Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU
Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU
Clinical Goals for Initial Resuscitation
| Parameter | Comment | Target |
|---|---|---|
| Mental Status | Lethargy, confusion, and agitation can be signs of poor end-organ perfusion | Alert and appropriate for age |
| Capillary Refill | Flash capillary refill (< 1 second) can be seen in warm shock, delayed capillary refill (> 3 seconds) can be seen in cold shock | Normal capillary refill is 1-3 seconds |
| Heart Rate | Tachycardia can be a sign of hypovolemia or ongoing shock Bradycardia can be a sign of shock |
Age-related |
| Systolic Blood Pressure (SBP) | Consider invasive monitoring with arterial line (more accurate measures at extremes of blood pressure) | Age-related |
| Diastolic Blood Pressure (DBP) | Consider invasive monitoring with arterial line (more accurate measures at extremes of blood pressure) | Age-related |
| Mean Arterial Blood Pressure (MAP) | Consider invasive monitoring with arterial line (more accurate measures at extremes of blood pressure) | Age-related |
| Urine Output (UOP) | Inadequate urine output is one sign of poor end-organ perfusion. Consider placing a Foley catheter for hourly urine output monitoring. | < 30 kg: > 1 ml/kg/hr ≥ 30 kg: ≥ 30 ml/hr |
| Lactate | Elevated lactate < 4 mmol/L may be sign of shock with inadequate oxygen delivery (ref: Puskarich et al Resuscitation, 2011 ) | < 4 mmol/L or ≥ 10% decrease every 2 hours |
| Hemoglobin | Hemoglobin is a primary determinant of O2 delivery, but blood product transfusion may carry risks. A transfusion threshold of 7g/dL is reasonable in hemodynamically stable children based on available evidence. Insufficient data are available to guide RBC transfusion thresholds in children with unstable septic shock. | Hgb > 7 g/dL (after resolution of shock) |
| Central Venous Pressure (CVP) | Most accurately measured from CVL with tip at the SVC-RA junction; femoral CVL, PICC and Broviac® measurements are less reliable, but trends may be useful | If CVP is high and the patient is not responding to fluid administration, consider not administering additional fluid boluses |
| Central Venous Oxygen Saturation (ScvO2 or Venous Co-oximetry) | Most accurately measured from CVL with tip at the SVC-RA junction or long femoral line with tip near RA | ≥ 70% Note: Elevated ScvO2 (> 80%) may occur in sepsis due to "cytopathic hypoxia" despite ongoing shock |
Age-related Vital Sign Targets
| Age | Heart Rate | SBP | MAP | DBP |
|---|---|---|---|---|
| 31 days to < 1 year | 100-160 | > 65 | > 45 | > 30 |
| 1 year to < 2 years | 90-160 | > 70 | > 50 | > 35 |
| 2 to < 6 years | < 140 | > 75 | > 50 | > 40 |
| 6 to < 13 years | < 130 | > 85 | > 60 | > 45 |
| ≥ 13 years | < 110 | > 90 | > 65 | > 50 |