Sepsis — Signs and Symptoms — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Signs and Symptoms Concerning for Sepsis and Septic Shock

Use clinical suspicion to identify patients with sepsis (infection with organ dysfunction) and septic shock (infection with cardiovascular organ dysfunction). Sepsis is a clinical syndrome in which an infection triggers an exaggerated immune response leading to inadequate tissue perfusion, organ dysfunction, and organ failure. Hypotension is a late finding. Early recognition and goal directed therapy improves patient outcomes.

The Following Clinical Criteria May Be Suggestive of Sepsis or Septic Shock

Temperature Abnormality Fever, hypothermia (< 36 °C)
Normothermia with concern for infection may also be suggestive of sepsis or septic shock
Heart Rate Abnormality See table below

PLUS, Any of the Following

Mental Status Abnormality
  • Anxiety, restlessness, agitation, irritability, inappropriate crying
  • Drowsiness, confusion, lethargy, obtundation
Perfusion Abnormality
  • Cool extremities, mottling, delayed capillary refill (> 3 sec), diminished pulses
  • Warm extremities, flushed, flash capillary refill (< 1 sec), bounding pulses
  • Urine output of < 0.5 mL/kg/hr
Hypotension See table below
Tachypnea See table below

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
  • < 60 days of age
  • Presence of a central line
  • Immunocompromised (e.g., Stem cell transplant, solid organ transplant, malignancy, asplenia/sickle cell disease, immunodeficiency, immunosuppressive medications)
  • Pre-existing neurologic dysfunction that limits mental status evaluation
  • Conditions that alter level of consciousness

Suggested Reference Values for Identifying Age-Based Vital Sign Abnormalities

Age Tachycardia
(beats per minute)		 Systolic BP
(mmHg)		 Diastolic BP
(mmHg)		 Tachypnea
(breaths per min)
1 month - 1 year > 180 < 75 < 30 > 65
2 - 5 years > 140 < 74 < 35 > 60
6 - 12 years > 130 < 83 < 45 > 30
13 - 18 years > 120 < 90 < 50 > 30
Vital signs cut offs and integration of heart rate parameters in Sepsis EHR Alerts may vary by patient location.
Remember, heart rate may be affected by pain, anxiety, medications and hydration status.

References

  • Goldstein B. Pediatr Crit Care Med, 2005;6
  • Gebara BM. Values for systolic blood pressure. Pediatr Crit Care Med 2005; 6:500
  • Bonafide CP et al. Development of Heart and Respiratory Rate Percentile Curves for Hospitalized Children. Pediatrics 2013; 131 (4): e150-e1157

Sepsis EHR Alert