Septic shock in children after the first hour ( Paediatric Intensive Care Unit ) - Guideline for the management of

Publication: 16/10/2019  --
Last review: 01/01/1900  
Next review: 16/10/2022  
Clinical Guideline
CURRENT 
ID: 6166 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the management of septic shock in children after the first hour
Paediatric Intensive Care Unit

  1. Aims
  2. Target group
  3. Introduction
  4. Definitions
  5. Resuscitation and initial management
  6. Approach to ongoing management
  7. Flowchart

1. Aims

To provide clear and structured guidance for the management of children with septic shock after the first hour of resuscitation who are admitted to the Paediatric Intensive Care Unit at Leeds Children’s Hospital.

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2. Target group

Medical, nursing and allied health professional staff working on the Paediatric Intensive Care Unit at Leeds Children’s Hospital.

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3. Introduction

Children with septic shock require early and aggressive management in order to optimise their survival. Mortality in children requiring PICU for septic shock is up to 25%. Children with the highest risk of poor outcome include:

  • Those between the ages of 1-12 months (around 11% mortality)
  • Those with other co-morbidities, especially children with cancer or HIV infection (12-16% mortality)
  • Those with infections in the CNS, with endocarditis, and primary bacteraemia (15-20% mortality)
  • Those with pneumococcal or fungal sepsis (15% and 13% respectively)
  • Those with multi-organ failure (mortality estimated at 0-7% for one affected organ system versus 20-50% with two or more failing systems)
  • Those on >1 vasoactive infusion

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4. Definitions

Sepsis is a clinical syndrome complicating severe infection that is characterized by systemic inflammation, immune dysregulation, microcirculatory derangements, and end organ dysfunction.

Septic shock refers to sepsis with cardiovascular dysfunction that persists despite administration of >40ml/kg fluid bolus in one hour.

Catecholamine-resistant shock is generally defined as cardiovascular dysfunction despite at least 40-60ml/kg fluid resuscitation and escalating doses of adrenaline, noradrenaline or dopamine.

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5. Resuscitation and initial management

The main components of initial management are identification of severe sepsis or septic shock, rapid clinical assessment, and rapid initiation of resuscitation. The key interventions in the initial resuscitation of children in septic shock should be according to Advanced Paediatric Life Support guidelines.
Goals in the first hour of resuscitation are to restore or maintain airway, breathing and circulation. To achieve this, the follow actions should be taken:

  • Maintain airway, oxygenation and ventilation
  • Vascular access within 5 minutes
  • Start fluid resuscitation within 30 minutes
  • Give broad spectrum antibiotics within 60 minutes
  • For children with fluid-refractory shock, start peripheral or central inotropes within 60 minutes

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6. Approach to ongoing management

Frequent reassessment is key to guiding clinical management and optimizing outcomes. In children who have responded to initial resuscitation, ongoing monitoring and antimicrobial therapy, with further treatment as needed, should continue.

In children with fluid-refractory hypotension, aggressive therapy should be targeted to therapeutic endpoints, under the guidance of a consultant in paediatric intensive care.

Priorities for the continued management of children with septic shock include:

  • Identify and treat the source of infection
  • Provide optimal respiratory support
  • Monitor tissue perfusion (capillary refill, heart rate, pulse volume, lactate, urine output, mental status)
  • Correct electrolyte and metabolic derangements

In children with fluid-refractory septic shock requiring vasopressor support, additional priorities include:

  • Invasive monitoring (central venous line, arterial line, urinary catheter)
  • Continued fluid resuscitation and vasopressor delivery
  • Administration of blood products as required
  • Treatment of adrenal insufficiency and evaluation of other potential reversible causes
  • Provision of advanced therapies when not responding to conventional therapy
For further guidance on each aspect of management please refer to the accompanying flow chart.

Flowchart

Provenance

Record: 6166
Objective:

To provide clear and structured guidance for the management of children with septic shock after the first hour of resuscitation who are admitted to the Paediatric Intensive Care Unit at Leeds Children’s Hospital.

Clinical condition:

Septic shock

Target patient group: Children
Target professional group(s): Secondary Care Nurses
Secondary Care Doctors
Allied Health Professionals
Adapted from:

With acknowledgement for the format of the flow chart to Phil Hyde, author of the Wessex Major Trauma Network Children’s Major Trauma Guidelines for Trauma Units.


Evidence base

  • Up to Date: Septic shock in children: Rapid recognition and initial resuscitation (first hour).l Topic updated 2018; literature review current to March 2019.
  • Up to Date: Septic shock in children: Ongoing management after resuscitation. Topic updated October 2017; literature review current to March 2019.
  • Advanced Paediatric Life Support: A Practical Approach to Emergencies. 6th Edition, Advanced Life Support Group 2016.
  • Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management. Clinical guideline [CG1-2] Published date: June 2010. Last updated: February 2015.

With acknowledgement for the format of the flow chart to Phil Hyde, author of the Wessex Major Trauma Network Children’s Major Trauma Guidelines for Trauma Units.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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