Sepsis Severe and Sepsis Critical Care — Patient with Suspected Sepsis — Clinical Pathway: Emergency, ICU and Inpatient

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Evaluate for Signs and Symptoms Concerning for Sepsis or Infection

Use clinical suspicion to identify patients at risk for sepsis (infection with organ dysfunction). Patients with sepsis have an infection which triggers an exaggerated immune response that causes inadequate tissue perfusion leading to organ dysfunction and failure. Hypotension is a late finding. Early recognition and goal directed therapy improves patient outcomes.

Use the following clinical criteria to identify children with history or symptoms suggestive of sepsis (infection with organ dysfunction):

Temperature abnormality Fever ≥ 38.5°C or < 36°C
Heart rate abnormality See table below

PLUS AT LEAST ONE OF THE FOLLOWING:

Mental status abnormality

Anxiety, restlessness, agitation, irritability, inappropriate crying
Drowsiness, confusion, lethargy, obtundation
Perfusion abnormality Cool extremities, delayed capillary refill (> 3 seconds), diminished pulses, mottling or
flushed, warm extremities, bounding pulses, flash capillary refill (< 1 second)
Hypotension See table below
Respiratory rate See table below
Urine output Urine output of < 0.5 mL/kg/hour

Other factors may also aid in identification of patients with organ dysfunction or who are at high risk for sepsis:

Existing laboratory findings

Metabolic acidosis, elevated lactate, thrombocytopenia, coagulopathy, or elevated creatinine
Other factors Other physical exam findings, including petechial and/or purpuric rash or erythroderma
High-risk conditions
  • < 56 days of age
  • Central line presence
  • Immunocompromised (BMT, solid organ transplant, malignancy, asplenia/sickle cell disease)
  • Pre-existing neurologic dysfunction that limits mental status evaluation (conditions that alter levels of consciousness)
Age Respiratory rate (per minute) Tachycardia Systolic BP Diastolic BP
1 month - 1 year 65 > 180 < 75 < 30
2 - 5 years 60 > 140 < 74 < 35
6 - 12 years 30 > 130 < 83 < 45
13 - 18 years 30 > 120 < 90 < 50

Remember, heart rate is affected by pain, anxiety, medications and hydration status.
Goldstein B. Pediatr Crit Care Med, 2005;6