An Emergency Department Septic Shock Protocol and Care Guideline for Children Initiated at Triage

Larsen, Gitte; Mecham, Nancy; Greenberg, Richard A.

doi:10.1542/peds.2010-3513

Cited by 187 publications

(165 citation statements)

References 18 publications

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“…However, there are many barriers to guideline adoption beyond lack of resources, including the perception of restriction of autonomy, biases, lack of familiarity and awareness, lack of outcome expectancy and lack of motivation (20). Our findings are consistent with several studies from the United States of America (USA) showing that even in resource-rich centres, adherence to sepsis guidelines is not achieved for many patients despite a concerted effort by a dedicated team (16,17,21). Together, these data suggest that addressing cultural barriers such as knowledge, behaviour and attitude, in addition to ensuring adequate training and resources, should be key considerations for improving sepsis care.…”

Section: Discussionsupporting

confidence: 85%

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Systems for Pediatric Sepsis: A Global Survey

et al. 2014

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Section: Discussionsupporting

confidence: 85%

“…Specific programmes designed to improve triage processes and sepsis recognition and adherence to goal-directed care have improved outcomes at individual institutions in both resource rich and poor environments (14)(15)(16)(17). At a global level, however, priority areas for research and intervention have not been systematically described.…”

Section: Introductionmentioning

confidence: 99%

Systems for Pediatric Sepsis: A Global Survey

et al. 2014

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“…Rapid administration of saline bolus volumes that approximate the patient's entire intravascular volume has not been uniformly successful and mortality in septic shock has not been dramatically reduced [4]. A recent meta-analysis on the association of fluid balance and outcomes in critically ill children demonstrated a 6 percent increase in the odds of mortality for every 1% increase in fluid overload [5].…”

Section: Commentarymentioning

confidence: 99%

The On-going Challenge of Pediatric Septic Shock: Optimizing Early Identification and Accurate Resuscitation

Fisher¹

2018

J Intensive Crit Care

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CommentaryShock in the pediatric emergency department is frequently a diagnostic and therapeutic challenge. The child arrives in an undifferentiated manner and there can be dramatic clinical overlap between a variety of pathophysiologic states, caused by conditions ranging from immediately life-threatening to relatively innocuous. As a member of a small group of young pediatric emergency physicians in the 1990's, our group initiated an observational study to examine our performance utilizing standard pediatric advanced life support measures [1]. We strove to identify patients early and initiate rapid but measured fluid replacement, as well as clinically indicated vasopressor administration and antibiotics. Our patients received an average of 58 ml/kg of fluid over the course of a 4-5 h ED course. During the 8 year period of data collection, septic shock represented 57% of our cases. Hypovolemic shock, distributive and cardiogenic shock contributed 24%, 14% and 5% respectively. Our mortality was 6% overall and 5% in patients with septic shock and an identified pathogen.As we accumulated our data, early goal directed therapy and the surviving sepsis campaign began, and with it came an even more aggressive fluid resuscitation strategy. Children were to be treated with 60 ml/kg of crystalloid over the course of 30 to 60 min [2]. Given that a child's intravascular volume is 80 ml/kg, our group was hesitant with these recommendations-we had seen first-hand the potential complications of this therapy, specifically acute respiratory failure in the ED requiring emergent intubation and mechanical ventilation. One such patient enrolled late in the study period, after the Surviving Sepsis campaign had been widely disseminated and impacted our practice, is vividly recalled. This was a two month old female presented with fever for three day. The child demonstrated tachycardia, but was awake and alert with normal oxygen saturation. Pyelonephritis was quickly diagnosed. Her pulses were initially palpable, but after an initial 20 ml/kg bolus of saline and ceftriaxone administration, her extremities were cold, mottled and she had pulses that were barely palpable. Was this just transient endotoxin release that would resolve with time or did it represent dissemination of infection and worsening capillary leak? Following peripheral pulses, breath sounds and liver edge as a guide to therapy, 40 ml per kg of saline was rapidly administered. The patient developed grunting, laboured respirations and increasing oxygen requirement. The decision to initiate mechanical ventilation was made. Laryngoscopy was difficult, and the patient's decreased residual capacity and alveolar capillary leak lead to rapid oxygen desaturation. The patient was successfully intubated on the third attempt with transient bradycardia but without the need for chest compressions. The child remained intubated for a week but survived. Did we overshoot this child's resuscitative requirements, or was the respiratory failure and difficult intubation inevitable?Because of...

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“…Recognition of the possibility of septic shock as a cause of symptoms in a particular child is fundamental to the management of septic shock as the earlier therapy is initiated, the better the outcome is likely to be [12,17,18]. Different age groups are characterized by different organisms and pathophysiological mechanisms.…”

Section: Recognitionmentioning

confidence: 99%

“…Recently Larsen et al [17] implemented a protocol for the recognition and management of septic shock in their emergency department. Over a 5-year period, they identified 297 children who met septic shock criteria.…”

Section: Adherence To Bundlesmentioning

confidence: 99%

What’s New in the Recognition and Management of Septic Shock in Children: Dos and Don'ts

Argent

2013

Curr Pediatr Rep

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While there has been a reduction in the number of children dying of septic shock in the richer countries of the world, septic shock remains an important cause of both mortality and morbidity for children across the world. Major reduction in the incidence of septic shock will depend on the implementation of public health measures, including immunization. Improvements in outcome of pediatric septic shock have been closely linked to early recognition (although this may be challenging in many situations); early antibiotic administration; early and appropriate fluid administration and subsequent escalation of critical care. A particular challenge has been the development and implementation of systems to ensure that these elements of management are reliably and efficiently implemented in children (even in well-resourced countries). Recent studies have highlighted the complexity of caring for patients with acute severe sepsis and septic shock in countries with fewer resources, and there is an urgent need for further studies to elucidate the implications of these studies for the management of children with septic shock, particularly in settings where additional critical care support such as inotropic or ventilator support may not be readily available.

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An Emergency Department Septic Shock Protocol and Care Guideline for Children Initiated at Triage

Abstract: Implementation of an ED septic shock protocol and care guideline improved compliance in delivery of rapid, aggressive fluid resuscitation and early antibiotic and oxygen administration and was associated with decreased length of stay.

Cited by 187 publications

References 18 publications

Systems for Pediatric Sepsis: A Global Survey

Systems for Pediatric Sepsis: A Global Survey

The On-going Challenge of Pediatric Septic Shock: Optimizing Early Identification and Accurate Resuscitation

What’s New in the Recognition and Management of Septic Shock in Children: Dos and Don'ts

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