sepsis - paediatric high risk sepsis
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Sepsis - Paediatric High Risk Sepsis
High Risk Sepsis (P Dykes, SAG) Page 1 of 18 January 2021
Title of Guideline Guideline for the Identification & Management of Children and Young People with High Risk Sepsis
Contact Name and Job Title Philip Dykes, Paediatric Emergency Department Consultant Laura Ashmore, Paediatric Consultant
Directorate & Speciality Medicine & Family Health – Paediatrics
Date of submission February 2021 Date when guideline reviewed November 2024 Guideline Number 1969 – Version 7 Explicit definition of patient group
to which it applies (e.g. inclusion and exclusion criteria, diagnosis)
Children and young people with sepsis
Abstract Identification and Management of children with high risk sepsis
Key Words Paediatrics, Children, Sepsis Statement of the evidence base of the guideline – has the guideline been peer reviewed
by colleagues? 1a Meta analysis of randomised controlled
trials X
2a at least one well -designed controlled study without randomisation
X
2b at least one other type of well -designed
quasi-experimental study
3 well –designed non-experimental descriptive studies (ie comparative /
correlation and case studies)
4 expert committee reports or opinions and / or clinical experiences of respected
authorities
5 recommended best practise based on the
clinical experience of the guideline developer
x
Consultation Process Consultants at Nottingham Children’s Hospital Members of the Sepsis Action Group; Andrew Wignell (Paediatric Pharmacist)
Target audience Staff at the Nottingham Children’s Hospital
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Statement of Compliance with Child Health Guidelines SOP
This guideline has been updated and approved by the Sepsis Action Group with minor amendment for this version only. A previous version has been approved following circulation to senior staff of the Children’s Hospital.
Maria Moran, Clinical Guideline Lead
1 March 2021
High Risk Sepsis (P Dykes, SAG) Page 3 of 18 January 2021
Document Control
Document Amendment Record
New Version 7 Changes:
Inclusion of defined timeframe as per NICE Guidelines (2016) during which “fails to improve”
should be measured (1hour)
Version Issue Date Author V1 April 2010
Kerry Webb, PICU Sister Dr Asrar Rashid, PICU Consultant
V2 July 2015 Catarina Silvestre, PICU Consultant Prof. Harish Vyas, PICU Consultant
V3 Aug 2016 Catarina Silvestre, PICU Consultant Prof. Harish Vyas, PICU Consultant
V4 Feb 2018 Catarina Silvestre, PICU Consultant
V5 Sept 2018 Catarina Silvestre, PICU Consultant Salma Ali, Senior Paediatric Trainee
V6 Nov 2019 Philip Dykes, PED Consultant
V7 Feb 2021 Sepsis Action Group (Dr L Ashmore Paeds Consultant, S Smith Paeds ED Consultant, N Taylor, PCCOT Sister)
SEPSIS FLOW CHART
Child screens positive for suspected sepsis
Suspected or proven infection
URGENT medical review + consider risk factors
Child NOT septic
Consider alternative
diagnosis
Rationale documented
Re-evaluate &
reconsider diagnosis
with URGENT senior
review if not
improving or
deteriorates
Discharge advice
leaflet if discharged
Child septic
Initiate sepsis bundle WITHIN 1 hour
AND Obtain SENIOR REVIEW (ST4+)
1. Apply O2
2. IV access & bloods incl. cultures
3. Lactate from VBG or Cap gas
4. IV antibiotics
5. IV fluid resuscitation/bolus
6. Monitor urine output
If no improvement within 60mins/further
deterioration/clinical concern OR if
given 30ml/kg fluid INVOLVE PCCU
NB If given 40ml/kg fluid
consider inotropes
High Risk Sepsis (P Dykes, SAG) Page 4 of 18 January 2021
INTRODUCTION
Sepsis is a dysregulated host response to infection in which there is an overwhelming
inflammatory reaction and microcirculatory derangement, resulting in organ dysfunction and
septic shock. The paediatric sepsis syndrome is a common cause of morbidity and mortality
worldwide with an estimated annual mortality of 1.6 million, with respiratory infections being
the leading cause especially in the under 5 years of age. It is estimated that over one-third of
children who die in PCCU, with sepsis, will have chronic co-morbidities. Early recognition of
sepsis, followed by aggressive treatment is the key to success.
The current definition of paediatric sepsis has been derived from the surviving sepsis
campaign international guidelines published in 2013 which includes presence of a systemic
inflammatory response (SIR) with suspected infection. Severe sepsis is associated with end
organ dysfunction and shock with cardiovascular failure with inadequate response to fluid
resuscitation.
In 2016, NICE introduced national recommendations based on physiological criteria to
identify early classification of sepsis. The term severe sepsis is now High risk sepsis.
https://www.nice.org.uk/guidance
High Risk Sepsis (P Dykes, SAG) Page 5 of 18 January 2021
SCREENING
At NUH children are automatically screened electronically via Nervecentre for possible
sepsis using criteria from NICE (guideline NG51, Sepsis: recognition, diagnosis and early
management). These are specific to each age group. It does not, however, take into
consideration the various environmental or external factors that may impact upon a child’s
observations. It is the clinician’s responsibility to correlate the observations with other clinical
findings.
The electronic screening to identify potential sepsis at NUH adheres entirely to NICE
Guidelines for High Risk Sepsis. Like many other Trusts in the UK, NUH enable clinical
decision making to support interpretation of the guidance, for example recognising that other
causes of tachycardia in children exist. The rationale for this is the high number of otherwise
well children that would trigger for sepsis and thus undergo invasive investigations and
receive antibiotics that they may otherwise not require.
RECOGNITION OF HIGH RISK SEPSIS
Certain patient groups are at higher risk of developing sepsis. These children need a
thorough review and careful consideration that they may have sepsis. If in doubt seek a
senior opinion (ST4+).
RISK FACTORS
Prematurity
Aged under 3 months
Maternal group B streptococcus infection
Prolonged rupture of membranes (>24 hours prior to delivery)
Chronic illness
Complex needs incl. Downs Syndrome (see Downs Syndrome Guideline)
Immunocompromised i.e. Oncology patients undergoing chemotherapy
Recent surgery
Indwelling central line incl. PICC lines, Portacath, Hickman lines
Recent chemotherapy
High Risk Sepsis (P Dykes, SAG) Page 6 of 18 January 2021
If the child has a suspected or proven infection and any of the following high risk criteria then
they MAY HAVE HIGH RISK SEPSIS
This is a MEDICAL EMERGENCY
HIGH RISK SEPSIS CRITERIA
∞ Temperature < 36.0oC or, if under 3 months < 36.0oC or ≥ 38.0oC
∞ Increased respiratory rate (according to age group)
∞ New O2 requirement to keep SpO2 >90% or increased oxygen requirement over baseline
∞ Tachycardia (according to the age group) not explained by any other
cause e.g. distress, pain, fever, medication
∞ Bradycardia
∞ Hypotension (according to age)
∞ Prolonged capillary refill time
∞ Not behaving normally: lethargy, sleepy, floppy, weak and high pitched
cry, confusion
∞ Not passing urine in the last 18 hours
∞ Non-blanching rash, mottled, ashen or cyanosis (see non-blanching
rash guidelines)
∞ Irritability, not feeding, bulging fontanelle (meningitis guidelines)
∞ Lactate >2 mmol/L
Tachycardia is a feature within the NICE criteria for identifying sepsis. Children can be
tachycardic for a variety of different reasons. They may be in pain, be scared or distressed
by being in an unfamiliar setting. Certain medications have a positive chronotropic effect
upon the heart e.g. Salbutamol and thus induce tachycardia.
It is widely recognised that fever itself can cause children to become tachycardic - a
phenomenon known as Liebermeisters rule in adults (but also proven locally in children) - an
increase of 8-10 beats per minute for every 1 degree increase in core temperature.
High Risk Sepsis (P Dykes, SAG) Page 7 of 18 January 2021
Tachycardia out of proportion indicates that a patient’s heart rate is higher than would
otherwise be expected for the degree of fever. For example a 5 year old with a fever of 39ºC
and a heart rate of 185 would be out of proportion.
Persistent tachycardia is a RED FLAG - Tachycardia that persists once a fever has settled
with antipyretics and other causes excluded is also concerning for potential sepsis.
If a patient has a persistent tachycardia or a tachycardia out of proportion to fever and/or has
a prolonged capillary refill then a further blood pressure should be obtained.
If the patient has a suspected or proven infection and any of the High Risk Criteria for sepsis,
Urgent Senior Review (ST4+ or Consultant) is required.
As part of the review consideration will be given to alternative medical diagnoses.
SEPSIS MIMICS
A variety of conditions can mimic the symptoms of sepsis and must be considered as part of
the senior review of the child. These include, but are not limited to, bronchiolitis, viral induced
wheeze, asthma and DKA.
During the winter months, more than half the population of children in emergency
departments present with runny noses due to viral infections, would satisfy the present
criteria for sepsis and so many will often ‘trigger for sepsis’ on Nervecentre screening.
If following senior review the decision is not to treat the child for sepsis, despite meeting
criteria, then the rationale MUST BE DOCUMENTED IN THE MEDICAL NOTES.
Remember, even if at the initial senior (ST4+) review the child is deemed not to have sepsis
that it should be reconsidered if the child deteriorates.
DISCHARGE ADVICE
If a child is deemed suitable for discharge and has an infection then the caregiver(s) must be
given safety net advice with regards to the symptoms and signs of sepsis in children. A
leaflet is available that explains this (see appendix). Any discussion must be documented in
the medical notes.
High Risk Sepsis (P Dykes, SAG) Page 8 of 18 January 2021
If sepsis is suspected then START SEPSIS RESUSCITATION BUNDLE
SEPSIS RESUSCITATION BUNDLE
Complete within the FIRST hour of the diagnosis of high risk sepsis
1. Oxygen
∞ Administered by non-rebreathe face mask or high flow oxygen regardless the oxygen
saturation
∞ Titrate oxygen to maintain saturations between 94-97% (or as prescribed) when
stable
2. Bloods/ IV access
∞ Peripheral cannula or intraosseous (IO) access should be gained.
∞ Blood cultures - two samples from different sites.
∞ FBC, UE, clotting screen, blood glucose, CRP
∞ Blood gas including lactate. >2 is concerning, >4 is significant and warrants fluid
resuscitation as below
3. Antibiotics
∞ Prescribe the first dose of antibiotics on the front of the drug chart.
∞ Blood cultures (x2) should be obtained ideally before administration of antibiotics.
∞ Empiric antibiotics must be given within 1 hour of identification of sepsis (table
below)
∞ Do not delay the administration of antibiotics if blood cultures impossible to obtain.
∞ Subsequent antibiotics should be prescribed according to the BNFc and/or local
guidelines. In community-acquired sepsis of unclear focus, follow the meningitis
guideline.
High Risk Sepsis (P Dykes, SAG) Page 9 of 18 January 2021
INITIAL ANTIBIOTICS FOR THOSE WITH HIGH RISK SEPSIS
Initial antibiotic treatment should be prescribed on the “once only” section of the prescription
chart and ask for them to be given immediately. If severe allergy to penicillin
(anaphylaxis, angioedema or immediate-onset urticaria), contact microbiology for
advice.
Please note Piperacillin tazobactam is a penicillin. Check allergy status.
None severe penicillin allergy definition: mild rash alone, with no anaphylactic
symptoms, angioedema or immediate-onset urticarial. Contact microbiology if severe
penicillin allergy.
*Do not use Ceftriaxone with calcium containing infusions or parenteral nutrition, instead use
Cefotaxime 50mg/kg max 3g. If patient is to require inotropes then patient is likely to require
calcium containing infusions. Though it is noted that at this point you may not know if entry to
PICU will be necessary.
High Risk Sepsis (P Dykes, SAG) Page 10 of 18 January 2021
Neonates until
3 months
Amoxicillin IV (dosing is based on chronological age for amoxicillin and cefotaxime)
Under 28 days:100mg/kg
Over 28 days:50mg/kg
PLUS Cefotaxime IV 50mg/kg
PLUS Gentamicin IV (see gentamicin guideline)
Use corrected gestational age, i.e. gestational age at birth (e.g. 33/40) plus current age in weeks (e.g. 7 weeks old). In this example the child would be 40 (33 + 7) weeks corrected.
If under 44 weeks corrected gestational age: 4mg/kg
If over 44 weeks corrected gestational age: 7mg/kg
PLUS Aciclovir IV 20mg/kg (if <14 days old) (consider on a case by case basis for 15-28 days)
Beyond 3 months
Unknown source Ceftriaxone IV 100mg/kg max 4g* PLUS if septic shock or blood pressure fails to respond to initial fluid bolus give a single dose of Gentamicin IV (see gent guideline)
Meningitis (refer to guideline) Ceftriaxone IV 100mg/kg max 4g*
Abdominal sepsis Ceftriaxone IV 50mg/kg max 2g*
PLUS Metronidazole IV 7.5mg/kg max 500mg PLUS Gentamicin IV (see gent guideline)
Urinary sepsis Ceftriaxone IV 50mg/kg max 2g*
PLUS if septic shock or blood pressure fails to respond to initial fluid bolus give a single dose of Gentamicin IV (see gent guideline)
Pulmonary sepsis Ceftriaxone IV 50mg/kg max 2g*
PLUS Clarithromycin IV: Under 12 years: 7.5mg/kg max 500mg Over 12 years: 500mg
*Do not use Ceftriaxone with calcium containing infusions or parenteral nutrition, instead use Cefotaxime 50mg/kg max 3g. If patient is to require inotropes then patient is likely to require calcium containing infusions. Though it is noted that at this point you may not know if entry to PICU will be necessary.
High Risk Sepsis (P Dykes, SAG) Page 11 of 18 January 2021
Further guidance on specific situations in ANY age group
Immunocompromised Piperacillin Tazobactam IV Under 12 years: 90mg/kg max 4.5g Over 12 years: 4.5g
Non-severe penicillin allergy: Meropenem IV (refer to BNFc for dose)
PLUS if septic shock or blood pressure fails to respond to initial fluid bolus give a single dose Gentamicin IV (see gent guideline)
Neutropenic sepsis Piperacillin Tazobactam IV
Under 12 years: 90mg/kg max 4.5g Over 12 years: 4.5g
Non-severe penicillin allergy: Meropenem IV (refer to BNFc for dose)
PLUS Gentamicin IV (see gent guideline)
Hospital acquired sepsis
Piperacillin Tazobactam IV Under 12 years: 90mg/kg max 4.5g Over 12 years 4.5g
Non- severe penicillin allergy: Meropenem IV (refer to BNFc for dose)
PLUS if failing to respond give single dose Gentamicin IV (see gent guideline)
Line sepsis Piperacillin Tazobactam IV
Under 12 years: 90mg/kg max 4.5g Over 12 years: 4.5g
Non- severe penicillin allergy: Meropenem IV (refer to BNFc for dose)
PLUS Vancomycin IV (see vancomycin guideline) PLUS if septic shock or blood pressure fails to respond to initial fluid bolus give a single dose of Gentamicin IV (see gent guideline)
Toxic shock syndrome (TSS) with refractory hypotension
Ceftriaxone IV 100mg/kg max 4g* PLUS Clindamycin IV 10mg/kg max 1.2g
Note subsequent dosing frequency varies with age, see TSS guidelines
*Do not use Ceftriaxone with calcium containing infusions or parenteral nutrition, instead use Cefotaxime 50mg/kg max 3g. If patient is to require inotropes then patient is likely to require calcium containing infusions. Though it is noted that at this point you may not know if entry to PICU will be necessary.
High Risk Sepsis (P Dykes, SAG) Page 12 of 18 January 2021
4. Fluid resuscitation:
∞ If tachycardia as described above, hypotensive or lactate >4 on venous gas GIVE 10
ml/ kg of isotonic fluid (PlasmaLyte 148 or 0.9 % saline); repeat fluid bolus if transient
haemodynamic response
∞ After 30ml/Kg CONTACT PCCU
∞ Once 40ml/kg given inotropic support may be required
1. Monitoring
∞ Ensure that a fluid balance chart is initiated
∞ Consider urinary catheter
∞ Aim for Urine output >0.5 ml/kg/hr
Senior help (ST4+) MUST be obtained should the child be
deemed to have sepsis
A Consultant must be informed if no response seen within
60 minutes. Contact PCCU if the child deteriorates, does
not show signs of improvement or there is ongoing clinical
concern.
High Risk Sepsis (P Dykes, SAG) Page 13 of 18 January 2021
REFERENCES:
2. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE,
Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR,
Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD,
Webb S, Beale RJ, Vincent JL, Moreno R. Surviving Sepsis Campaign: international
guidelines for management of severe sepsis and septic shock, 2012. Intensive Care
Med. 2013 Feb;39(2):165-228
3. Myburgh J, Mythen M. Resuscitation Fluids N Engl Med. 2013; 36913: 1243-
51Overgaard C, Dzavik V, Inotropes and Vasopressors: Review of physiology and
Clinic Use in Cardiovascular Disease. Circulation. 2008: 118:1047-56.
4. ProCESS Investigators. A randomized trial of Protocol Based Care for early Septic
Shock. N Engl J Med.2014: 370 (8):1683-93.
5. ARISE Investigators, ANZICS Clinical Trial Group. Goal-Directed Resuscitation for
Patients with Early Septic Shock. N Engl J Med. 2014: 371 (16): 1496-1506.
6. TRISS trial Group, Scandinavian Critical Care Trials Group. Lower versus
haemoglobin Threshold for Transfusion in Septic Shock. N Engl J Med. 2014: 371
(15):1381-91.
7. Joosten A, Brenton A, Cannesson M. Defining Goals of resuscitation in Critically ill
Patient. Crit Care Clin. 2015: 31: 113-132.
8. Pomerantz W, Weiss S. Systemic inflammatory response syndrome (SIRS) and
sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis.
Uptodate.
9. Pomerantz W, Weiss. Septic shock: Rapid recognition and initial resuscitation in
children. Uptodate.
10. https://www.nice.org.uk/guidance
11. Schlapbach L J. Defining Pediatric Sepsis. JAMA Pediatr. 2018;172(4):313-314.
12. Davies P, Maconochie I. The relationship between body temperature, heart rate and
respiratory rate in children Emerg Med J. 2009 Sep;26(9):641-3
High Risk Sepsis (P Dykes, SAG) Page 14 of 18 January 2021
NICE HIGH RISK SEPSIS TRIGGERS
Greater than 144months = 12 years and over
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 130 /min
E-obs BP ( Systolic) ≤90
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs Inspired 02 ≥10 litres ≥40%
E-obs RR ≥25
E-obs Colour Grey Cyanosed
E-Obs Non blanching rash
Yes
E-Obs Urine output Has not passed urine in last 18 hours
Greater than 96 months -144 months = 8-11 years
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 115 /min <60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR ≥25
E-obs Colour Grey Cyanosed
E-Obs Non blanching rash
Yes
High Risk Sepsis (P Dykes, SAG) Page 15 of 18 January 2021
Greater than 72months -96 months = 6 -7 years
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 120 / min
<60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR ≥ 27
E-obs Colour Grey Cyanosed
E-Obs Non blanching rash
Yes
Greater than 60 months – 72 months = 5 years
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 130 / min
<60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR ≥ 29
E-obs Colour Grey Cyanosed
E-Obs Non blanching rash
Yes
High Risk Sepsis (P Dykes, SAG) Page 16 of 18 January 2021
Greater than 36 months – 60 months = 3-4 years
Source Parameter Values Values Values Values
E-obs Heart rate ≥140 / min
<60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR ≥ 40
E-obs Work of breathing
Moderate effort
Severe effort
E-obs Colour Grey Cyanosed
E-obs temperature <36
E-Obs Non blanching rash
Yes
Greater than 12 months – 36 months = 1-2 years
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 150 / min
<60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR ≥ 50
E-obs Work of breathing
Moderate effort
Severe effort
E-obs Colour Grey Cyanosed
E-obs temperature <36
E-Obs Non blanching rash
Yes
High Risk Sepsis (P Dykes, SAG) Page 17 of 18 January 2021
3 months - 12 months = 3 months - 1year
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 160 / min
<60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR ≥ 60
E-obs Work of breathing
Moderate effort
Severe effort
E-obs Colour Grey Cyanosed
E-obs temperature <36
E-Obs Non blanching rash
Yes
Less than 3 months
Source Parameter Values Values Values Values
E-obs Heart rate ≥ 160 / min <60
E-obs AVPU Responds to Voice
Responds to Pain
Unresponsive
E-obs Behaviour Lethargy Not responding normally
Unable to stay awake If roused
Unable to rouse
E-obs RR > 60
E-obs Work of breathing
Moderate effort
Severe effort
E-obs Colour Grey Cyanosed
E-obs temperature
<36 ≥38
E-Obs Non blanching rash
Yes
High Risk Sepsis (P Dykes, SAG) Page 18 of 18 January 2021
Appendix 1 Details of amendments made to this guideline: Version 2 incorporated changes recommended by Surviving Sepsis Campaign (2012) which included:
1. Use of high flow oxygen 2. Blood cultures and lactate monitoring 3. Judicious use of fluid bolus 4. Early use of inotrope 5. Monitoring Urine output 6. EARLY ADMINISTRATION OF ANTIBIOTICS
Version 4 key changes: - Use of peripheral adrenaline - Gentamicin prescription – includes suggested iv gentamicin doses by age
New Version 5 changes: - Updated to incorporate recent NICE guidance including terminology and recognition - Clarification of antibiotic dosing in line with other trust guidance - Note: April 2019 – updated Ceftriaxone dosing to 100mg/kg iv
New Version 6 Changes:
Key title, abstract and full title of guideline changed
Removal of SIRS criteria Removal of warm and cold shock definitions
Update high risk features
Update high risk criteria
How we screen for sepsis Why we do not strictly follow NICE guidelines
Statement on tachycardia
Sepsis mimics
Need to document why the clinician doesn’t think the child has sepsis Need to document discharge advice Including leaflet provision
Altering antibiotic table
Removal of treatments that are PICU focused NICE screening criteria for sepsis
Removal of joint ED & PICU sepsis flow chart
Addition of Sepsis flow chart
Addition of Sepsis poster Addition of infection discharge leaflet
New Version 7 Changes: Inclusion of defined timeframe as per NICE Guidelines (2016) during which “fails to improve” should be measured
(1hour)
Appendix 2
Appendix 3: Paediatric Safety – netting leaflet – available on the internet and internet.
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