Sepsis Clinical Pathway – Emergency Department, Inpatient and PICU

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Provider Resources

Related Pathways

Infants and Children with Suspected Sepsis

Identification of Signs and Symptoms Concerning for Sepsis/Septic Shock by Physical Assessment
or
EHR Alert by Care Area

ED Alert

Inpatient Alert

ICU Alert

Sepsis Huddle
Focused H&P
Identify Evidence of Shock or
Sepsis-associated Organ Dysfunction

Signs and Symptoms
Concerning for Septic Shock

Fever, Temp < 36 °C, or concern for infection
Tachycardia
Altered Mental Status
- Lethargy, obtundation, agitation
Hypotension or perfusion abnormality
- Diminished pulses, delayed/flash capillary refill, oliguria
Tachypnea
Skin
- Petechial and/or purpuric rash or erythroderma

Green Zone: Low Suspicion for Sepsis

Suspected infection or non-infectious syndrome, no clinical shock or concern for sepsis-associated organ dysfunction.

If antibiotics indicated, see antibiotic choices for suspected bacterial infections in the PICU

Yellow Zone: Sepsis Watcher Suspected Infection, No Shock
Evaluation	Expedited work-up for infection, organ dysfunction within 180 min of sepsis alert Consider IV Access Laboratory Considerations
Treatment	Initial IVF NS or LR 10-20 mL/kg as indicated Antibiotic Recommendations — Yellow Zone Aim to administer antibiotics within 180 min of sepsis alert if concern for infection persists For children with SCD: Aim to administer antibiotics within 60 min of arrival or sepsis alert
Reassessment	Assess mental status, WOB, perfusion, and vital signs every 30 min for 1 hr Monitor Response, Vital Sign Targets

Red Zone: Septic Shock or Sepsis Associated Organ Dysfunction
Evaluation	Expedited work-up for infection, organ dysfunction Immediate IV Access, IV Escalation Plan Recommended Labs
Treatment	Initial IVF NS or LR 10-20 mL/kg as indicated Antibiotic Recommendations — Red Zone Give antibiotics within 60 min of sepsis alert
Reassessment	Assess mental status, WOB, perfusion, and vital signs every 15 min Monitor Response, Vital Sign Targets

Clinical Goals Met
Consider care de-escalation

Fluid Choice and Blood Products

Respiratory Support

Intubation and Sedation Medications

Serial Laboratory Monitoring

Adjuvant Therapies
IVIG, Plasma Exchange, Diuresis, RRT

Immunocompromised Patients

Nutrition, PICU/PCU, Initiation and Advancement Pathway

Monitor Response and
Vital Sign Targets

Repeat
10-20 mL/kg boluses

Escalation
ICU, CAT or CODE

H&P to Identify Source of Infection

Correct
hypoglycemia, hypocalcemia

Fluid Refractory Shock

Assess Cardiac Function if available

Do not delay initiation of vasoactive therapy

Initiate First-line Vasoactive
Titrate epinephrine, norepinephrine
Consider CVL, Arterial line, Foley

ICU Management

Catecholamine Resistant Shock

Consider Stress Dose Hydrocortisone
Evaluate for:
- Pericardial effusion
- Pneumothorax
- Intra-abdominal hypertension
- Primary cardiac dysfunction
Consider ETT
Consider ECMO

Posted: May 2022
Last Revised: October 2024

Authors:
- MK. Abbadessa, ACCNS-P;
- H. Stinson, MD;
- J. Fitzgerald, MD;
- K. Chiotos, MD;
- F. Balamuth, MD;
- S. Weiss, MD;
- B. Ku, MD;
- J. Lavelle, MD;
- B. Pagliaro, RN;
- H. Dashefsky, RN;
- J. Jacob-freese, RN;
- E. Shelov, MD;
- C. Moore, MSN;
- B. Blowey, PharmD;
- L. Goldstein, MD;
- J. Hemberger, MD;
- E. Vorel, MD

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Emergency Department, PICU, and Inpatient Clinical Pathway for Infants > 28 Days and Children with Suspected Sepsis, Sepsis and Septic Shock

Evidence