SHOCK

FRAN BALAMUTH, MD, PhD, MSCE, DEBRA A. POTTS, MSN, RN, CPEN, CEN, MARY KATE FUNARI, MSN, RN, CPEN AND JANE LAVELLE, MD

BACKGROUND (EPIDEMIOLOGY, EVIDENCE)

Pediatric sepsis syndrome is a leading source of morbidity, mortality, and healthcare costs in infants and children in the United States. In the United States, there are approximately 21,000 cases of severe sepsis requiring hospitalization annually with estimated mortality estimates from 5% to 20%. Timely antimicrobial therapy and fluid resuscitation is essential in the treatment of severe sepsis and septic shock. The Surviving Sepsis Campaign recommends antibiotic administration within 1 hour of recognition of septic shock, as well as prompt fluid resuscitation in both adults and children. In addition, timely sepsis care has been identified as a quality metric. Several pediatric institutions have successfully implemented protocol-based sepsis care and have demonstrated associated improvements in the timeliness of care delivery. These improvements have been associated with improved ICU and hospital length of stay. Recognizing which patient requires these intensive severe sepsis therapies remains a challenge. Ideally, sepsis recognition tools should be built with high sensitivity such that no patients with sepsis are missed, they should also have high specificity to avoid unnecessary antibiotic use and resource utilization. Because of the time-sensitive nature of sepsis interventions, implementing pediatric sepsis protocols in the emergency department settings requires strong teamwork and strong interdisciplinary collaboration.

PATHWAY GOALS AND MEASUREMENTS

Goals

Improved identification of patients with severe sepsis

Timely antibiotic therapy

Timely fluid resuscitation

Decrease patients in whom sepsis is diagnosed within 24 hours of admission

Measurements

Time to fluid management (40 mL per kg, 60 mL per kg)

Time to first appropriate antibiotics, percent in <1 hour

Multisystem organ failure at 0, 24, 48 hours

Algorithm and Key Hyperlinks

See Figure 91.1 (http://www.chop.edu/clinical-pathway/severe-sepsis-clinical-pathway-infants-28-days-age-and-children)

See Tables 91.1 and 91.2

FIGURE 91.1 Pathway for evaluation and treatment of infants >28 days of age and children with severe sepsis. Pathway Authors: F Balamuth, MD; MK Funari, RN; H Scott, MD; E Alpern, MD; D Davis, MD; M Mittal, MD; C Jacobstein, MD; J Gerber, MD; T Metjian, PharmD; J Lavelle, MD.

TABLE 91.1

PATIENT POPULATION/STRATIFYING PATIENT RISKS