percussive Ventilation (VDR)

Oxygenation Index
Indicates severity of arterial blood hypoxemia given FiO2 and mean airway pressure provided

OI = FiO2 x MAP Values:
  PaO2 OI 4-8 = Mild Pediatric ARDS
    OI 8-16 = Moderate Pediatric ARDS
    OI > 16 = Severe Pediatric ARDS
http://www.medcalc.com/oxygen.html
Pa02/FiO2Ratio
Indicates severity of arterial blood hypoxemia given FiO2 only
Values: (based on Berlin definitions of ARDS)
Normal (95/.21) 452
Mild ARDS 201-300
Moderate ARDS 101-200
Severe ARDS < 100