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
- Increased insensible loss
- High output drain loss
- Child 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 or Epinephrine
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: December 2022
Authors: G. Bird, MD; E. Schwartz, CRNP; K. Chiotos, MD; K. Pough, PharmD; S. Schachtner, MD; D. Holbein, CRNP; C. Field, RN; M. Yowell, CRNP; S. Helman, RN; S. Moran, RN
Revised: December 2022
Authors: G. Bird, MD; E. Schwartz, CRNP; K. Chiotos, MD; K. Pough, PharmD; S. Schachtner, MD; D. Holbein, CRNP; C. Field, RN; M. Yowell, CRNP; S. Helman, RN; S. Moran, RN
Evidence
- American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock
- Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children
- Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association
- Heart Failure in Pediatric Septic Shock: Utilizing Inotropic Support
- Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference
- Sepsis in Pediatric Cardiac Intensive Care