CICU/CCU Clinical Pathway for Children with Suspected Sepsis

High-risk Conditions
  • Cardiac
  • Infants with a single ventricle
  • Recent device/implant
  • Immune
  • Immune suppression
  • Chronic steroids
  • 22q11 deletion
  • Asplenia, Sickle Cell Disease
  • Malignancy
  • Transplant recipient
  • General
  • Central line, urinary catheter
  • Technology dependent
    • Trach, VP Shunt, G-tube
  • Age < 56 days
  • Severe developmental delay, CP
  • For occluded/malfunctioning central lines:
  • Do not delay culture/antibiotics
  • Consider peripheral IV
  • If unable to gain IV access in 30 minutes consider:
  • IM/IO
  • CVL placement
  • Cath lab assist/surgical cutdown
  • If re-occurring fever/sepsis concern:
  • Consult ID for additional interventions/recommendations

Temperature Abnormality

< 56 days T > 38° C
> 56 days T > 38.5° C
All ages T < 36° C

And 1 or more of the following:
Mental status change: Agitation, distress,
inconsolable, lethargy
Perfusion change: cool, mottled, grey
High-risk condition: See box at right.

No
Yes
Low Concern for Sepsis
High Concern for Sepsis
  • Notify:
  • Bedside RN, FLOC, CICU/CCU Attending
  • Consider antipyretic
  • Consider lab studies
  • Reassess in 1 Hour
  • Notify:
  • Bedside RN, FLOC, Charge RN, CICU/CCU Attending
Escalate Care without Delay
  • Ensure IV access
  • Obtain blood culture
    • Bedside RN or FLOC
    • Do not wait for phlebotomy
  • Administer 1st antibiotic within 60 minutes
    • Use Suspected Sepsis Order Set
    • Do not delay antibiotic administration to obtain other labs (e.g., Cx, CBC, CRP, etc.)
Risk for Hypovolemia
Low Cardiac Output
  • Polyuria, increased insensible loss
  • High output drain loss
  • Patient on 2 or more diuretics
  • Bleeding
  • Vomiting, diarrhea
  • Known cardiac dysfunction
  • Poor response to fluid resuscitation
  • Consider Normal Saline Bolus
    • 10 mL/kg bolus
    • RN/FLOC reassessment for clinical response and need for additional fluid
  • Notify: CICU Attending, CT Surgeon, Charge RN
  • Consider: 1st line vasoactive medications
    • Dopamine
    • Epinephrine
Consider Additional IV Access
CVL/CVP volume, medications
Arterial Access BP monitoring, blood samples
Refractory Shock Considerations
  • Stress dose hydrocortisone
  • Echo (fluid function check)
  • Chest X-ray (pneumothorax)
  • Pressure sensing urinary catheter (intra-abdominal hypertension)
  • VA/ECMO
Posted: July 2017
Revised: August 2019 (Reviewed), October 2019
Authors: G. Bird MD, S. Helman RN, J. Connard CRNP, L. DiFusco RN, C. Field RN, M. Gibbons CRNP, D. Holbein CRNP, L. Kohr CRNP, S. Schachtner MD, S. Boben CRNP, M. Yowell CRNP