international guidelines for the management of septic
TRANSCRIPT
International Guidelines for the Management of Septic Shock & Sepsis-Associated Organ
Dysfunction in Children (SSCGC)
National Implementation Plan
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 2
The National Implementation Plan (NIP) for the SSCGC was developed, by the
HSE National Sepsis Programme (NSP), to support the implementation of the
SSCGC recommendations in the Irish context.
Using this Implementation Plan • The SSCGC has been adopted by the HSE NSP for use in Ireland and applies
to children (including infants, school-aged children and adolescents) with septic
shock and other sepsis-associated organ dysfunction in all clinical settings in
the acute sector. While the SSCGC recommendations apply to all patients from
greater than or equal to 37 weeks gestation at birth to 18 years old with severe
sepsis or septic shock, the NIP committee recognises that the definition of a
child in an Irish Healthcare setting is from birth to 16yrs, neonates defined as
under 4 weeks of age (HSE, National Clinical Programme for Critical Care,
2019). The SSCGC included term neonates (0–28 days) born at greater than
or equal to 37 weeks gestation within the scope of these guidelines because
these infants may be recognized and resuscitated outside of a newborn or
neonatal ICU setting. However, neonatal sepsis is recognised as an entity of
itself and deserves special attention and a separate guideline in the future.
• There is a separate National Clinical Guideline for adult patients and pregnant
women (HSE, 2020).
• This NIP is relevant to all healthcare professionals involved in the care of
children with sepsis and suspicion of sepsis, working in the acute healthcare
sector in the Republic of Ireland.
• This NIP supports the recommendations of the SSCGC (Weiss et al. 2020) in
the acute Irish healthcare system. The wording of the recommendations has
not been changed from the SSCGC publication with the exception of units of
measurement applicable to the Irish context.
• The NIP provides Implementation Points after the SSCGC recommendations
to aid the implementation of the guideline within the acute Irish healthcare
system and are aimed, primarily, at the pre and post-critical care setting.
• National Implementation Plan References are listed alphabetically.
2
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 3
Follow link to the SSCGC
Date Version Details December 2020 1 National Implementation Plan (NIP) for the SSCGC February 2020
This NIP is relevant to all healthcare professionals involved in the care of
children with sepsis and those with suspicion of sepsis, working in the acute
healthcare sector in the Republic of Ireland.
The SSCGC and the NIP are also relevant to:
• The HSE to provide appropriate structured support and adequate resources for
the governance, operationalisation, audit and data reporting of sepsis
management.
• The Hospital Group Leadership Team, Hospital Management and Clinical
Directors to support sepsis quality improvement and to foster and facilitate the
implementation process, audit and data reporting. They are also responsible
for effecting and monitoring change arising from outlier intervention.
• Pre-Hospital Emergency Care to inform their clinical practice guidelines.
• The public as an information resource.
Disclaimer NSP: The SSCGC and NIP do not replace professional judgment on particular
cases, whereby the clinician or health professional decides that individual guideline
recommendations are not appropriate in the circumstances presented by an individual
patient, or whereby an individual patient/parent/guardian declines a recommendation
as a course of action in their child’s/their ward’s care or treatment plan. In these
circumstances the decision not to follow a recommendation should be appropriately
recorded in the patient’s healthcare record.
Published by: The Health Services Executive (HSE) National Sepsis Programme © HSE 16/08/2021
Users of this NIP must ensure they have the current version (hardcopy or softcopy) by checking the relevant section in the HSE National Sepsis Programme website: https://www.hse.ie/eng/about/who/cspd/ncps/sepsis/resources/
3
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 4
Foreword Sepsis is a leading cause of morbidity, mortality and healthcare utilisation for children
worldwide (Weiss, et al., 2020). This NIP is intended to be relevant to all healthcare
staff involved in the care of children with sepsis and the suspicion of sepsis in the
Republic of Ireland.
The Surviving Sepsis Campaign (SSC) is a global initiative which brings together
professional organizations with the aim of reducing mortality from sepsis. The purpose
of the SSC is to create an international collaborative effort to improve the treatment of
sepsis and reduce the high mortality rate associated with the condition.
The SSC published guidelines for Managing Septic Shock and Sepsis-Associated
Organ Dysfunction in Children in 2020 (SSCGC). A panel of 49 international experts
representing 12 international organisations, as well as three methodologists and three
public members was convened. The SSCGC panel provided 77 statements on early
management and resuscitation of children with septic shock and sepsis-associated
organ dysfunction.
The NSP is very grateful to the SSC for their kind permission to adopt the SSCGC as
the Irish National Clinical Guideline on Sepsis Management for Children.
We also wish to acknowledge all the members of the National Sepsis Steering
Committee (Appendix 2), the NIPDG (Appendix 3) and the paediatric sepsis form
development group who gave freely of their time and expertise (Appendix 4).
Dr Martina Healy, Clinical Lead for the National Sepsis Programme Signed by the National Clinical Lead: Date: 9/8/21 Martina Healy
Dr Fidelma Fitzpatrick, Chair, National Sepsis Steering Committee.
Signed by the Chair: Date: 9/8/21 Fidelma Fitzpatrick Dr Vida Hamilton, National Clinical Advisor and Group Lead (Acute Hospitals), Chair, Guideline Development Group.
Signed by NCAGL,: Date: 9/8/21 Acute Operations, HSE Vida Hamilton
4
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 5
This National Implementation Plan (NIP) for the International Guidelines for the
Management of Septic Shock & Sepsis-Associated Organ Dysfunction in Children
(SSCGC) has been developed by the National Implementation Plan Development
Group (NIPDG), within the HSE National Sepsis Programme (NSP), and approved
by the CCO Clinical Forum, HSE on 16/08/2021.
Implementing Clinical Guidelines
Providing standardised clinical care to patients in healthcare is challenging. This is
due to a number of factors, among them diversity in environments of care and complex
patient presentations. It is self-evident that safe, effective care and treatment are
important in ensuring that patients get the best outcomes from their care.
Implementing Clinical Guidelines sets a standard nationally, to enable healthcare
professionals to deliver safe and effective care and treatment while monitoring their
individual, team and organisation’s performance.
The SSCGC 2020 are international evidence-based recommendations intended to
guide “best practice” rather than to establish a treatment algorithm or to define a
standard of care. In the Irish healthcare setting this NIP gives further direction to some
of the SSCGC recommendations where relevant, while acknowledging that each acute
care setting will need to adapt this document to local needs.
5
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 6
Contents Section 1. SSCGC Recommendations ................................................................... 8 1.1 Summary of recommendations .................................................................................... 8 Section 2. Development of the National Implementation Plan (NIP) ..................... 21
2.1Background .................................................................................................................. 21 2.2 Aims and Objectives of NIP ....................................................................................... 24 2.3 Definitions .................................................................................................................... 25
2.4 Process ....................................................................................................................... 27 2.5 Consultation summary ................................................................................................ 29 2.6 Monitoring and audit ................................................................................................... 29
Practical guidance ............................................................................................................. 32 2.7 Financial impact of the National Implementation Plan .............................................. 34 2.8 Plan to update this National Implementation Plan .................................................... 34
Section 3. SSCGC recommendations incorporating the NIP ................................ 35 3.1 SSCGC recommendations ........................................................................................ 35 3.1.1 Screening, diagnosis, and systematic management of sepsis (SSCGC Recommendations 1-4) .................................................................................................... 35 3.1.2 Antimicrobial therapy (SSCG Recommendations 5-14) ........................................ 48 3.1.3 Source Control (SSCGC Recommendations 15-16) ............................................. 52
3.1.4 Fluid Therapy (SSCGC Recommendations 17-23) ............................................... 53 3.1.5 Haemodynamic monitoring (SSCGC Recommendations 24-27) ......................... 56 3.1.6 Vasoactive medications (SSCGC Recommendations 28-33) .............................. 58
3.1.7 Ventilation (SSCGC Recommendations 34-43) .................................................... 61 3.1.8 Corticosteroids (SSCGC Recommendations 44-45) ............................................. 63 3.1.9 Endocrine and Metabolic (SSCGC Recommendations 46-50) ............................. 64
3.1.10 Nutrition (SSCGC Recommendations 51-64) ...................................................... 66 3.1.11 Blood Products (SSCGC Recommendations 65-68) .......................................... 68 3.1.12 Plasma exchange, renal replacement, and extracorporeal support ................... 69
(SSCGC Recommendations 69-74) ................................................................................ 69 3.1.13 Immunoglobulins (SSCGC Recommendation 75) ............................................... 70 3.1.14 Prophylaxis (SSCGC Recommendations 76-77) ................................................ 70
3.2 Rehabilitation and post-discharge care ..................................................................... 71 3.3 Parental considerations ................................................................................... 71 Section 4: Appendices ...................................................................................................... 73
Appendix 1: National Sepsis Steering Committee membership – 2019 /2020 ............. 73 Appendix 2: National Sepsis Programme Team (NSP) .................................................. 74 Appendix 3: National Implementation Plan Development Group (NIPDG) ................... 74
Appendix 4: National Paediatric Sepsis Form Development Group 2019 ..................... 75
6
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 7
Appendix 5: Glossary of Terms and Abbreviations ......................................................... 76 Appendix 6: Guideline search strategy for Paediatric Sepsis ......................................... 79
Appendix 7: Paediatric Sepsis Awareness ...................................................................... 80 Appendix 8: Enablers and Barriers to implementing the NIP ......................................... 81 Appendix 9. Paediatric Sepsis Form ................................................................................ 84
Appendix 10: Supporting tools ......................................................................................... 86 Appendix 11: Flowchart of implementation of SSCGC recommendations within the Irish acute healthcare sector. ................................................................................ 87 Appendix 12: Start Smart and then Focus’ approach for antimicrobial therapy 2012. .. 88 Appendix 13. Irish Paediatric Acute Transport Service (IPATS) .................................... 89 Appendix 14. SSCGC Initial Resuscitation Algorithm for Children ................................. 90
Appendix 15 SSCGC Fluid and Vasoactive-Inotrope Management Algorithm for children .............................................................................................................................. 91
Appendix 16. PHECC CPG for Septic Shock- Paediatric ≤ 15yrs (2021) ..................... 92 Appendix 17: Surviving Sepsis Campaign References .................................................. 93 Appendix 18: National Implementation Plan References ............................................... 94
List of Tables PAGE
Table 1. Paediatric sepsis associated incidence and crude mortality rates 2011–
2019............................................................................................................................22
Table 2. Databases searched..................................................................................... 23
Table 3. Search Terms Strategy for Paediatric Sepsis Management ........................ 23
Table 4. Definitions of Sepsis..................................................................................... 26
Table 5. Costings related to the development of an e-learning paediatric sepsis
component ................................................................................................................. 34
List of Figures PAGE
Figure 1. The National Sepsis Programme Governance Structure ........................ 36
Figure 2. Sepsis Education Overview ................................................................... 38
Figure 3. Flowchart for the Implementation of the SSCGC recommendations ...... 39
Figure 4. Paediatric Sepsis Form ........................................................................... 42
Figure 5. Sepsis 6 bundle ...................................................................................... 43
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Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
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Sect
ion
1. S
SCG
C R
ecom
men
datio
ns
1.1
Sum
mar
y of
reco
mm
enda
tions
Ta
ble
1. T
he S
urvi
ving
Sep
sis
Cam
paig
n (S
SC) r
ecom
men
datio
ns
Sect
ion
Rec
omm
enda
tion
Qua
lity
of
Evid
ence
Stre
ngth
of
Rec
omm
en-
datio
n N
atio
nal I
mpl
emen
tatio
n Po
ints
SCR
EEN
ING
, D
IAG
NO
SIS,
A
ND
SY
STEM
ATI
C
MA
NA
GEM
ENT
OF
SEPS
IS
1.In
chi
ldre
n w
ho p
rese
nt a
s ac
utel
y un
wel
l, w
esu
gges
t im
plem
entin
g sy
stem
atic
scr
eeni
ng fo
rtim
ely
reco
gniti
on o
f sep
tic s
hock
and
oth
erse
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n.
Very
low
Weak
ØN
atio
nal S
epsi
s Pr
ogra
mm
e w
ill im
plem
ent a
sys
tem
wid
e pr
oces
s to
sup
port
seps
is s
cree
ning
and
mon
itor
seps
is p
erfo
rman
ce im
prov
emen
t.
2.W
e w
ere
unab
le to
issu
e a
reco
mm
enda
tion
abou
t usi
ng b
lood
lact
ate
valu
es to
stra
tify
child
ren
with
sus
pect
ed s
eptic
sho
ck o
r oth
erse
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n in
to lo
w-
vers
us h
igh-
risk
of h
avin
g se
ptic
sho
ck o
r sep
sis.
How
ever
, in
our p
ract
ice,
if la
ctat
e le
vels
can
be
rapi
dly
obta
ined
, we
ofte
n m
easu
re b
lood
lact
ate
in c
hild
ren
whe
n ev
alua
ting
for s
eptic
sho
ck a
ndot
her s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
ØPe
rsis
tent
ly e
leva
ted
lact
ate
leve
ls o
f >4
mm
ol/L
afte
r20
mLs
/kg
fluid
ther
apy
is in
dica
tive
of o
rgan
dysf
unct
ion.
ØH
ealth
care
pro
vide
rs s
houl
d be
aw
are
of th
eir
inst
itutio
ns P
OC
acc
essi
bilit
y an
d us
age.
ØH
ospi
tals
sho
uld
be a
war
e of
the
requ
irem
ent f
orPo
int o
f car
e (P
OC
) lac
tate
ava
ilabi
lity
and
shou
ldsu
ppor
t, w
here
app
ropr
iate
, app
licat
ions
for a
dditi
onal
equi
pmen
t.
3.W
e re
com
men
d im
plem
entin
g a
prot
ocol
/gui
delin
e fo
r man
agem
ent o
f chi
ldre
nw
ith s
eptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
orga
n dy
sfun
ctio
n.
BPS
ØTh
e N
SP p
rovi
des
a pa
edia
tric
seps
is fo
rm w
hich
inco
rpor
ates
an
early
reco
gniti
on, t
reat
men
t and
refe
rral a
lgor
ithm
for t
he m
anag
emen
t of c
hild
ren
with
sept
ic s
hock
or o
ther
sep
sis-
asso
ciat
ed o
rgan
dysf
unct
ion.
ØSt
rate
gies
for t
he u
tilis
atio
n an
d im
plem
enta
tion
of th
eSe
psis
NIP
and
Sep
sis
form
sho
uld
be in
itiat
ed b
yea
ch in
stitu
tion.
ØEd
ucat
ion
on fo
rm u
se is
par
t of n
atio
nal e
duca
tion
rollo
ut.
8
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
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sis
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9
4.
We
reco
mm
end
obta
inin
g bl
ood
cultu
res
befo
re
initi
atin
g an
timic
robi
al th
erap
y in
situ
atio
ns w
here
th
is d
oes
not s
ubst
antia
lly d
elay
ant
imic
robi
al
adm
inis
tratio
n.
BP
S Ø
If
obta
inin
g bl
ood
cultu
res
is d
iffic
ult,
it sh
ould
not
im
pede
ant
ibio
tic in
itiat
ion
with
in th
e fir
st h
our.
AN
TIM
ICR
OB
IAL
THER
APY
5.
In
chi
ldre
n w
ith s
eptic
sho
ck, w
e re
com
men
d st
artin
g an
timic
robi
al th
erap
y as
soo
n as
po
ssib
le, w
ithin
1 h
our o
f rec
ogni
tion.
very
low
St
rong
Ø
In
itiat
e th
e Se
psis
6 b
undl
e w
ithin
1 h
our o
f re
cogn
ition
of s
eptic
sho
ck.
6.
In c
hild
ren
with
sep
sis-
asso
ciat
ed o
rgan
dy
sfun
ctio
n bu
t with
out s
hock
, we
sugg
est
star
ting
antim
icro
bial
ther
apy
as s
oon
as p
ossi
ble
afte
r app
ropr
iate
eva
luat
ion,
with
in 3
hou
rs o
f re
cogn
ition
.
Very
low
W
eak
Ø
Initi
ate
the
Seps
is 6
bun
dle
with
in 3
hou
rs o
f re
cogn
ition
of s
epsi
s.
7.
We
reco
mm
end
empi
ric b
road
-spe
ctru
m th
erap
y w
ith o
ne o
r mor
e an
timic
robi
als
to c
over
all
likel
y pa
thog
ens.
BP
S Ø
Em
piric
bro
ad-s
pect
rum
ther
apy
until
the
caus
ativ
e or
gani
sm a
nd it
s an
timic
robi
al s
usce
ptib
ilitie
s ar
e de
fined
, as
per l
ocal
ant
imic
robi
al g
uide
lines
.
8.
Onc
e th
e pa
thog
en(s
) and
sen
sitiv
ities
are
av
aila
ble,
we
reco
mm
end
narro
win
g em
piric
an
timic
robi
al th
erap
y co
vera
ge.
BP
S Ø
R
ecom
men
datio
ns (8
-14)
Ø
St
art S
mar
t the
n Fo
cus
stra
tegy
for a
ll an
timic
robi
al
reco
mm
enda
tions
.
9.
If no
pat
hoge
n is
iden
tifie
d, w
e re
com
men
d na
rrow
ing
or s
topp
ing
empi
ric a
ntim
icro
bial
th
erap
y ac
cord
ing
to c
linic
al p
rese
ntat
ion,
site
of
infe
ctio
n, h
ost r
isk
fact
ors,
and
ade
quac
y of
cl
inic
al im
prov
emen
t in
disc
ussi
on w
ith in
fect
ious
di
seas
e an
d/or
mic
robi
olog
ical
exp
ert a
dvic
e.
BP
S
10.
In c
hild
ren
with
out i
mm
une
com
prom
ise
and
with
out h
igh
risk
for m
ultid
rug-
resi
stan
t pa
thog
ens,
we
sugg
est a
gain
st th
e ro
utin
e us
e of
em
piric
mul
tiple
ant
imic
robi
als
dire
cted
aga
inst
th
e sa
me
path
ogen
for t
he p
urpo
se o
f syn
ergy
.
Very
low
Wea
k
9
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
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10
11.
In c
hild
ren
with
imm
une
com
prom
ise
and/
or a
t hi
gh ri
sk fo
r mul
tidru
g-re
sist
ant p
atho
gens
, we
sugg
est u
sing
em
piric
mul
ti-dr
ug th
erap
y w
hen
sept
ic s
hock
or o
ther
sep
sis-
asso
ciat
ed o
rgan
dy
sfun
ctio
n is
pre
sent
/sus
pect
ed.
Very
low
W
eak
Ø
An
tifun
gal a
nd a
ntiv
iral a
gent
s sh
ould
be
cons
ider
ed
as p
art o
f the
initi
al re
gim
en fo
r sus
cept
ible
pat
ient
s e.
g. o
ncol
ogy/
haem
atol
ogy
patie
nts.
12.
We
reco
mm
end
usin
g an
timic
robi
al d
osin
g st
rate
gies
that
hav
e be
en o
ptim
ized
bas
ed o
n pu
blis
hed
phar
mac
okin
etic
/pha
rmac
odyn
amic
s pr
inci
ples
and
with
con
side
ratio
n of
spe
cific
dru
g pr
oper
ties.
BP
S
13.
In c
hild
ren
with
sep
tic s
hock
or s
epsi
s-as
soci
ated
or
gan
dysf
unct
ion
who
are
rece
ivin
g an
timic
robi
als,
we
reco
mm
end
daily
ass
essm
ent
(e.g
., cl
inic
al, l
abor
ator
y as
sess
men
t) fo
r de-
esca
latio
n of
ant
imic
robi
al th
erap
y.
BP
S
14.
We
reco
mm
end
dete
rmin
ing
the
dura
tion
of
antim
icro
bial
ther
apy
acco
rdin
g to
the
site
of
infe
ctio
n, m
icro
bial
etio
logy
, res
pons
e to
tre
atm
ent,
and
abilit
y to
ach
ieve
sou
rce
cont
rol.
BP
S
SOU
RC
E C
ON
TRO
L 15
. W
e re
com
men
d th
at e
mer
gent
sou
rce
cont
rol
inte
rven
tion
be im
plem
ente
d as
soo
n po
ssib
le
afte
r a d
iagn
osis
of a
n in
fect
ion
amen
able
to a
so
urce
con
trol p
roce
dure
is m
ade.
BP
S R
ecom
men
datio
ns (1
5-16
) Ø
Pa
tient
s w
hose
infe
ctio
n is
not
set
tling
on
appr
opria
te
antim
icro
bial
s ne
ed to
be
re-a
sses
sed
for s
ourc
e co
ntro
l.
16.
We
reco
mm
end
rem
oval
of i
ntra
vasc
ular
acc
ess
devi
ces
that
are
con
firm
ed to
be
the
sour
ce o
f se
psis
or s
eptic
sho
ck a
fter o
ther
vas
cula
r ac
cess
has
bee
n es
tabl
ishe
d an
d de
pend
ing
on
the
path
ogen
and
the
risks
/ben
efits
of a
sur
gica
l pr
oced
ure.
Low
St
rong
Ø
Pa
tient
s w
hose
infe
ctio
n is
not
set
tling
on
appr
opria
te
antim
icro
bial
s ne
ed to
be
re-a
sses
sed
for s
ourc
e co
ntro
l inc
ludi
ng re
view
ing
impl
ante
d de
vice
s an
d ca
thet
ers
as p
oten
tial s
ourc
es.
FLU
ID T
HER
APY
17
. In
hea
lthca
re s
yste
ms
with
ava
ilabi
lity
of
inte
nsiv
e ca
re, w
e su
gges
t adm
inis
terin
g up
to
40–6
0 m
L/kg
in b
olus
flui
d (1
0–20
mL/
kg p
er
Low
W
eak
Ø
In a
cute
car
e se
tting
s w
ith a
cces
s to
inte
nsiv
e ca
re
capa
bilit
y/su
ppor
t, flu
id m
anag
emen
t is
base
d on
the
prin
cipl
e of
flui
d ad
min
istra
tion
of u
p to
40-
60m
L/kg
10
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
11
bolu
s) o
ver t
he fi
rst h
our,
titra
ted
to c
linic
al
mar
kers
of c
ardi
ac o
utpu
t and
dis
cont
inue
d if
sign
s of
flui
d ov
erlo
ad d
evel
op, f
or th
e in
itial
re
susc
itatio
n of
chi
ldre
n w
ith s
eptic
sho
ck o
r ot
her s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
over
the
first
hou
r whe
re th
e re
spon
se to
eac
h bo
lus
of 1
0-20
mL/
kg is
ass
esse
d. F
luid
vol
ume
shou
ld b
e ca
lcul
ated
bas
ed u
pon
idea
l bod
y w
eigh
t.
18.
In h
ealth
care
sys
tem
s w
ith n
o av
aila
bilit
y of
in
tens
ive
care
and
in th
e ab
senc
e of
hyp
oten
sion
, w
e re
com
men
d ag
ains
t bol
us fl
uid
adm
inis
tratio
n w
hile
sta
rting
mai
nten
ance
flui
ds.
Hig
h St
rong
19.
In h
ealth
care
sys
tem
s w
ith n
o av
aila
bilit
y of
in
tens
ive
care
, if h
ypot
ensi
on is
pre
sent
, we
sugg
est a
dmin
iste
ring
up to
40
mL/
kg in
bol
us
fluid
(10–
20 m
L/kg
per
bol
us) o
ver t
he fi
rst h
our
with
titra
tion
to c
linic
al m
arke
rs o
f car
diac
out
put
and
disc
ontin
ued
if si
gns
of fl
uid
over
load
de
velo
p.
Low
W
eak
20.
We
sugg
est u
sing
cry
stal
loid
s, ra
ther
than
al
bum
in, f
or th
e in
itial
resu
scita
tion
of c
hild
ren
with
sep
tic s
hock
or o
ther
sep
sis-
asso
ciat
ed
orga
n dy
sfun
ctio
n.
Mod
erat
e W
eak
21.
We
sugg
est u
sing
bal
ance
d/bu
ffere
d cr
ysta
lloid
s,
rath
er th
an 0
.9%
sal
ine,
for t
he in
itial
re
susc
itatio
n of
chi
ldre
n w
ith s
eptic
sho
ck o
r ot
her s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
Very
low
W
eak
Ø
For c
hild
ren
with
sep
tic s
hock
trea
ted
in s
ettin
gs w
ith
acce
ss to
acu
te in
tens
ive
care
cap
abilit
y, p
atie
nts
with
out s
igns
of f
luid
ove
rload
sho
uld
rece
ive
10m
L/kg
to
20m
L/kg
bol
uses
of b
alan
ced
crys
tallo
id
solu
tion
such
as
lact
ated
Rin
ger's
sol
utio
n (H
artm
ann’
s so
lutio
n); 0
.9%
Nor
mal
Sal
ine
is a
n ac
cept
able
alte
rnat
ive
if la
ctat
ed R
inge
r's s
olut
ion
is
not a
vaila
ble.
22
. W
e re
com
men
d ag
ains
t usi
ng s
tarc
hes
in th
e ac
ute
resu
scita
tion
of c
hild
ren
with
sep
tic s
hock
or
oth
er s
epsi
s as
soci
ated
org
an d
ysfu
nctio
n.
Mod
erat
e St
rong
11
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
12
23.
We
sugg
est a
gain
st u
sing
gel
atin
in th
e re
susc
itatio
n of
chi
ldre
n w
ith s
eptic
sho
ck o
r ot
her s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
Low
W
eak
HEM
OD
YNA
MIC
M
ON
ITO
RIN
G
24.
We
wer
e un
able
to is
sue
a re
com
men
datio
n ab
out w
heth
er to
targ
et m
ean
arte
rial b
lood
pr
essu
re (M
AP) a
t the
5th
or 5
0th
perc
entil
e fo
r ag
e in
chi
ldre
n w
ith s
eptic
sho
ck a
nd o
ther
se
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n. H
owev
er, i
n ou
r pra
ctic
e, w
e ta
rget
MAP
to b
etw
een
the
5th
and
50th
per
cent
ile o
r gre
ater
than
50t
h pe
rcen
tile
for a
ge.
25.
We
sugg
est n
ot u
sing
bed
side
clin
ical
sig
ns in
is
olat
ion
to c
ateg
oriz
e se
ptic
sho
ck in
chi
ldre
n as
“w
arm
” or “
cold
”.
Very
low
W
eak
26.
We
sugg
est u
sing
adv
ance
d he
mod
ynam
ic
varia
bles
, whe
n av
aila
ble,
in a
dditi
on to
bed
side
cl
inic
al v
aria
bles
to g
uide
the
resu
scita
tion
of
child
ren
with
sep
tic s
hock
or o
ther
sep
sis-
asso
ciat
ed o
rgan
dys
func
tion.
Low
W
eak
Ø
It is
the
resp
onsi
bilit
y of
clin
icia
ns to
be
fam
iliar w
ith
the
proc
edur
es a
nd to
kno
w th
e ad
vant
ages
and
lim
itatio
ns o
f any
adv
ance
d ha
emod
ynam
ic
mon
itorin
g eq
uipm
ent d
eplo
yed.
27.
We
sugg
est u
sing
tren
ds in
blo
od la
ctat
e le
vels
, in
add
ition
to c
linic
al a
sses
smen
t, to
gui
de
resu
scita
tion
of c
hild
ren
with
sep
tic s
hock
and
ot
her s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
Very
Low
W
eak
Ø
Elev
atio
n of
blo
od la
ctat
e >2
.0 m
mol
/L s
ugge
sts
hypo
perfu
sion
.
VASO
AC
TIVE
M
EDIC
ATI
ON
S 28
. W
e su
gges
t usi
ng e
pine
phrin
e, ra
ther
than
do
pam
ine,
in c
hild
ren
with
sep
tic s
hock
. Lo
w
Wea
k
29.
We
sugg
est u
sing
nor
epin
ephr
ine,
rath
er th
an
dopa
min
e, in
chi
ldre
n w
ith s
eptic
sho
ck
Very
low
W
eak
30.
We
wer
e un
able
to is
sue
a re
com
men
datio
n fo
r a
spec
ific
first
-line
vas
oact
ive
infu
sion
for c
hild
ren
with
sep
tic s
hock
. H
owev
er, i
n ou
r pra
ctic
e, w
e se
lect
eith
er e
pine
phrin
e or
nor
epin
ephr
ine
as
Ø
If va
soac
tive
med
icat
ion
is w
arra
nted
, see
k PI
CU
su
ppor
t.
12
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
13
the
first
-line
vas
oact
ive
infu
sion
gui
ded
by
clin
icia
n pr
efer
ence
, ind
ivid
ual p
atie
nt p
hysi
olog
y,
and
loca
l sys
tem
fact
ors.
Ø
If th
ere
is n
o PI
CU
sup
port
on s
ite, s
eek
advi
ce o
n na
tiona
l 24-
hour
hot
line.
31.
We
wer
e un
able
to is
sue
a re
com
men
datio
n ab
out i
nitia
ting
vaso
activ
e ag
ents
thro
ugh
perip
hera
l acc
ess
in c
hild
ren
with
sep
tic s
hock
. H
owev
er, i
n ou
r pra
ctic
e, w
e of
ten
or s
omet
imes
ad
min
iste
r a d
ilute
con
cent
ratio
n of
the
initi
al
vaso
activ
e m
edic
atio
n th
roug
h a
perip
hera
l vei
n if
cent
ral v
enou
s ac
cess
is n
ot re
adily
acc
essi
ble.
Ø
Vaso
pres
sors
and
inot
rope
s ar
e m
ost u
sual
ly
pres
crib
ed b
y cr
itica
l car
e an
d un
less
fam
iliar w
ith
them
, it i
s pr
uden
t to
obta
in c
ritic
al c
are
supp
ort w
hen
star
ting
them
. Ø
If
cent
ral v
enou
s ac
cess
is n
ot re
adily
ava
ilabl
e,
cons
ider
adm
inis
terin
g pe
riphe
ral v
asoa
ctiv
e m
edic
atio
ns w
ith s
enio
r clin
ical
sup
port,
unt
il ce
ntra
l ac
cess
can
be
obta
ined
.
32.
We
sugg
est e
ither
add
ing
vaso
pres
sin
or fu
rther
tit
ratin
g ca
tech
olam
ines
in c
hild
ren
with
sep
tic
shoc
k w
ho re
quire
hig
h-do
se c
atec
hola
min
es.
Low
W
eak
33.
We
wer
e un
able
to is
sue
a re
com
men
datio
n ab
out a
ddin
g an
inod
ilato
r in
child
ren
with
sep
tic
shoc
k an
d ca
rdia
c dy
sfun
ctio
n de
spite
oth
er
vaso
activ
e ag
ents
. How
ever
, in
our p
ract
ice,
we
som
etim
es u
se in
odila
tors
in c
hild
ren
with
sep
tic
shoc
k an
d ev
iden
ce o
f per
sist
ent h
ypop
erfu
sion
an
d ca
rdia
c dy
sfun
ctio
n de
spite
oth
er v
asoa
ctiv
e ag
ents
.
Ø
The
deci
sion
to in
trodu
ce a
n in
odila
tor i
s ba
sed
on
the
child
’s c
ardi
ovas
cula
r res
pons
e to
sep
sis
man
agem
ent p
roto
cols
. It i
s re
com
men
ded
that
cr
itica
l car
e pe
rson
nel a
re re
spon
sibl
e fo
r its
ad
min
istra
tion,
usi
ng th
e pa
edia
tric
criti
cal c
are
stan
dard
con
cent
ratio
n in
fusi
on p
roto
cols
.
VEN
TILA
TIO
N
34.
We
wer
e un
able
to is
sue
a re
com
men
datio
n ab
out w
heth
er to
intu
bate
chi
ldre
n w
ith fl
uid-
refra
ctor
y, c
atec
hola
min
e-re
sist
ant s
eptic
sho
ck.
How
ever
, in
our p
ract
ice,
we
com
mon
ly in
tuba
te
child
ren
with
flui
d-re
fract
ory,
cat
echo
lam
ine-
resi
stan
t sep
tic s
hock
with
out r
espi
rato
ry fa
ilure
.
Ø
Early
intu
batio
n an
d m
echa
nica
l ven
tilat
ion
is
cons
ider
ed if
the
child
is c
ritic
ally
ill a
nd is
un
resp
onsi
ve to
initi
al re
susc
itatio
n, in
ord
er to
fa
cilit
ate
proc
edur
es a
nd to
dec
reas
e w
ork
of
brea
thin
g/ o
xyge
n co
nsum
ptio
n.
35.
We
sugg
est n
ot to
use
eto
mid
ate
whe
n in
tuba
ting
child
ren
with
sep
tic s
hock
or o
ther
se
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n.
Low
W
eak
13
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
14
36.
We
sugg
est a
tria
l of n
onin
vasi
ve m
echa
nica
l ve
ntila
tion
(ove
r inv
asiv
e m
echa
nica
l ven
tilat
ion)
in
chi
ldre
n w
ith s
epsi
s in
duce
d pe
diat
ric A
RD
S (P
ARD
S) w
ithou
t a c
lear
indi
catio
n fo
r int
ubat
ion
and
who
are
resp
ondi
ng to
initi
al re
susc
itatio
n
Very
low
W
eak
Ø
A tri
al o
f non
-inva
sive
mec
hani
cal v
entil
atio
n (o
ver
inva
sive
mec
hani
cal v
entil
atio
n) in
chi
ldre
n w
ith
hypo
xem
ia a
nd n
orm
al a
bilit
y to
pro
tect
thei
r airw
ay
who
do
not h
ave
over
t res
pira
tory
failu
re a
nd w
ho a
re
resp
ondi
ng to
initi
al re
susc
itatio
n is
reas
onab
le.
37.
We
sugg
est u
sing
hig
h po
sitiv
e en
d-ex
pira
tory
pr
essu
re (P
EEP)
in c
hild
ren
with
sep
sis-
indu
ced
PAR
DS.
Very
low
W
eak
38.
We
cann
ot s
ugge
st fo
r or a
gain
st th
e us
e of
re
crui
tmen
t man
oeuv
res
in c
hild
ren
with
sep
sis
indu
ced
PAR
DS
and
refra
ctor
y hy
poxe
mia
.
39.
We
sugg
est a
tria
l of p
rone
pos
ition
ing
in c
hild
ren
with
sep
sis
and
seve
re P
ARD
S
Low
W
eak
40.
We
reco
mm
end
agai
nst t
he ro
utin
e us
e of
in
hale
d ni
tric
oxid
e (iN
O) i
n al
l chi
ldre
n w
ith
seps
is in
duce
d PA
RD
S.
Low
St
rong
41.
We
sugg
est u
sing
iNO
as
a re
scue
ther
apy
in
child
ren
with
sep
sis
indu
ced
PAR
DS
and
refra
ctor
y hy
poxe
mia
afte
r oth
er o
xyge
natio
n st
rate
gies
hav
e be
en o
ptim
ized
.
Mod
erat
e W
eak
42.
We
wer
e un
able
to is
sue
a re
com
men
datio
n to
us
e hi
gh fr
eque
ncy
osci
llato
ry v
entil
atio
n (H
FOV)
ve
rsus
con
vent
iona
l ven
tilat
ion
in c
hild
ren
with
se
psis
indu
ced
PAR
DS.
How
ever
, in
our
prac
tice,
ther
e is
no
pref
eren
ce to
use
or n
ot u
se
HFO
V in
pat
ient
s w
ith s
ever
e PA
RD
S an
d re
fract
ory
hypo
xia.
14
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
15
43.
We
sugg
est u
sing
neu
rom
uscu
lar b
lock
ade
in
child
ren
with
sep
sis
and
seve
re P
ARD
S.
Very
low
W
eak
CO
RTI
CO
STE-
RO
IDS
44.
We
sugg
est a
gain
st u
sing
IV h
ydro
corti
sone
to
treat
chi
ldre
n w
ith s
eptic
sho
ck if
flui
d re
susc
itatio
n an
d va
sopr
esso
r the
rapy
are
abl
e to
re
stor
e he
mod
ynam
ic s
tabi
lity.
Low
W
eak
45.
We
sugg
est t
hat e
ither
IV h
ydro
corti
sone
or n
o hy
droc
ortis
one
may
be
used
if a
dequ
ate
fluid
re
susc
itatio
n an
d va
sopr
esso
r the
rapy
are
not
ab
le to
rest
ore
hem
odyn
amic
sta
bilit
y.
Low
W
eak
Ø
Hyd
roco
rtiso
ne is
mos
t usu
ally
giv
en in
a c
ritic
al
care
set
ting
END
OC
RIN
E A
ND
M
ETA
BO
LIC
46
. W
e re
com
men
d ag
ains
t ins
ulin
ther
apy
to
mai
ntai
n a
bloo
d gl
ucos
e ta
rget
at o
r bel
ow 1
40
mg/
dL (7
.8 m
mol
/L).
Mod
erat
e St
rong
47.
We
wer
e un
able
to is
sue
a re
com
men
datio
n re
gard
ing
wha
t blo
od g
luco
se ra
nge
to ta
rget
for
child
ren
with
sep
tic s
hock
or o
ther
sep
sis-
asso
ciat
ed o
rgan
dys
func
tion.
How
ever
, in
our
prac
tice,
ther
e w
as c
onse
nsus
to ta
rget
blo
od
gluc
ose
leve
ls b
elow
180
mg/
dL (1
0 m
mol
/L) b
ut
ther
e w
as n
ot c
onse
nsus
abo
ut th
e lo
wer
lim
it of
th
e ta
rget
rang
e.
Ø
Hyp
ergl
ycae
mic
con
trol s
houl
d on
ly b
e co
nsid
ered
in
the
ICU
set
ting.
48.
We
wer
e un
able
to is
sue
a re
com
men
datio
n as
to
whe
ther
to ta
rget
nor
mal
blo
od c
alci
um le
vels
in
chi
ldre
n w
ith s
eptic
sho
ck o
r sep
sis-
asso
ciat
ed
orga
n dy
sfun
ctio
n. H
owev
er, i
n ou
r pra
ctic
e, w
e of
ten
targ
et n
orm
al c
alci
um le
vels
for c
hild
ren
with
sep
tic s
hock
requ
iring
vas
oact
ive
infu
sion
su
ppor
t.
15
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
16
49.
We
sugg
est a
gain
st th
e ro
utin
e us
e of
le
voth
yrox
ine
in c
hild
ren
with
sep
tic s
hock
and
ot
her s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n in
a
sick
eut
hyro
id s
tate
.
Low
W
eak
50.
We
sugg
est e
ither
ant
ipyr
etic
ther
apy
or a
pe
rmis
sive
app
roac
h to
feve
r in
child
ren
with
se
ptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
org
an
dysf
unct
ion.
Mod
erat
e W
eak
Ø
The
deci
sion
to a
dmin
iste
r ant
ipyr
etic
s is
bas
ed o
n se
nior
clin
icia
n ad
vice
, deg
ree
of p
yrex
ia a
nd th
e ov
eral
l con
ditio
n of
chi
ld.
NU
TRIT
ION
51
. W
e w
ere
unab
le to
issu
e a
reco
mm
enda
tion
rega
rdin
g ea
rly h
ypoc
alor
ic/tr
ophi
c en
tera
l fe
edin
g fo
llow
ed b
y sl
ow in
crea
se to
full
ente
ral
feed
ing
vers
us e
arly
full
ente
ral f
eedi
ng in
ch
ildre
n w
ith s
eptic
sho
ck o
r sep
sis-
asso
ciat
ed
orga
n dy
sfun
ctio
n w
ithou
t con
train
dica
tions
to
ente
ral f
eedi
ng. H
owev
er, i
n ou
r pra
ctic
e, th
ere
is a
pre
fere
nce
to c
omm
ence
ear
ly e
nter
al
nutri
tion
with
in 4
8 ho
urs
of a
dmis
sion
in
child
ren
with
sep
tic s
hock
or s
epsi
s-as
soci
ated
or
gan
dysf
unct
ion
who
hav
e no
co
ntra
indi
catio
ns to
ent
eral
nut
ritio
n an
d to
in
crea
se e
nter
al n
utrit
ion
in a
ste
pwis
e fa
shio
n un
til n
utrit
iona
l goa
ls a
re m
et.
Ø
Ente
ral n
utrit
ion
shou
ld b
e in
itiat
ed in
all
criti
cally
ill
child
ren,
unl
ess
it is
con
train
dica
ted,
with
in 2
4-48
ho
urs.
Fee
ds s
houl
d be
adv
ance
d ac
cord
ing
to
inst
itutio
nal g
uide
lines
and
ste
pwis
e al
gorit
hms.
52.
We
sugg
est n
ot w
ithho
ldin
g en
tera
l fee
ding
sol
ely
on th
e ba
sis
of v
asoa
ctiv
e-in
otro
pic
med
icat
ion
adm
inis
tratio
n.
Low
W
eak
53.
We
sugg
est e
nter
al n
utrit
ion
as th
e pr
efer
red
met
hod
of fe
edin
g an
d th
at p
aren
tera
l nut
ritio
n m
ay b
e w
ithhe
ld in
the
first
7 d
ays
of P
ICU
ad
mis
sion
in c
hild
ren
with
sep
tic s
hock
or o
ther
se
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n.
Mod
erat
e W
eak
Ø
Indi
vidu
al a
sses
smen
t is
requ
ired
to d
eter
min
e w
heth
er p
aren
tera
l nut
ritio
n is
a) i
ndic
ated
b) v
iabl
e an
d c)
ben
efic
ial.
PIC
U s
houl
d ha
ve a
cces
s to
a
dedi
cate
d di
etiti
an o
r nut
ritio
n su
ppor
t tea
m. C
are
shou
ld b
e ta
ken
to e
nsur
e th
at n
utrit
ion
supp
ort i
s no
t en
tirel
y w
ithhe
ld fr
om e
xtre
mel
y vu
lner
able
chi
ldre
n.
Any
deci
sion
to w
ithho
ld n
utrit
ion
supp
ort s
houl
d be
re
visi
ted
daily
.
16
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
17
54.
We
sugg
est a
gain
st s
uppl
emen
tatio
n w
ith
spec
ializ
ed li
pid
emul
sion
s in
chi
ldre
n w
ith s
eptic
sh
ock
or o
ther
sep
sis
asso
ciat
ed o
rgan
dy
sfun
ctio
n.
Very
low
W
eak
55.
We
sugg
est a
gain
st th
e ro
utin
e m
easu
rem
ents
of
gas
tric
resi
dual
vol
umes
(GR
Vs) i
n ch
ildre
n w
ith s
eptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
or
gan
dysf
unct
ion.
Low
W
eak
56.
We
sugg
est a
dmin
iste
ring
ente
ral f
eeds
thro
ugh
a ga
stric
tube
, rat
her t
han
a po
stpy
loric
feed
ing
tube
, to
child
ren
with
sep
tic s
hock
or o
ther
se
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n w
ho h
ave
no c
ontra
indi
catio
ns to
ent
eral
feed
ing.
Low
W
eak
57.
We
sugg
est a
gain
st th
e ro
utin
e us
e of
pro
kine
tic
agen
ts fo
r the
trea
tmen
t of f
eedi
ng in
tole
ranc
e in
ch
ildre
n w
ith s
eptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
Low
W
eak
58.
We
sugg
est a
gain
st th
e us
e of
sel
eniu
m in
ch
ildre
n w
ith s
eptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
Low
W
eak
59.
We
sugg
est a
gain
st th
e us
e of
glu
tam
ine
supp
lem
enta
tion
in c
hild
ren
with
sep
tic s
hock
or
othe
r sep
sis-
asso
ciat
ed o
rgan
dys
func
tion.
Low
W
eak
60.
We
sugg
est a
gain
st th
e us
e of
arg
inin
e in
the
treat
men
t of c
hild
ren
with
sep
tic s
hock
or o
ther
se
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n.
Very
low
W
eak
61.
We
sugg
est a
gain
st u
sing
zin
c su
pple
men
tatio
n in
chi
ldre
n w
ith s
eptic
sho
ck a
nd o
ther
sep
sis-
asso
ciat
ed o
rgan
dys
func
tion.
Very
low
W
eak
17
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
18
62.
We
sugg
est a
gain
st th
e us
e of
asc
orbi
c ac
id
(vita
min
C) i
n th
e tre
atm
ent o
f chi
ldre
n w
ith s
eptic
sh
ock
or o
ther
sep
sis
asso
ciat
ed o
rgan
dy
sfun
ctio
n.
Very
low
W
eak
63.
We
sugg
est a
gain
st th
e us
e of
thia
min
e to
trea
t ch
ildre
n w
ith s
epsi
s-as
soci
ated
org
an
dysf
unct
ion.
Low
W
eak
64.
We
sugg
est a
gain
st th
e ac
ute
repl
etio
n of
vi
tam
in D
def
icie
ncy
(VD
D) f
or tr
eatm
ent o
f sep
tic
shoc
k or
oth
er s
epsi
s-as
soci
ated
org
an
dysf
unct
ion.
Very
low
W
eak
BLO
OD
PR
OD
UC
TS
65.
We
sugg
est a
gain
st tr
ansf
usio
n of
RBC
s if
the
bloo
d he
mog
lobi
n co
ncen
tratio
n is
gre
ater
than
or
equ
al to
7 g
/dL
in h
emod
ynam
ical
ly s
tabi
lized
ch
ildre
n w
ith s
eptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
org
an d
ysfu
nctio
n.
Low
W
eak
66.
We
cann
ot m
ake
a re
com
men
datio
n re
gard
ing
hem
oglo
bin
trans
fusi
on th
resh
olds
for c
ritic
ally
ill
child
ren
with
uns
tabl
e se
ptic
sho
ck.
Ø
Follo
w
TAXI
(T
rans
fusi
on
and
Anem
ia
Expe
rtise
In
itiat
ive)
gui
delin
es.
67.
We
sugg
est a
gain
st p
roph
ylac
tic p
late
let
trans
fusi
on b
ased
sol
ely
on p
late
let l
evel
s in
no
nble
edin
g ch
ildre
n w
ith s
eptic
sho
ck o
r oth
er
seps
is-a
ssoc
iate
d or
gan
dysf
unct
ion
and
thro
mbo
cyto
peni
a.
Very
low
W
eak
68.
We
sugg
est a
gain
st p
roph
ylac
tic p
lasm
a tra
nsfu
sion
in n
onbl
eedi
ng c
hild
ren
with
sep
tic
shoc
k or
oth
er s
epsi
s as
soci
ated
org
an
dysf
unct
ion
and
coag
ulat
ion
abno
rmal
ities
.
Very
low
W
eak
18
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
19
PLA
SMA
EX
CH
AN
GE,
R
ENA
L R
EPLA
CEM
ENT,
A
ND
EX
TRA
CO
RPO
RE
AL
SUPP
OR
T
69.
We
sugg
est a
gain
st u
sing
pla
sma
exch
ange
(P
LEX)
in c
hild
ren
with
sep
tic s
hock
or o
ther
se
psis
-ass
ocia
ted
orga
n dy
sfun
ctio
n w
ithou
t th
rom
bocy
tope
nia-
asso
ciat
ed m
ultip
le o
rgan
fa
ilure
(TAM
OF)
.
Very
low
W
eak
70.
We
cann
ot s
ugge
st fo
r or a
gain
st th
e us
e of
PL
EX in
chi
ldre
n w
ith s
eptic
sho
ck o
r oth
er
seps
is-a
ssoc
iate
d or
gan
dysf
unct
ion
with
TA
MO
F.
71.
We
sugg
est u
sing
rena
l rep
lace
men
t the
rapy
to
prev
ent o
r tre
at fl
uid
over
load
in c
hild
ren
with
se
ptic
sho
ck o
r oth
er s
epsi
s-as
soci
ated
org
an
dysf
unct
ion
who
are
unr
espo
nsiv
e to
flui
d re
stric
tion
and
diur
etic
ther
apy.
Very
low
W
eak
72.
We
sugg
est a
gain
st h
igh-
volu
me
hem
ofilt
ratio
n (H
VHF)
ove
r sta
ndar
d he
mof
iltra
tion
in c
hild
ren
with
sep
tic s
hock
or o
ther
sep
sis-
asso
ciat
ed
orga
n dy
sfun
ctio
n w
ho a
re tr
eate
d w
ith re
nal
repl
acem
ent t
hera
py.
Low
W
eak
73.
We
sugg
est u
sing
ven
oven
ous
ECM
O in
chi
ldre
n w
ith s
epsi
s in
duce
d PA
RD
S an
d re
fract
ory
hypo
xia.
Very
low
W
eak
74.
We
sugg
est u
sing
ven
oarte
rial E
CM
O a
s a
resc
ue th
erap
y in
chi
ldre
n w
ith s
eptic
sho
ck o
nly
if re
fract
ory
to a
ll ot
her t
reat
men
ts.
Very
low
W
eak
IMM
UN
O-
GLO
BU
LIN
S 75
. W
e su
gges
t aga
inst
the
rout
ine
use
of IV
im
mun
e gl
obul
in (I
VIG
) in
child
ren
with
sep
tic
shoc
k or
oth
er s
epsi
s as
soci
ated
org
an
dysf
unct
ion.
Low
W
eak
19
Nat
iona
l Im
plem
enta
tion
Plan
for S
SCG
C P
aedi
atric
Sep
sis
Gui
delin
es
CD
I014
/202
1
20
PRO
PHYL
AXI
S 76
. W
e su
gges
t aga
inst
the
rout
ine
use
of s
tress
ul
cer p
roph
ylax
is in
crit
ical
ly il
l chi
ldre
n w
ith
sept
ic s
hock
or o
ther
sep
sis-
asso
ciat
ed o
rgan
dy
sfun
ctio
n, e
xcep
t for
hig
h-ris
k pa
tient
s.
Very
low
W
eak
77.
We
sugg
est a
gain
st ro
utin
e de
ep v
ein
thro
mbo
sis
(DVT
) pro
phyl
axis
(mec
hani
cal o
r ph
arm
acol
ogic
) in
criti
cally
ill c
hild
ren
with
sep
tic
shoc
k or
oth
er s
epsi
s-as
soci
ated
org
an
dysf
unct
ion,
but
pot
entia
l ben
efits
may
out
wei
gh
risks
and
cos
ts in
spe
cific
pop
ulat
ions
.
Low
W
eak
The
SSC
GC
pro
vide
s ex
plan
atio
n on
gra
ding
of r
ecom
men
datio
ns a
nd le
vels
of e
vide
nce
(Wei
ss e
t al.,
202
0).
20
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 21
Section 2. Development of the National Implementation Plan (NIP) The glossary of terms and abbreviations used throughout this document are explained in (Appendix 5). 2.1 Background 2.1.1 Impact of Sepsis in the paediatric population Globally, an estimated 22 cases of childhood sepsis per 100,000 person-years and
2202 cases of neonatal sepsis per 100,000 live births occur, translating into 1.2 million
cases of childhood sepsis per year (Weiss, et al., 2020). 2015 SPROUT (Sepsis
Prevalence, Outcomes, and Therapies) study demonstrated that the prevalence of
severe sepsis (defined by 2005 criteria) was 8.2% among children in ICU (<18 years
old) with the associated hospital mortality of 25%, which was not different by age and
between developed and developing countries (Weiss, et al., 2015).
In Ireland, the Hospital Inpatient Enquiry (HIPE) database is used to extract data on
the burden of sepsis in the acute hospital sectors, but has its limitations, namely sepsis
may be a direct or indirect contributor to morbidity and mortality. The crude sepsis data
for 2019 documented a diagnosis of sepsis or septic shock in 642 children and these
patients had a mortality rate of 3.7% (HSE, 2019) Table 1.
21
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 22
Table 1. Paediatric sepsis associated incidence and crude mortality rates 2011 - 2019
Year
Children aged 0-15 Years with a Diagnosis of Sepsis
Number of Inpatients Crude Mortality Rate
2011 737 3.0%
2012 763 3.9%
2013 763 3.8%
2014 746 4.0%
2015 765 2.1%
2016 791 3.5%
2017 820 3.9%
2018 746 4.4%
2019 642 3.7%
Providing standardised clinical care to patients in healthcare is challenging. This is
due to a number of factors, among them diversity in environments of care and complex
patient presentations. It is self-evident that safe, effective care and treatment are
important in ensuring that patients get the best outcomes from their care.
Implementing Clinical Guidelines sets a standard nationally, to enable healthcare
professionals to deliver safe and effective care and treatment while monitoring their
individual, team and organisation’s performance.
The SSC published guidelines for Managing Septic Shock and Sepsis-Associated
Organ Dysfunction in Children in 2020 (SSCGC).
The SSCGC focuses on the management of sepsis and septic shock in children and
underwent a robust process to identify the evidence relating to five areas of practice:
1) recognition and management of infection, 2) haemodynamics and resuscitation, 3)
ventilation, 4) endocrine and metabolic therapies and 5) adjunctive therapies. A sixth
22
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 23
subgroup was added to review research priorities in paediatric sepsis. An extensive
search was performed for each PICO and the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) system principles were used to
guide the assessment of the quality of evidence and to determine the strength of the
recommendations. Both of these are fully described in the SSC Guideline for Children
(Weiss, et al., 2020). The SSCGC provides recommendations for good practice that
are based on the best available clinical and cost effectiveness evidence.
Before a decision was made to adopt these guidelines for use in Ireland, a literature
search was undertaken by the NSP to identify if any other published paediatric sepsis
clinical guidelines were available that could be adopted or adapted for use in the Irish
Healthcare setting. The search strategy is outlined in Tables 2 and 3.
The literature search identified the SSCGC guideline as the only available guideline
for the management of Paediatric Sepsis. In this context, the National Sepsis
Programme (NSP) decided to fully adopt the SSCGC and to provide a NIP to support
the implementation of the SSCGC recommendations within the acute paediatric
healthcare setting in Ireland.
Table 2. Databases searched Date Database September 2020 NICE (National Institute Clinical Effectiveness)
GINN (Guidelines International network) TRIP (Turning Research into Practice), American Clearing House Web of Science, PubMed, Scopus, Embase, Google Scholar
Table 3. Search Terms Strategy for Paediatric Sepsis Management Search Sepsis OR blood poisoning OR septicaemia OR SIRS OR systemic inflammatory response system OR Septic shock OR severe sepsis. Filters: Guideline, Meta-analysis, Practice Guideline, Systematic review.
Paediatric OR Childhood OR Neonates OR Infants
Excluding foreign language, specific types of Sepsis e.g. acute meningitis, meningococcal Sepsis
23
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
CDI014/2021 24
2.2 Aims and Objectives of NIP Aim To implement the SSCGC evidence-based recommendations in a format that applies
to the structures and functions of the acute healthcare setting for children in Ireland.
Objectives 1. To reduce unnecessary variations in practice and provide an evidence base for
the most appropriate healthcare to optimize children’s survival from sepsis.
2. That all healthcare professionals have an understanding of the diagnostic
criteria for sepsis and its basic pathophysiology.
3. That all healthcare professionals recognise children at high risk of mortality from
sepsis.
4. That all healthcare professionals are:
i. Familiar with the initial management of children with a high risk of
mortality from sepsis.
ii. Able to use the Paediatric Sepsis Form (Appendix 9), a clinical decision
support tool that forms part of the child’s clinical notes.
Why is the pre-critical care setting important? It is recognised that the presentation of sepsis is variable in symptoms, signs and time
course. Thus, sepsis may not be present or not diagnosed on first presentation and
may not become apparent until the clinical condition evolves further. Deterioration
whilst on treatment (including supportive) needs to be reviewed and diagnosis and
treatment amended accordingly. The Paediatric Early Warning System (2016)
(PEWS) combined with clinical judgment should be deployed to recognise and
respond to a deterioration in a child’s condition, once admitted to an acute paediatric
care setting, outside of ICU (HSE, 2016a).
In 2016, the Centres for Disease Control (CDC) in the U.S. performed a medical record
review of paediatric presentations and found 57% were community-associated sepsis
cases without health care factors i.e. (≥2 days in long-term or other acute care hospital,
receipt of intravenous antimicrobials, peritoneal or haemodialysis, surgery, total
parenteral nutrition, chemotherapy, wound therapy, or presence of a central venous
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catheter) (Novasad, et al., 2016). The remaining 43% of patients had sepsis with
health care factors.
In Ireland, these patients present to the acute hospital sector via the Paediatric
Emergency Dept. (PED), Mixed Emergency Departments, the Paediatric Observation
Department (POD), Paediatric Assessment Units (PAUs), the Urgent Care Centres
(UCC) and to a lesser extent the Outpatient Department (OPD).
In order for patients to have the best opportunity to survive, they need to present for
medical review and have sepsis recognised and managed in an appropriate and timely
manner. There is an important role for primary and community care in terms of risk
recognition and for public awareness of the signs and symptoms of deterioration that
may signal the development of sepsis, in order to ensure the right patient is in the right
place at the right time, to receive the right treatment.
In September 2020, the NSP launched a public awareness campaign to promote
awareness of the signs and symptoms of sepsis in children, adults, and maternal care.
The campaign aims to educate patients and families about early warning signs of
sepsis, to empower patient and families to seek urgent medical attention and ask,
“could this be sepsis?” and to highlight preventative measures to reduce the risk of
infection.
Available resources at www.hse.ie/eng/about/who/cspd/ncps/sepsis/ include videos
on paediatric sepsis that can be shared on social media platforms, in community health
centres and in GP practices. Patient information leaflets and sepsis awareness posters
/ cards are also available to download from this site (Appendix 7).
2.3 Definitions The concept of sepsis as life-threatening organ dysfunction caused by a dysregulated
response to infection has face validity for children, but the most appropriate criteria for
operationalizing organ dysfunction and the utility of lactate in paediatric sepsis have
not yet been established. Nevertheless, studies support using a stratified scoring
system for organ dysfunction over Systemic Inflammatory Response Syndrome
(SIRS) criteria in children [12], and efforts to update the definition and clinical criteria
for paediatric sepsis are currently underway.
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Until revised data-driven clinical criteria are determined to better describe paediatric
sepsis and septic shock, existing consensus criteria should continue to be used to
define paediatric sepsis (Weiss & Pomerantz, Septic shock in children: Rapid
recognition and initial resuscitation (first hour), 2020) i.e. 2005 definitions (Goldstein,
Giroir, & Randolph, 2005) [1]. The Society of Critical Care Medicine’s (SCCM)
Paediatric Sepsis Definition Taskforce are currently conducting a systematic review to
collate evidence on individual factors, clinical criteria, and/or illness severity scores for
the recognition of possible sepsis, sepsis, septicaemia, and septic shock in children.
(Menon, et al., 2020)
Table 4. Definitions of Sepsis
Infection As per 2005 (International Consensus Conference on Paediatric
Sepsis) definition, infection is defined as a suspected or proven
(by positive culture, tissue stain, or polymerase chain reaction
test) infection caused by any pathogen OR a clinical syndrome
associated with a high probability of infection. Evidence of
infection includes positive findings on clinical exam, imaging, or
laboratory tests (e.g. white blood cells in a normally sterile body
fluid, perforated viscus, chest radiograph consistent with
pneumonia, petechial or purpuric rash, or purpura fulminans).
Sepsis As per 2005 (International Consensus Conference on Paediatric
Sepsis) definition, sepsis is defined as Systemic Inflammatory
Response Syndrome (SIRS) in the presence of or as a result of
suspected or proven infection.
SIRS criteria The presence of at least two of the following four criteria, one of
which must be abnormal temperature or leukocyte count:
● Core temperature of >38.5°C or <36°C.
● Leukocyte count elevated or depressed for age (not secondary
to chemotherapy-induced leukopenia) or 10% immature
neutrophils.
● Tachycardia, defined as a mean heart rate 2 SD above normal
for age in the absence of external stimulus, chronic drugs, or
painful stimuli; or otherwise unexplained persistent elevation over
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a 0.5- to 4-hr time period OR for children <1 yr old: bradycardia,
defined as a mean heart rate <10th percentile for age in the
absence of external vagal stimulus, beta-blocker drugs, or
congenital heart disease; or otherwise unexplained persistent
depression over a 0.5-hr time period.
● Mean respiratory rate 2 SD above normal for age or mechanical
ventilation for an acute process not related to underlying
neuromuscular disease or the receipt of general anaesthesia.
Septic shock For the purpose of the SSCGC 2020, septic shock in children is
defined as severe infection leading to cardiovascular dysfunction
(including hypotension, need for treatment with a vasoactive
medication or impaired perfusion).
Sepsis-associated organ dysfunction
For the purpose of the SSCGC 2020, sepsis-associated organ
dysfunction in children is defined as severe infection leading to
cardiovascular and/or noncardiovascular organ dysfunction.
NOTE Because several methods to identify acute organ dysfunction in
children are currently available (17, 19, 20, 22, 23), SSCGC chose
not to require a specific definition or scheme for this purpose.
2.4 Process A NIP Development group was convened to oversee the development of this plan. The
NIPDG was chaired by Dr Martina Healy, National Clinical Lead for Sepsis. This NIP
is supported by HSE Clinical Strategy and Programmes Division.
Membership nominations were sought from a variety of clinical and non-clinical
backgrounds so as to be representative of all key stakeholders within the acute
healthcare sector. NIPDG members included those involved in clinical practice,
education, administration, research methodology and persons representing patients
and the public.
A NIP Development group was convened to oversee the development of this plan.
Membership detailed in (Appendix 3).
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The NIP is structured as follows:
i. SSCGC Recommendations and remarks (if present).
ii. NIP - Implementation Points (where relevant) Implementation points are
included to guide implementation of the SSCGC recommendations in Ireland,
particularly in the non-critical care environment. The implementation points
arise from piloting clinical decision support tools in the acute hospital sector,
in particular, in emergency departments (EDs) and paediatric hospitals and
units to ensure that the implementation recommendations could be affected
within the resources of our healthcare system and had the support of end-
users. The feedback from these pilots was overviewed by the National
Paediatric Sepsis Form Development Group and the forms amended based
on this feedback and re-piloted. Thus, the implementation programme is
informed by end-users and by multidisciplinary specialist input.
References that have been incorporated through this document are listed
alphabetically under National Implementation Plan References (Appendix 17). In
addition, some SSCGC references are cited in this document and are numbered as
per the SSCGC document (Appendix 16).
Appendix 8 identifies the enablers and barriers to implementing the recommendations
together with the responsibilities and timelines.
The recommendations of the SSCGC are included so that it can be read as a
standalone document. However, it is recommended that clinicians familiarise
themselves with the 2020 SSCGC,
https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Pediatric-Patients
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2.5 Consultation summary The NIPDG sought to ensure that all stakeholders had an opportunity to review and
contribute to the development of a National Implementation Plan for Sepsis in children.
The NIPDG gratefully acknowledges the contribution made by all those who
contributed from professional, academic and patient groups.
2.6 Monitoring and audit Implementing the SSCGC aims to reduce unnecessary variations in practice
and provide an evidence base for the most appropriate healthcare to optimise
children’s survival from sepsis.
The aims and objectives of the NIP will be monitored by the NSP in two ways:
(1) Audit of implementation of the SSCGC (Clinical audit/Process audit); and
(2) Audit of outcomes resulting from implementation of the SSCGC (National SepsisReport).
Clinical audit/Process audit:
Is the systematic review and evaluation of current practice against research-based
standards with a view to improving clinical care for service users and is an important
part of any quality improvement programme. The purpose of these audits is to
benchmark different areas of practice against these guidelines for the purpose of
informing on-going education and performance improvement initiatives.
The National Sepsis Programme will agree the process audit schedule annually and
inform Hospital Group leadership of same. The Group Sepsis ADONs will also notify
local sepsis committees and plan accordingly.
The process audits will be carried out by the Group ADONs in collaboration with
appropriate staff in local hospitals.
Process audit does not review the context of decision-making in patient management
and as such, cannot comment on the standard of care relating to an individual patient.
However, if during the course of an audit, the possibility of a serious patient safety
incident is considered this should be brought to the attention of the Sepsis/
Deteriorating Patient Committee. It is the responsibility of the Committee to decide if
any further action is warranted.
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It is the responsibility of the hospital sepsis committee to inform clinicians of the audit
findings and to adjust the hospital’s sepsis education programme to improve
management and to effect, along with hospital management, any outlier interventions.
Audit of outcomes: The primary aim of optimising patient survival should be audited by the publication of
age and co-morbidity adjusted sepsis-associated (direct and in-direct) hospital
mortality rates for each acute children’s hospital and benchmarked against the national
average. International benchmarking of the national sepsis-associated hospital
mortality rate should be done against other high-income jurisdictions that publish such
mortality rates.
The National Sepsis Report is published annually and describes the burden of sepsis,
in terms of the number of cases and the associated age adjusted mortality, to our
healthcare system.
The NSP suggests that the annual sepsis outcome report includes, but is not limited
to:
• the risk-adjusted hospital mortality rates;
• the incidence, patient characteristics and healthcare utilization of patients with
sepsis during their hospitalization;
• hospital group level amalgamated process audit results and
• balancing measures.
Rationale: A culture of openness promotes good practice and confidence in the healthcare
system. It is important that the community is aware of the limitations of sepsis care, its
high mortality risk and the efforts being made to reduce that risk. Sepsis guidelines
are based on the best available information at the time of publication; however, they
are just guidelines and cannot anticipate the complexity of an individual case. Data
collection on patient characteristics and risk factors allows the identification of high-
risk patients for prioritisation. However, for every patient prioritised there are others
who have been deemed less at risk. When capacity is challenging, getting this right is
a vital and difficult component of time-dependent care especially when the clinical
scenario is evolving. A hospital working within the control limits of the national average
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demonstrates that it is providing a service, in terms of sepsis care, that is as good as
anywhere else within the state.
The National Sepsis report (HSE, 2019) recommends the development of a sepsis
mortality prediction model and scoring system to compare age and co-morbidity
adjusted hospital sepsis-associated mortality rates nationally and internationally.
Secondary outcome aims include healthcare utilisation assessment such as the total
number of bed days, average length of stay, critical care admission rates and average
length of stay, and hospital readmission rates within three months (Chang, Tseng, &
Shapiro, 2015) and should be reported where possible. The assessment of healthcare
utilisation is important as a monitor of the effectiveness of the sepsis quality
improvement programme and also provides data for resource planning.
Outlier management: Hospitals whose outcome measures are in excess of the control limits will, in the first
instance have their data reviewed by the national sepsis audit committee (Appendix
1). There are 3 possible outcomes from this initial review:
1. No action warranted
2. Monitor pending further review
3. Outlier intervention warranted
Outlier interventions: 1. The NSP, including the Hospital Group Sepsis ADON, will discuss the findings and
the outcome of the National Audit Committee data review with the Hospital
Management and Clinical Director/s.
2. An improvement plan will be formulated by Hospital Management, the Clinical
Director/s and the Sepsis/ Deteriorating Patient Committee, with advice from
National Sepsis Team.
3. Audit of the improvement plan, its implementation and effect by the Hospital, with
support from the Hospital Group Sepsis ADON and collaboration from hospital
sepsis committees and the Hospital Group Leadership Team to ensure any
identified issues are addressed.
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Balancing measures: Audits should also include considerations of potential unintended consequences of the
National Sepsis Programme including inappropriate antimicrobial use. Inappropriate
antimicrobial use is a patient safety issue (e.g. adverse reactions, Clostridioides
difficile infection) and of public health concern (increased rates of multidrug resistant
organisms, MDRO) (Department of Health, 2017).
In relation to antimicrobial use, there are at least three potential unintended
consequences of implementing the Sepsis 6 bundle:
1. Children who have deteriorated but have no evidence of potential infective
source/sepsis are commenced inappropriately on antimicrobial therapy.
2. Children with sepsis are commenced on inappropriate antimicrobial therapy
that is not in line with local /national guidelines, with due consideration of the
clinical circumstances.
3. Empiric antimicrobial therapy that has been commenced in a child with
suspected sepsis is not reviewed at 24-48 hours as recommended by the Start
Smart, then Focus Antimicrobial Care bundle (RCPI , 2012) Appendix 10.
All hospitals should have antimicrobial stewardship programmes in place as outlined
in National Guidelines (Department of Health, 2017) (HSE, 2020) that monitor process
and outcome measures to ensure that antimicrobials are not being prescribed
unnecessarily due to inappropriate application of Sepsis 6. Ensuring antimicrobials are
used appropriately for all infections, not just those associated with sepsis, will
maximise clinical cure and minimise harm, for the individual patient.
Practical guidance The NSP suggests that a tool be developed to risk adjust sepsis-associated hospital
mortality (direct and in-direct) based on the Hospital In-patient Enquiry (HIPE)
database and that each acute hospital, on this database, have annual risk-adjusted
sepsis-associated mortality rates benchmarked against the national average.
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Rationale: Optimising survival from sepsis depends on the hospital system working efficiently and
effectively as a whole. It requires effective communication, adequate resources and
capacity both in infrastructure and staffing. Sepsis management and risk-adjusted
sepsis-associated hospital mortality are robust markers of the quality of acute health
care delivery.
Monitoring and acting on outcome audit ensures improvement occurs throughout the
acute healthcare system and is not sporadic. It informs the population a hospital
serves and its staff on the effectiveness of its sepsis management and it supports
improvement processes.
Roles and responsibilities: The National Sepsis Programme is responsible for publishing an annual sepsis
outcome report. Working with the Health Pricing Office (HPO), the National Sepsis
Programme will provide guidance on what outcomes, processes and patient
characteristics to audit and will review audit methodology and results to ensure that
they make clinical and statistical sense. It is the responsibility of the Programme to
provide outlier support to hospitals when indicated.
It is the responsibility of sepsis committees, Hospital Management and Hospital Group
Leadership to effect recommendations arising out of outlier intervention.
It is the responsibility of the Department of Health, the HSE, Hospital Group
Leadership and Hospital Management to support the audit process and to ensure that
adequate resources are available to perform the audit and to effect change required
based on audit results.
It is the responsibility of the Department of Health and the HSE to resource a risk-
adjusted sepsis-associated hospital mortality rate audit tool as the key performance
indicator for sepsis in Ireland.
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2.7 Financial impact of the National Implementation Plan A performance improvement programme for hospitals at both group and local level is
provided by the National Sepsis Programme with the provision of audits and education
to improve performance in the recognition and management of sepsis. Support for the
implementation of this NIP and associated costs are included in the National Clinical
Guideline No. 6 (2020 Update) – Sepsis Management for Adults (including maternity),
available on the NCEC website.
Specifically, for this NIP, the NIPDG systematically reviewed all 77 SSCGC
recommendations to determine if any had an additional budget impact for
implementation in Ireland. Each recommendation statement was discussed and
determined as either having no budget impact if the recommendation was currently
practiced, or as having a requirement for a budget resource. The costs were then
determined for the latter.
Key findings relating to costs Only 2 of 77 recommendations was determined to have a potential budgetary impact.
SSCGC Recommendation 1 In children who present as acutely unwell, we suggest
implementing systematic screening for timely recognition of septic shock and other
sepsis-associated organ dysfunction.
SSCGC Recommendation 3 We recommend implementing a protocol/guideline for
management of children with septic shock or other sepsis-associated organ dysfunction.
Educational methodologies to address paediatric sepsis screening tools and
implementation of sepsis protocols will need to be developed. A similar programme
to that of the National Sepsis Programme E-learning education “Introduction to the
Sepsis Management for Adults including Maternity “to optimise sepsis recognition and
treatment, will be essential to ensure widespread adoption of this NIP.
Table 5. Costings related to the development of an e-learning paediatric sepsis component
Potential costings
Education: E-Learning programme on HSEland, approximate costing based on Adult programme
€54,000
Sepsis form development and colour printing €356.70 per 1000
2.8 Plan to update this National Implementation Plan This NIP will be updated in line with the SSC plan to review every 4 years or sooner if
breaking and relevant evidence becomes available.
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Section 3. SSCGC recommendations incorporating the NIP Recommendations from the Surviving Sepsis Campaign International Guidelines for
the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in
Children 2020 (SSCGC) are adopted in total for use in Ireland. Recommendations are
labelled 1-77 and are divided into sections with each one pertaining to a different
aspect of patient care. Additionally, National Implementation Points are provided and
are for the purpose of implementing the SSCGC, in the Irish context, particularly in the
non-critical care environment.
The following guidance is based on the best available evidence. The Surviving Sepsis Campaign Guideline for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children 2020 (SSCGC) can be found in the Intensive Care Medicine journal, 46 (Suppl 1):S10–S67 at this link giving details of the methods and the evidence used to formulate the recommendations.
3.1 SSCGC recommendations
3.1.1 Screening, diagnosis, and systematic management of sepsis (SSCGC Recommendations 1-4)
SSCGC Recommendation 1 In children who present as acutely unwell, we suggest implementing systematic screening for timely recognition of septic shock and other sepsis-associated organ dysfunction Quality/level of evidence: Very low + Strength of recommendation: Weak SSCGC Remarks Systematic screening needs to be tailored to the type of patients, resources, and procedures within each institution. Evaluation for the effectiveness and sustainability of screening should be incorporated as part of this process.
SSCGC Recommendation 2 We were unable to issue a recommendation about using blood lactate values to stratify children with suspected septic shock or other sepsis-associated organ dysfunction into low- versus high-risk of having septic shock or sepsis. However, in our practice, if lactate levels can be rapidly obtained, we often measure blood lactate in children when evaluating for septic shock and other sepsis-associated organ dysfunction.
SSCGC Recommendation 3 We recommend implementing a protocol/guideline for management of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: ungraded + Strength of recommendation: BPS
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SSCGC Recommendation 4 We recommend obtaining blood cultures before initiating antimicrobial therapy in situations where this does not substantially delay antimicrobial administration. Quality/level of evidence: ungraded + Strength of recommendation: BPS
National Implementation point 1 (SSCGC Recommendation 1) The National Sepsis Programme will implement a system wide process to support sepsis screening and monitor sepsis performance improvement in the paediatric population, promoting safe and high-quality sepsis care.
The National Sepsis Programme follows the governance structure outlined in Figure 1. to coordinate the implementation and audit of the NIP.
Figure 1. The National Sepsis Programme Governance Structure
The National Sepsis Steering Committee is a multi-disciplinary committee
recognising that sepsis affects all specialties and services. Its membership is listed in
Appendix 1.
The National Sepsis Team reports to the steering committee and the office of the
National Clinical Advisor and Group Lead for Acute Hospitals, Health Services
Executive (HSE) and works with the National Clinical Effectiveness Committee for the
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scheduled updates of the National Clinical Guideline and advises the Department of
Health on issues related to sepsis. Its membership is listed in Appendix 2.
Hospital Sepsis Committee
All paediatric hospitals and acute hospitals with paediatric units are required to have
a Sepsis Committee whose role is to guide the implementation of the SSCGC
recommendations and this NIP in their hospital. This committee oversees the
coordination of sepsis education, introduction and utilisation of the sepsis form and
reviews audit feedback to inform this process.
The sepsis committee, together with Hospital Management and the Clinical Directors,
has responsibility for effecting and monitoring the improvements identified as audit
outlier interventions. This committee is multi-disciplinary with a named medical and
nursing lead, and should include nursing; NCHDs; clinical microbiology; pharmacy
(e.g. antimicrobial pharmacist); coding; practice facilitators and educators and may
invite other specialties as required.
The committees liaise with their Group Sepsis Assistant Director of Nursing (ADON) and
the National Team. This is a two-way relationship with the sepsis committees feeding back
to the programme on the usefulness of aids and algorithms, suggestions to improve sepsis
management and suggesting specific audits. Ideally, there should be a Hospital Group
Sepsis ADON as a member of each hospital committee in their group.
In turn the National Team provides tools to assist education, implementation and audit
feedback. Should outlier intervention be required, the National Team can advise the
Hospital Sepsis Committee and Management and offer further education and audit
support. The Hospital Group Sepsis ADON works with the hospital, the Hospital Group
Leadership Team and the National Sepsis Team to support sepsis quality
improvement.
Sepsis Education
This guideline recognises that the responsibility for sepsis education falls under a number
of domains and recommends that education providers ensure that their education curricula
are consistent with the SSCGC recommendations and this NIP. (Fig.2)
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Figure 2. Sepsis Education Overview
Roles and Responsibilities It is the responsibility of the HSE to provide appropriate structured support and
adequate resources for the governance, operationalisation, and audit of sepsis
management in the acute healthcare sector for children.
It is the responsibility of the Sepsis Steering Committee to provide clinical expertise
and guidance for the National Sepsis Programme.
It is the responsibility of the National Sepsis Team to ensure that clinical guidance is
in line with best international practice, to provide clinical advice and decision support
tools to local hospital sepsis committees and to oversee process and outcome audit,
provide feedback and to advise on outlier intervention when required.
It is the responsibility of the Hospital Group Leadership Team, Hospital Management
and Clinical Directors to support sepsis quality improvement and to foster and facilitate
the implementation process and audit. They are also responsible for effecting and
monitoring change arising from outlier intervention.
Under graduate Nursing/
Midwifery & Medical
PostgraduateNursing/
Midwifery & Medical
National Intern
Training Programme
Hospital based
learning
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It is the responsibility of hospital sepsis committees to co-ordinate SSCGC
recommendations and NIP implementation in their hospital and to work with the
Hospital Group Sepsis Assistant Directors of Nursing (ADON) and the National Sepsis
Team with the aim of optimising sepsis recognition and treatment (Appendix 11).
Figure 3. Flowchart for the Implementation of the SSCGC recommendations.
It is the responsibility of the Sepsis ADON to help support the local hospital sepsis
committees’ aims by performing audit and feedback on the sepsis care in their
institution and by liaising with the National Sepsis Programme to ensure effective
communication between the Programme, the Hospital Group Leadership and Local
IDENTIFY LOCAL
IMPLEMENTATION LEADS TO
COORDINATE
IMPLEMENTATION OF SEPSIS
GUIDELINE (NIP)
LOCAL SEPSIS COMMITTEE
(Adult committee should have representation from
Paediatrics)
Membership should include:
• Medical and Nursinggrades
• Quality & Risk• Audit,• Education personnel
/practice development• Hospital management• Pharmacy• Microbiology /IPC• Sepsis ADON• PEWS representative
Sepsis champions on each site
Educational material
Sepsis form utilisation
Audit process
NATIONAL SEPSIS TEAM
SEPSIS ADON
Annual process audits
National Sepsis report
Educational material
Sepsis Guideline
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Hospitals. The Sepsis ADONs also have a role in fostering new sepsis initiatives and
international benchmarking.
It is the responsibility of Nursing/Midwifery and Medical Colleges, Under and Post-
Graduate to ensure that their sepsis curricula are consistent with the SSCGC
recommendations and NIP and to provide their graduates with the appropriate
knowledge and skillset to be able to comply with the recommendations therein.
Healthcare professionals are responsible for undertaking relevant education as often
as they deem necessary to develop their professional practice and maintain their
professional competence.
Implementation point 2 (SSCGC Recommendation 2) Lactate levels should be monitored as part of the ongoing assessment of
cardiovascular dysfunction. In Ireland, persistently elevated lactate levels of >4
mmol/L after 20mLs/kg fluid therapy is indicative of organ dysfunction. The target
therapeutic lactate level is < 2mmol/L.
Although blood lactate may be affected by the conditions of the blood draw (e.g. use
of a tourniquet), both elevated venous and arterial lactate measurements have been
shown to be associated with increased risk of organ dysfunction, resuscitative
therapies and critical illness (Scott, Donoghue, Gaieski, Marchese, & Mistry, 2012).
There is evidence from a number of studies that agreement between peripheral
venous and arterial lactate is satisfactory at normal lactate concentration ≤ 2.0 mmol/
L, but declines as lactate concentration increases (Samaraweera, Gibbons, Gour,
& Sedgwick, 2017).
Blood tests must be sent marked urgent and must be reviewed and acted upon in a
timely fashion.
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Roles and Responsibilities To undertake venepuncture and obtain blood samples, healthcare practitioners must
have completed appropriate training and maintain best practice when undertaking
these procedures. Hospitals should be aware of the requirement for Point of care
(POC) lactate availability and should support, where appropriate, applications for
additional equipment.
Healthcare providers should be aware of their institutions POC accessibility and
usage. It is the responsibility of the hospital and laboratory management to ensure
that all point of care equipment is subjected to laboratory governance including internal
quality control and external quality assurance.
Implementation point 3 (SSCGC Recommendation 3) The NSP provides a paediatric sepsis form which incorporates an early recognition,
treatment and referral algorithm for the management of children with septic shock or
other sepsis-associated organ dysfunction (Fig. 3).
The paediatric sepsis form is a clinical decision support tool (Appendix 9) (Fig.4)
designed by the Paediatric Sepsis Working Group and is aimed at providing guidance
for clinicians to recognise and treat sepsis in a timely manner. It does not replace
clinical judgement but it does ensure that all criteria are considered when treating a
child who may have sepsis.
Clinical decision support tools help clinicians to identify high-risk patients, consider sepsis as
a differential diagnosis during examination and initiate timely treatment if required. Such
protocols have been shown to improve the speed and reliability of care for children with septic
shock or other sepsis-associated organ dysfunction (Weiss, et al., 2020)
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Figure 4. Paediatric Sepsis Form
Familiarity with the paediatric sepsis form is required, if early detection of sepsis is to
be successful. Bedside identification and severity assessment for sepsis can be
instigated using the tool, in conjunction with clinical judgement.
If there is a clinical suspicion of infection and the child appears unwell – you need
to ask – COULD THIS BE SEPSIS.
Broad categorisations of high risk criteria (red flags) and intermediate risk criteria
(amber flags & risk factors) are displayed algorithmically, to empower the clinician to
act promptly. Following screening for sepsis with the paediatric form, patients who
trigger a “red flag” require immediate medical review, patients with an amber flag +/-
risk factors, have an increased risk of deterioration from sepsis and need to be
reviewed promptly.
The outcome of screening is NOT the Sepsis 6 bundle but rather an early thorough
medical review to develop a differential diagnosis for the patient’s presentation.
42
☐ Inappropriate tachypnoea i.e. does not respond with simple measures☐ Altered functional status (e.g. severe leg pain, or inability to weight-bear or decreased activity)☐ Healthcare professional concern ☐ Parental concern☐ Increasing PEWS ☐ Other:
≥1 Amber Flag
Start Sepsis 6 within 1hrTime:
Yes NoSigns of Shock 3hr window for diagnostic
work up - see “take 3”Suspicion Time:
YesSuspected SepsisWorking Diagnosis:
Review within:
Sepsis NOT likely at this time
Addressograph
Paediatric Sepsis FormFor early recognition, treatmentand referral (ALWAYS USE CLINICAL JUDGEMENT)
PAEDIATRIC PATIENTS(from 4 weeks (or 4 wkscorrected age)to 16 years)
There are separate sepsis criteria formaternity patients and adults
Ver
sion
5 -
12/0
8/20
21
Complete this form if there is a clinical suspicion of infection and the child appears unwell. When complete, sign and place in child’s healthcare record. Seek senior expert help early if sepsis is suspected.
Page 1 of 2, continue overleaf
Doctor (Print Name): Doctor Signature:
MCRN: Date: Time:
Print name:Signature:
Role:NMBI or MCRN:
Date: Time:
Is Sepsis likely at this time?
Urgent medical review if ≥1 Amber Flag +/- Risk Factor(s)
Certain conditions will increase risk of sepsis and should lower threshold for initiation of Sepsis 6. These include:☐ Immunocompromised (follow national haematology/oncology guidelines for children with cancer)☐ Age ≤3 months ☐ Chronic disease☐ Recent surgery ☐ Break in skin (including chickenpox)☐ Indwelling line/device ☐ Signs of infection in a wound (including chickenpox) ☐ Incomplete vaccination record ☐ Other:
Risk Factor(s)
No Red FlagYes
Immediate medical review
☐ Altered mental status- P or U on AVPU ☐ Hypotension ☐ Prolonged central capillary re�ll☐ Tachycardia unexplained by fever/crying ☐ Non-blanching rash ☐ Clinical deterioration as in-patient
≥1 Red Flag
COULD THIS BE SEPSIS?
Look for signs of septic shock (following administration
of �uid bolus of up to 40ml/kg)
☐ Hypotension
☐ Prolonged central CRT
☐ Core to peripheral temperature gap ≥30C
☐ Unexplained metabolic acidosis
☐ Oliguria: ≤1ml/kg/hour up to 11 years or ≤0.5ml/kg/hour in the 12+ age group
☐ Need for inotropic support
☐ This is SEPTIC SHOCK
Time:
In addition to senior clinical support at the bedside early involvement of PICU support is encouraged. Where PICU support is not on site a national 24-hour hotline is available for urgent referrals providing advice and arranging transfer – 1800 222 378.
Tick samples taken:☐ Blood cultures ☐ FBC☐ Glucose ☐ Blood gas☐ Coag screen incl �brinogen☐ Lactate☐ U&E ☐ LFTs☐ CRP☐ Urinalysis☐ PCRs if available
☐ Urine output assessment/measurement
☐ Early senior input (essential) as per local escalation policy
Time Sepsis 6 completed:
Name: MCRN:
GIVE 3TAKE 3
☐ IV access Time or ☐ IO access Time
Paediatric Sepsis FormOngoing clinical review and interpretation of results (ALWAYS USE CLINICAL JUDGEMENT)
Mo
chua
Pri
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Des
ign
| ww
w.m
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Page 2 of 2
File this document in the child’s healthcare record.
Doctor (Print Name): Doctor Signature:
MCRN: Date: Time:
Reassess the child as clinically indicated and complete formwithin 1 hour of initiating the Sepsis 6 bundle
☐ Oxygen to achieve saturations ≥94% titrating to e�ect or as appropriate in chronic lung or cardiac disease
☐ IV/IO �uids- Titrate 10-20mls/kg Hartmann’s Solution over 5-10min, 0.9% NaCL is
an acceptable alternative – repeat as per clinical response- Call critical care/anaesthesia in haemodynamic collapse- Consider early inotropic support- Assess for �uid overload, monitor for crepitations or
hepatomegaly
☐ IV/IO Antimicrobials according to the site of infection and following local antimicrobial guidelines.Drug name: Dose: Time given:
Paediatric Sepsis 6 – complete within 1 hour
Look for signs of new organ dysfunction after the Sepsis 6 bundle has been given or from blood test results – any one is su�cient:Cardiovascular☐ Lactate ≥4 after 20mls/kg �uid
therapy
Central Nervous System☐ Glasgow coma score (GCS) ≤11 or
poorly responsive☐ Acute change in mental status
with a decrease in GCS ≥3 points from usual baseline
Haematological☐ Platelet count ≤80,000/mm3
Coagulation☐ International normalised ratio ≥2
Respiratory ☐ Increasing need for Oxygen to
maintain saturations ≥ 94% titrating to e�ect or as appropriate in chronic lung or cardiac disease
☐ Need for nonelective invasive or noninvasive mechanical ventilation
Renal ☐ Serum creatinine ≥2 times upper limit
of normal for age or 2-fold increase in baseline creatinine
Liver ☐ Total bilirubin Bilirubin ≥ 38 µmol/L
(micromoles/L) not applicable for newborn
☐ ALT 2 times upper limit of normal for age
Any new organ dysfunction due to infection: ☐ This is SEPSISInform Consultant and Anaesthesia/PICU. Time:Reassess frequently in the �rst hour. Consider other investigations and management +/- source control if child does not respond to initial therapy.No new organ dysfunction due to infection: ☐ This is NOT SEPSIS If infection is diagnosed, proceed with usual treatment pathway for that infection.
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SEPSIS 6 BUNDLE: Initial treatment For children with septic shock, for whom clinical recognition of abnormal perfusion or
hypotension is evident, without the need for additional laboratory testing, the Sepsis 6
bundle should be completed within one hour of recognition, (i.e. TIME ZERO) (Weiss
& Pomerantz, Septic shock in children: Rapid recognition and initial resuscitation (first
hour), 2020).
For children with suspected sepsis but without clinical evidence of shock, the same
management steps are recommended if additional laboratory and clinical testing to
assess for infection and organ dysfunction support the diagnosis of sepsis. Initiation
of the Sepsis 6 bundle should occur within three hours of initial suspicion of sepsis
(but start as soon as sepsis is evident) (Weiss & Pomerantz, Septic shock in children:
Rapid recognition and initial resuscitation (first hour), 2020).
The SSCGC Initial Resuscitation Algorithm for Children illustrates this clearly
(Appendix 13).
Antimicrobials are the primary medical therapy that directly targets the underlying
cause of sepsis, and there is strong biologic rationale for rapid delivery of
antimicrobials in patients with sepsis (Weiss, et al., 2020)
Figure 5. Sepsis 6 Bundle
43
Look for signs of septic shock (following administration
of �uid bolus of up to 40ml/kg)
☐ Hypotension
☐ Prolonged central CRT
☐ Core to peripheral temperature gap ≥30C
☐ Unexplained metabolic acidosis
☐ Oliguria: ≤1ml/kg/hour up to 11 years or ≤0.5ml/kg/hour in the 12+ age group
☐ Need for inotropic support
☐ This is SEPTIC SHOCK
Time:
In addition to senior clinical support at the bedside early involvement of PICU support is encouraged. Where PICU support is not on site a national 24-hour hotline is available for urgent referrals providing advice and arranging transfer – 1800 222 378.
Tick samples taken:☐ Blood cultures ☐ FBC☐ Glucose ☐ Blood gas☐ Coag screen incl �brinogen☐ Lactate☐ U&E ☐ LFTs☐ CRP☐ Urinalysis☐ PCRs if available
☐ Urine output assessment/measurement
☐ Early senior input (essential) as per local escalation policy
Time Sepsis 6 completed:
Name: MCRN:
GIVE 3TAKE 3
☐ IV access Time or ☐ IO access Time
Paediatric Sepsis FormOngoing clinical review and interpretation of results (ALWAYS USE CLINICAL JUDGEMENT)
Mo
chua
Pri
nt &
Des
ign
| ww
w.m
och
uap
rint
.ie
Page 2 of 2
File this document in the child’s healthcare record.
Doctor (Print Name): Doctor Signature:
MCRN: Date: Time:
Reassess the child as clinically indicated and complete formwithin 1 hour of initiating the Sepsis 6 bundle
☐ Oxygen to achieve saturations ≥94% titrating to e�ect or as appropriate in chronic lung or cardiac disease
☐ IV/IO �uids- Titrate 10-20mls/kg Hartmann’s Solution over 5-10min, 0.9% NaCL is
an acceptable alternative – repeat as per clinical response- Call critical care/anaesthesia in haemodynamic collapse- Consider early inotropic support- Assess for �uid overload, monitor for crepitations or
hepatomegaly
☐ IV/IO Antimicrobials according to the site of infection and following local antimicrobial guidelines.Drug name: Dose: Time given:
Paediatric Sepsis 6 – complete within 1 hour
Look for signs of new organ dysfunction after the Sepsis 6 bundle has been given or from blood test results – any one is su�cient:Cardiovascular☐ Lactate ≥4 after 20mls/kg �uid
therapy
Central Nervous System☐ Glasgow coma score (GCS) ≤11 or
poorly responsive☐ Acute change in mental status
with a decrease in GCS ≥3 points from usual baseline
Haematological☐ Platelet count ≤80,000/mm3
Coagulation☐ International normalised ratio ≥2
Respiratory ☐ Increasing need for Oxygen to
maintain saturations ≥ 94% titrating to e�ect or as appropriate in chronic lung or cardiac disease
☐ Need for nonelective invasive or noninvasive mechanical ventilation
Renal ☐ Serum creatinine ≥2 times upper limit
of normal for age or 2-fold increase in baseline creatinine
Liver ☐ Total bilirubin Bilirubin ≥ 38 µmol/L
(micromoles/L) not applicable for newborn
☐ ALT 2 times upper limit of normal for age
Any new organ dysfunction due to infection: ☐ This is SEPSISInform Consultant and Anaesthesia/PICU. Time:Reassess frequently in the �rst hour. Consider other investigations and management +/- source control if child does not respond to initial therapy.No new organ dysfunction due to infection: ☐ This is NOT SEPSIS If infection is diagnosed, proceed with usual treatment pathway for that infection.
Addressograph
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Having administered the Sepsis 6 bundle, the patient should be reviewed with the
results of the tests and investigations sent as a consequence of their medical review.
This provides the first opportunity to review the working diagnosis and treatment. If a
non-infective aetiology for the patients’ presentation has been identified, stop
antimicrobials.
If the investigations have localised the site of infection, review antimicrobial
prescription using local antimicrobial guidelines to ensure it is the most appropriate
choice. If not already reviewed when empiric antimicrobial therapy was prescribed,
review patients past microbiology results, as a previous history of multi-drug resistant
organisms may influence choice of antimicrobial. Complex cases may benefit from
Clinical Microbiology/ Infectious Disease speciality review.
In general terms, if discharging a child or infant from an acute care setting, ensure that
verbal and preferably written safety net advice has been given. If the diagnosis is
uncertain, that uncertainty should be communicated to the patient (or parent/carer) so
that they are empowered to re-consult if necessary (Roland, Jones, Neill, Thompson,
& Lakhanpaul, 2014).
In the context of possible sepsis, safety net advice should include the specific clinical
features that the patient (or parent/carer) should look out for and when they should
seek medical help. Parent information leaflets are a useful aide memoire for
parents/carers (HSE parent leaflet Appendix 7).
Roles and Responsibilities All clinicians (medical and nursing) should be familiar with the Sepsis 6 treatment
bundle; they should work together to ensure that patients, who on history and
examination have a suspicion of infection and are identified by screening as high risk
of mortality from sepsis, receive the components of the Sepsis 6 bundle within the
recommended timeframe.
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Sepsis diagnosis Sepsis is diagnosed when acute organ dysfunction consequent to infection occurs.
This diagnosis can be made before or after the initiation of the Sepsis 6 bundle
depending on whether the organ dysfunction is diagnosed clinically or based on the
laboratory results.
Infection, sepsis and septic shock are clinical diagnoses. There is no one test that will
confirm the presence of infection, sepsis or septic shock to the exclusion of other
diagnoses. Rather, the suite of symptoms and signs together with tests and
investigations need to be weighed against the differential diagnoses and a clinical
decision made. The presence of positive cultures does much to support an infective
aetiology but only occurs in 40-60% of sepsis cases, (Martin, Mannino, Eaton, & Moss,
2003) (Brun-Buisson, et al., 1995) ( (Phua, et al., 2003) and has a time lag to positivity
(HSE, 2020).
SSCGC defines septic shock as severe infection leading to cardiovascular dysfunction
(including hypotension, treatment with a vasoactive medication, or impaired perfusion)
and “sepsis-associated organ dysfunction” in children as severe infection leading to
cardiovascular and/or noncardiovascular organ dysfunction. New or progressive organ
dysfunction is associated with higher mortality in children with suspected infections
(Lin, et al., 2017).
Identifying an organ dysfunction scoring system for children, similar to the adult model
e.g. SOFA score has proven difficult due to the differences that exist in physiology,
immune responses and co- morbidities in the paediatric patient population (Hsu, et al.,
2019). Similar organ dysfunction scoring systems for children are currently being
explored, primarily in critical care settings, to help define robust organ dysfunction
categorisation (Schlapbach, Straney, Bellomo, MacLaren, & Pilcher, 2018).
Implementation point 4 (SSCGC Recommendation 3) Early escalation to senior support is vital so that early sepsis treatment can be initiated.
Use of early warning systems in conjunction with the sepsis form will support this to
occur in acute healthcare settings for children.
In-patients: However, the sepsis form must work well with existing or planned early warning and
rapid response systems that may also have inherent limitations (Weiss, et al., 2020).
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For example, children can often compensate well during a disease process like
sepsis. This means that subtle changes can be missed until they suddenly
decompensate and become extremely unwell. Using national paediatric observation
charts, it is essential to note any individual outlying parameters, observe trends, and
be aware that a child showing no signs of improvement may quickly lose the ability to
compensate (HSE, 2016a). The Irish Paediatric Early Warning System (PEWS) is
recommended as the system to be used to identify high risk and deteriorating
admitted children with infection and sepsis (HSE, 2016a) (HSE, 2018)
http://health.gov.ie/wp-content/uploads/2017/02/NCG-12-PEWS-full-report-V21.pdf Sepsis awareness and education should be interlinked with the PEWS programme to
ensure consistency and cohesion of the sepsis NIP.
Emergency Department: Many children with sepsis will present with non-specific signs and symptoms early in
their disease course, with the full severity of the illness becoming manifest later. This
presents a challenge to clinicians working in an ED regarding when to initiate the
Paediatric Sepsis Form for the un-differentiated child. In the paediatric emergency
department setting, the Irish Children’s Triage System (ICTS) facilitates the prompt
recognition of acuity for ill or injured children (HSE, 2016b). The presenting complaint
determines how quickly a child will be medically reviewed. Children who present in
septic shock must have the Sepsis 6 completed within 1 hour of presentation and
children who are at risk of sepsis but do not present in septic shock, should be
medically reviewed and have the Sepsis 6 completed within 3 hours if appropriate.
The Paediatric Sepsis Form is a clinical decision support tool that will help in this
decision-making process.
Implementation point 5 (SSCGC Recommendation 3) Strategies for the utilisation and implementation of the sepsis form should be initiated
by each institution to enable continuous improvement and embedding of good
practice. Education on using the sepsis form in a clinical context needs to be
consistently driven by each paediatric acute care setting through a variety of
methodologies. The development of a virtual learning programme will be a key driver
in the education of paediatric sepsis nationally.
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Implementation point 6 (SSCGC Recommendation 4) In children with suspected sepsis or septic shock, blood cultures should be obtained
before initiation of antimicrobial therapy if it results in no substantial delay to the start
of antimicrobials. The collection of other biological specimens to identify pathogens
from nonblood sites (e.g. urine, cerebrospinal fluid, tracheal aspirate, broncho-alveolar
lavage, drainage from collections) should also happen as soon as possible, and
depending on the suspected site of infection, such specimens may have a higher yield
of pathogen identification than blood cultures. Where cultures yield specific target
pathogens, these should be sent to relevant reference laboratories for confirmation.
Blood cultures should always be taken using an aseptic (no touch) technique. Care
should be taken to prevent contamination when obtaining cultures as this may lead to
the initiation of unnecessary antimicrobial therapy and investigations, potential
adverse events, as well as lengthening hospital stays and costs (HSE, 2020).
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3.1.2 Antimicrobial therapy (SSCG Recommendations 5-14)
SSCGC Recommendation 5 In children with septic shock, we recommend starting antimicrobial therapy as soon as possible, within 1 h of recognition Quality/level of evidence: very low + Strength of recommendation: Strong
SSCGC Recommendation 6 In children with sepsis-associated organ dysfunction but without shock, we suggest starting antimicrobial therapy as soon as possible after appropriate evaluation, within 3 h of recognition Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 7 We recommend empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens Quality/level of evidence: ungraded + Strength of recommendation: BPS
SSCGC Recommendation 8 Once the pathogen(s) and sensitivities are available, we recommend narrowing empiric antimicrobial therapy coverage. Quality/level of evidence: ungraded + Strength of recommendation: BPS
SSCGC Recommendation 9 If no pathogen is identified, we recommend narrowing or stopping empiric antimicrobial therapy according to clinical presentation, site of infection, host risk factors, and adequacy of clinical improvement in discussion with infectious disease and/or microbiological expert advice. Quality/level of evidence: ungraded + Strength of recommendation: BPS
SSCGC Recommendation 10 In children without immune compromise and without high risk for multidrug-resistant pathogens, we suggest against the routine use of empiric multiple antimicrobials directed against the same pathogen for the purpose of synergy. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Remarks: In certain situations, such as confirmed or strongly suspected group B streptococcal sepsis, use of empiric multiple antimicrobials directed against the same pathogen for the purpose of synergy may be indicated
SSCGC Recommendation 11 In children with immune compromise and/or at high risk for multidrug-resistant pathogens, we suggest using empiric multi-drug therapy when septic shock or other sepsis-associated organ dysfunction is present/suspected. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 12 We recommend using antimicrobial dosing strategies that have been optimized based on published pharmacokinetic/pharmacodynamic principles and with consideration of specific drug properties. Quality/level of evidence: ungraded + Strength of recommendation: BPS
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SSCGC Recommendation 13 In children with septic shock or sepsis-associated organ dysfunction who are receiving antimicrobials, we recommend daily assessment (e.g., clinical, laboratory assessment) for de-escalation of antimicrobial therapy. Quality/level of evidence: ungraded + Strength of recommendation: BPS
SSCGC Remarks: This assessment should include a review of the ongoing indication for empiric antimicrobial therapy after the first 48 h that is guided by microbiologic results and in response to clinical improvement and/or evidence of infection resolution. This recommendation applies to patients being treated with empiric, targeted, and combination therapy.
SSCGC Recommendation 14 We recommend determining the duration of antimicrobial therapy according to the site of infection, microbial aetiology, response to treatment, and ability to achieve source control. Quality/level of evidence: ungraded + Strength of recommendation: BPS
Implementation point 7 (SSCGC Recommendations 5-6) Children with sepsis or septic shock generally warrant empiric broad-spectrum therapy
until the causative organism and its antimicrobial susceptibilities are defined. At that
point, the spectrum of coverage should be narrowed by eliminating unneeded
antimicrobials and replacing broad-spectrum agents with more specific agents.
However, if relevant cultures are negative, empiric narrowing of coverage based on a
good clinical response is appropriate. Collaboration with antimicrobial stewardship
programmes is encouraged to ensure appropriate choices and rapid availability of
effective antimicrobials for treating septic patients (HSE Health Protection Surveillance
Centre, 2009) (HSE, 2020).
Managing sepsis in the era of increasing rates of multi-drug resistant organisms
(MDRO) should be tightly linked with antimicrobial stewardship. Coupled with rising
rates of MDRO, few new antimicrobials are being developed, therefore, prescribing
antimicrobials appropriately is essential for patient safety (to minimise adverse effects
and maximise clinical cure) and to minimise the risk of causing antimicrobial resistance
in the individual, that may also have an impact for other patients, so that effective
antimicrobials are available to manage infection and sepsis. It is recommended that
the ‘Start Smart and then Focus’ approach is employed for antimicrobial therapy
(Royal College of Physicians of Ireland, 2020) (Appendix 11).
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Start Smart Intravenous antimicrobials are administered as part of the Sepsis 6 bundle within one
hour of diagnosis of infection in children with septic shock OR within a three-hour
window for those patients with suspected infection without clinical signs of shock or
organ dysfunction. All acute hospitals have local antimicrobial age related guidelines
for the empiric use of antimicrobials in children that are appropriate for the local MDRO
epidemiology. It is recommended that these guidelines be used to choose empiric
therapy for patients with infection, taking the following into consideration:
1. Source of the infection
• Community acquired
• Health-care associated
• Hospital acquired.
2. Site of the infection
Based on the history and the examination of the patient e.g. respiratory,
abdominal, genito-urinary, device or catheter-related, cellulitis, central
nervous system, bone or joint or unknown.
3. Patient considerations
Patient factors that need to be taken into consideration and may influence the
choice of empiric antimicrobial therapy include:
• Age: neonates and young infants < 3months, infants >3 months-1 yr
and children
• Vaccination Status
• Malignancy and immunocompromising medical conditions.
• Previous infection or colonisation with MDRO such as methicillin
resistant Staphylococcus aureus (MRSA), extended-spectrum B-
lactamase (ESBL) producing /gram negative organism etc.
• Recent antimicrobial therapy
• Current outbreaks
• Recent infections in close contacts
• Recent travel or hospitalization and/or residence in another country
• Allergy status
• Renal/hepatic impairment
• Drug interactions
• Conditions that make some antimicrobials a greater risk
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Local/national antimicrobial prescribing guidelines take these principles into account
when recommending doses for differing infection severities and infections at
particular body sites.
Contact a senior colleague or infection specialist (microbiologist, infectious diseases
physician or antimicrobial pharmacist) for advice regarding dose optimisation.
Then Focus
It is important to review the patient daily and to assess the antimicrobial therapy in
terms of the patients’ clinical response and laboratory results during the acute phase
of the illness and to decide on and document the duration of treatment appropriate to
the illness. Important determinants of the required duration of antimicrobial therapy
include site of infection, ability to drain or remove fixed infectious foci, choice of
antimicrobial therapy, time to clearance of positive cultures, the nature of the causative
pathogen, and the integrity of the host immune response. (Royal College of Physicians
of Ireland, 2020).
For children with septic shock, broad-spectrum IV antimicrobial therapy should
commence within one hour of presentation, preferably after obtaining appropriate
cultures. Effective delivery of antibiotics usually requires two ports or sites for IV
access: one devoted to fluid resuscitation and one for antimicrobial delivery. If
obtaining blood cultures is difficult, it should not impede antibiotic initiation within the
first hour.
Antifungal and antiviral agents should be considered as part of the initial regimen for
susceptible patients e.g. oncology/haematology patients. Contact a senior colleague
or infection specialist (microbiologist, infectious diseases physician) for further advice
if required. Local/national guidelines may include alternative antibiotics for susceptible
patients.
In cases of suspected Toxic Shock Syndrome, seek senior clinician support, consult
with microbiology and consider Clindamycin as an adjunctive agent.
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3.1.3 Source Control (SSCGC Recommendations 15-16)
SSCGC Recommendation 15 We recommend that emergent source control intervention be implemented as soon possible after a diagnosis of an infection amenable to a source control procedure is made Quality/level of evidence: ungraded + Strength of recommendation: BPS
SSCGC Remarks: Appropriate diagnostic testing to identify the site of infection and microbial aetiology should be performed, and advice from specialist teams (e.g., infectious diseases, surgery) should be sought, as appropriate, in order to prioritize interventions needed to achieve source control
SSCGC Recommendation 16 We recommend removal of intravascular access devices that are confirmed to be the source of sepsis or septic shock after other vascular access has been established and depending on the pathogen and the risks/ benefits of a surgical procedure Quality/level of evidence: low + Strength of recommendation: Strong
Implementation point 8 (SSCGC Recommendations 15-16)
In order to achieve compliance with these recommendations a number of steps need to occur:
1. Microbiology or infectious diseases consult and advice
2. Identification of the need for source control
3. Early consultation with appropriate surgical team
4. Access to diagnostics
5. Feasibility of achieving source control
6. Access to interventional radiology/ surgery
Patients whose infection is not settling on appropriate antimicrobials need to be re-
assessed for source control including reviewing implanted devices and catheters as
potential sources. If such devices are potential sources, they should be removed or
treated where possible and sent for culture and antimicrobial susceptibility testing.
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3.1.4 Fluid Therapy (SSCGC Recommendations 17-23)
SSCGC Recommendation 17 In healthcare systems with availability of intensive care, we suggest administering up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour, titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 18 In healthcare systems with no availability of intensive care and in the absence of hypotension, we recommend against bolus fluid administration while starting maintenance fluids Quality/level of evidence: high + Strength of recommendation: Strong
SSCGC Recommendation 19 In healthcare systems with no availability of intensive care, if hypotension is present, we suggest administering up to 40 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour with titration to clinical markers of cardiac output and discontinued if signs of fluid overload develop Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Remarks: Clinical markers of cardiac output may include heart rate, blood pressure, capillary refill time, level of consciousness, and urine output. In all settings, the need for fluid administration should be guided by frequent reassessment of clinical markers of cardiac output, serial blood lactate measurement and advanced monitoring, when available. Signs of fluid overload that should limit further fluid bolus therapy may include clinical signs of pulmonary edema or new or worsening hepatomegaly
SSCGC Recommendation 20 We suggest using crystalloids, rather than albumin, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: moderate + Strength of recommendation: Weak
SSCGC Remarks: Although there is no difference in outcomes, this recommendation takes into consideration cost and other barriers of administering albumin compared with crystalloids.
SSCGC Recommendation 21 We suggest using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
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Implementation point 9 (Recommendations 17-23) For children with septic shock treated in settings with access to acute intensive care
capability, (either locally or via inter-hospital transfer), patients without signs of fluid
overload should receive 10-20mL/kg of balanced crystalloid solution such as lactated
Ringer's solution (Hartmann’s solution); 0.9% Normal Saline is an acceptable
alternative if lactated Ringer's solution is not available. (Advanced Paediatric Life
Support Group, 2016). The volume of either 10-20mL/kg of fluid resuscitation
acknowledges clinician discretion with regard to the individual patient, considering
aetiology, pathophysiology, age, i.e. infants < 3mths, comorbidities, pre-existing
cardiac disease. Fluids should be rapidly infused over a 5-10 minute period, either via
intravenous (IV) or intraosseous (IO) access. Fluid volume should be calculated based
upon ideal body weight.
If the patient develops signs of fluid overload (e.g., rales, worsening respiratory
distress, new or worsening oxygen requirement, gallop rhythm, hepatomegaly, or
cardiomegaly or pulmonary oedema on chest X-ray), the fluid bolus should be omitted
or reduced. After the initial infusion, the child should be quickly reassessed for signs
of inadequate end-organ perfusion to determine if additional fluid is needed and to
identify any signs of fluid overload. Further fluid boluses should be titrated according
to cardiovascular response. If, following 40mL/kg fluid bolus within the first hour, the
child continues to show signs of cardiovascular dysfunction and/or new organ
dysfunction and a third bolus is warranted, senior clinical input is required.
SSCGC Recommendation 22 We recommend against using starches in the acute resuscitation of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: moderate + Strength of recommendation: Strong
SSCGC Recommendation 23 We suggest against using gelatin in the resuscitation of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
Caution: Some medications interact with Ringers Lactate/Hartmann’s Solution Check local guidelines
Note: Children with fluid-refractory, hypotensive septic shock, warrant initiation of vasoactive medication. If there is no PICU support on site, seek advice on national 24-hour hotline 1800 222 378.
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IPATS (Irish Paediatric Acute Transport Service) supports the transfer of critically ill
infants and children (aged 4 weeks to 16 years) from a referring hospital to the
Paediatric Intensive Care Unit (PICU) in CHI at Crumlin or CHI at Temple
Street (Appendix 12).
Services include:
• 24 hour/day PICU referral and advice
• 5 day IPATS Critical Care Transport Team – IPATS transfers critically ill infants
and children (aged 4 weeks to 16 years) to the Paediatric Intensive Care unit
(PICU) in CHI at Crumlin or CHI at Temple Street
• IPATS website have documents and guidelines to assist a local team transfer
outside of IPATS operational hours, to facilitate the safe transfer of children.
www.nasccrs.ie/IPATS
NNTP (National Neonatal Transport Programme) is a 24/7 retrieval service for the
stabilisation and transportation of premature and sick neonates up to the age of 6
weeks corrected gestational age.
While it is acknowledged that critical care facilities for children are not available in all
hospitals that anaesthetise children, facilities for initiating intensive care prior to
transfer/retrieval to a designated regional PICU/HDU facility should be available. This
may involve the short-term use of adult/general ICU facilities (HSE Model of Care for
Paediatric Critical Care, 2019).
Where critically ill children present to the adult critical care service, the care principles are
focused on resuscitation and transport/retrieval. (HSE, Critical Care Programme, 2014).
All paediatric facilities where undifferentiated paediatric patients present must retain
the equipment and competencies to resuscitate, stabilise and transfer out critically ill
children. (HSE, National Clinical Programme for Anaesthesia, 2019).
In centres that do not have an on-site PICU, anaesthesia involvement will also be
required in the management of critically ill children who frequently require intubation,
resuscitation and initiation of intensive care, before the arrival of the retrieval team or
direct transfer to a PICU. (HSE,National Clinical Programme for Anaesthesia, 2015).
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In all circumstances, arrangements should be made as soon as possible with the
paediatric critical care network for the transfer/retrieval of the critically ill child.
3.1.5 Haemodynamic monitoring (SSCGC Recommendations 24-27)
Implementation point 10 (SSCGC Recommendations 24-27) Hypotension can be defined as
(1) systolic blood pressure of
• Less than 50 mm Hg in children younger than 12 months old,
• less than 60 mm Hg in children 1–5 years old,
• less than 70 mm Hg in children older than 5 years old [183]
SSCGC Recommendation 24 We were unable to issue a recommendation about whether to target mean arterial blood pressure (MAP) at the 5th or 50th percentile for age in children with septic shock and other sepsis-associated organ dysfunction. However, in our practice, we target MAP to between the 5th and 50th percentile or greater than 50th percentile for age.
SSCGC Recommendation 25 We suggest not using bedside clinical signs in isolation to categorize septic shock in children as “warm” or “cold”. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 26 We suggest using advanced hemodynamic variables, when available, in addition to bedside clinical variables to guide the resuscitation of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Remarks: Advanced hemodynamic monitoring may include cardiac output/cardiac index, systemic vascular resistance, or central venous oxygen saturation (Scvo2).
SSCGC Recommendation 27 We suggest using trends in blood lactate levels, in addition to clinical assessment, to guide resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Remarks: In children with an elevated blood lactate, repeat testing that reveals a persistent elevation in blood lactate may indicate incomplete hemodynamic resuscitation and should prompt efforts, as needed, to further promote hemodynamic stability.
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OR
(2) by the WHO criteria of cold extremities “with” prolonged capillary refill greater than
3 secs, accompanied by a weak, fast pulse [14]. (Appendix 14)
The systolic blood pressure reading should be checked against an appropriate BP
centile chart to ensure that it is within normal parameters (Advanced Paediatric Life
Support Group, 2016). The arm should be used for measuring blood pressure, but if
this is not possible in infants, the lower leg can be used ensuring alignment with the
artery. If regular BP measurements are being undertaken, the same limb should be
used to identify any changes (Royal College of Nursing, 2017).
During ongoing management of septic shock, monitoring of tissue perfusion using
physiologic indicators and target goals should continue.
The clinician should determine the need for invasive monitoring via intra-arterial and
central venous cannulas. Non-invasive blood pressure measurement is acceptable
in patients who have markedly improved or had total reversal of septic shock. Efforts
to obtain intra-arterial access should not interfere with the resuscitation of septic
shock. However, automated blood pressures overestimate systolic blood pressure
relative to intra-arterial or Doppler ultrasound measurements in hypotensive children
and underestimate systolic blood pressure among hypertensive patients. Therefore,
insertion of an intra-arterial catheter is suggested if restoration of arterial perfusion
pressures is expected to be a protracted process (Weiss & Pomerantz, Septic shock
in children: Rapid recognition and initial resuscitation (first hour), 2020).
Central venous access is indicated for patients with fluid-resistant septic shock
because these patients frequently are dependent upon uninterrupted vasoactive
medication administration to prevent further decompensation. If they also have poor
perfusion, then they are at a greatly increased risk of extravasation and significant
local tissue damage from peripherally administered vasoactive medications.
Furthermore, central venous access permits monitoring of central venous pressures
and ScvO2 in these unstable patients, which helps guide ongoing therapy (Weiss &
Pomerantz, Septic shock in children: Rapid recognition and initial resuscitation (first
hour), 2020).
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Serial cardiac ultrasound can also help to identify patients with persistent
hypovolaemia, myocardial dysfunction, and/or pericardial effusion that may be
contributing to persistent shock. This is especially important for children who do not
improve with initial fluid resuscitation or develop signs of fluid overload, for whom direct
assessment of cardiac function can more accurately gauge physiologic derangements
than physical examination alone.
Blood lactate can be obtained by bedside testing. Limited evidence suggests that
serum lactate that decreases with treatment is associated with better outcomes for
children with sepsis. The therapeutic target is <2 mmol/L. Elevation of blood lactate
>2.0 mmol/L suggests hypoperfusion. Small observational studies in children have
demonstrated that lactate can correlate with severity of shock and prognosis in sepsis
[11-13]. In one observational study of septic shock in children, normalization of lactate
(blood lactate <2 mmol/L) within four hours was associated with reduced organ
dysfunction, but lactate clearance (reduction ≥10 percent decrease in lactate level)
was not (Weiss & Pomerantz, Septic shock in children: Rapid recognition and initial
resuscitation (first hour), 2020). Each site caring for children should have access to
point of care testing for Lactate as per local guidelines.
See Recommendation 2
Roles and Responsibilities It is the responsibility of clinicians to be familiar with the procedures and to know
the advantages and limitations of any advanced haemodynamic monitoring
equipment deployed.
3.1.6 Vasoactive medications (SSCGC Recommendations 28-33)
SSCGC Recommendation 28 We suggest using epinephrine, rather than dopamine, in children with septic shock. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 29 We suggest using norepinephrine, rather than dopamine, in children with septic shock. Quality/level of evidence: very low + Strength of recommendation: Weak
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SSCGC Recommendation 30 We were unable to issue a recommendation for a specific first-line vasoactive infusion for children with septic shock. However, in our practice, we select either epinephrine or norepinephrine as the first-line vasoactive infusion guided by clinician preference, individual patient physiology, and local system factors.
SSCGC Recommendation 31 We were unable to issue a recommendation about initiating vasoactive agents through peripheral access in children with septic shock. However, in our practice, we often or sometimes administer a dilute concentration of the initial vasoactive medication through a peripheral vein if central venous access is not readily accessible.
SSCGC Remarks (28-31): It is reasonable to begin vasoactive infusions after 40–60 mL/kg of fluid resuscitation if the patient continues to have evidence of abnormal perfusion, or sooner if fluid overload develops or other concerns for fluid administration are present. Either epinephrine or norepinephrine may be administered through a peripheral vein (or intraosseous, if in place) if central venous access is not readily accessible. Dopamine may be substituted as the first-line vasoactive infusion, administered either peripherally or centrally, if epinephrine or norepinephrine is not readily available.
SSCGC Recommendation 32 We suggest either adding vasopressin or further titrating catecholamines in children with septic shock who require high-dose catecholamines. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Remarks: No consensus was achieved on the optimal threshold for initiating vasopressin. Therefore, this decision should be made according to individual clinician preference.
SSCGC Recommendation 33 We were unable to issue a recommendation about adding an inodilator in children with septic shock and cardiac dysfunction despite other vasoactive agents. However, in our practice, we sometimes use inodilators in children with septic shock and evidence of persistent hypoperfusion and cardiac dysfunction despite other vasoactive agents.
Implementation point 11 (Recommendations 28-33) When treating a child with septic shock, it is wise to pre-empt the need for vasoactive
infusions if the child has received 40mL/kg bolus and continues to show signs of
cardiovascular dysfunction. In children, it reasonable to begin vasoactive infusions
after 40–60 mL/kg of fluid resuscitation if the patient continues to have evidence of
abnormal perfusion or sooner if fluid overload develops. Vasopressors and inotropes
are most usually prescribed by critical care and unless familiar with them, it is
prudent to obtain critical care support when starting them.
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Resources to assist with calculations of inotropes and other medications are available
on the IPATS website http://www.nasccrs.ie/IPATS/Calculators. Use of drug
calculators, especially in a time critical event, is a safety tool that assists in the
reduction of medication errors.
Starting vasopressors requires multidisciplinary support for central venous access,
constitution and delivery of the vasopressors and aseptic technique. If central venous
access is not readily available, consider administering peripheral vasoactive
medications, with senior clinical support, until central access can be obtained. All
vasoactive agents may be initiated through peripheral venous (or intraosseous, if in
place) access if central venous access is not readily available to avoid delays in
therapy. In these situations, close monitoring of PIVC site is recommended for early
identification of chemical phlebitis.
Inodilators have shown to improve cardiac dysfunction despite an adequate correction
of intravascular volume and mean arterial pressure by fluid administration and
vasopressor support (Ospina-Tascon & Calderon-Tapia, 2020). The decision to
introduce an inodilator e.g. Milrinone is based on the child’s cardiovascular response
to sepsis management protocols. It is recommended that critical care personnel are
responsible for its administration, using the paediatric critical care standard
concentration infusion protocols.
Roles and responsibilities It is the responsibility of hospital management to ensure the appropriate equipment
and staff is available to provide this service.
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3.1.7 Ventilation (SSCGC Recommendations 34-43)
SSCGC Recommendation 34 We were unable to issue a recommendation about whether to intubate children with fluid-refractory, catecholamine-resistant septic shock. However, in our practice, we commonly intubate children with fluid refractory, catecholamine-resistant septic shock without respiratory failure.
SSCGC Recommendation 35 We suggest not to use etomidate when intubating children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 36 We suggest a trial of non-invasive mechanical ventilation (over invasive mechanical ventilation) in children with sepsis-induced paediatric ARDS (PARDS) without a clear indication for intubation and who are responding to initial resuscitation.
SSCGC Remarks: When non-invasive mechanical ventilation is initiated, clinicians should carefully and frequently re-evaluate the patient’s condition Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 37 We suggest using high positive end-expiratory pressure (PEEP) in children with sepsis-induced PARDS Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Remarks: The exact level of high PEEP has not been tested or determined in PARDS patients. Some RCTs and observational studies in PARDS have used and advocated for use of the ARDS-network PEEP to Fio2 grid though adverse hemodynamic effects of high PEEP may be more prominent in children with septic shock.
SSCGC Recommendation 38 We cannot suggest for or against the use of recruitment manoeuvres in children with sepsis-induced PARDS and refractory hypoxemia.
SSCGC Remarks: If a recruitment manoeuvre is considered, the use of a stepwise, incremental and decremental PEEP titration manoeuvre is preferred over sustained inflation techniques that have not been optimized through direct testing in PARDS patients. All PARDS patients must be carefully monitored for tolerance of the manoeuvre.
SSCGC Recommendation 39 We suggest a trial of prone positioning in children with sepsis and severe PARDS Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Remarks: Research trials in adults with ARDS and children with PARDS have emphasized prone positioning for at least 12 h per day, as tolerated.
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SSCGC Recommendation 40 We recommend against the routine use of inhaled nitric oxide (iNO) in all children with sepsis-induced PARDS Quality/level of evidence: low + Strength of recommendation: Strong
SSCGC Recommendation 41 We suggest using iNO as a rescue therapy in children with sepsis-induced PARDS and refractory hypoxemia after other oxygenation strategies have been optimized Quality/level of evidence: moderate + Strength of recommendation: Weak
SSCGC Recommendation 42 We were unable to issue a recommendation to use high-frequency oscillatory ventilation (HFOV) versus conventional ventilation in children with sepsis induced PARDS. However, in our practice, there is no preference to use or not use HFOV in patients with severe PARDS and refractory hypoxia.
SSCGC Recommendation 43 We suggest using neuromuscular blockade in children with sepsis and severe PARDS (weak recommendation, very low quality of evidence). Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Remarks: The exact duration of neuromuscular blockade to use in severe PARDS patients has not been determined to date. Most of the adult RCT data and paediatric observational data support treatment for 24–48 h after ARDS onset.
Implementation point 12 (Recommendations 34-43) In an Irish context, early intubation and mechanical ventilation is considered if the child
is critically ill and is unresponsive to initial resuscitation, in order to facilitate procedures
and to decrease work of breathing/oxygen consumption. Early communication with
senior clinical support/critical care personnel within each institution is recommended and
early involvement of PICU services is encouraged. Advice and referral to a PICU is
available 24/7.
In patients with continued shock, worsening hypoxemia, or progression to PARDS,
advanced airway support (i.e. non-invasive or invasive ventilation) is frequently
needed. A trial of non-invasive mechanical ventilation (over invasive mechanical
ventilation) in children with hypoxemia and normal ability to protect their airway who
do not have overt respiratory failure and who are responding to initial resuscitation is
reasonable. However, for children with high metabolic demand from refractory shock,
typically indicated by progressive lactic acidosis and end-organ dysfunction, early
intubation and mechanical ventilation prior to overt hypoxemic or hypercarbic
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respiratory failure can help to mitigate deficits in systemic oxygen delivery (Weiss &
Pomerantz, Septic shock in children: Rapid recognition and initial resuscitation (first
hour), 2020).
COVID-19 The SSCGC suggests that systematic screening should be implemented for timely
recognition of septic shock and other sepsis-associated organ dysfunction. The
underlying rationale for this recommendation is grounded in the often subtle and
nonspecific manner in which sepsis and septic shock may present in children. With
the advent of Coronavirus disease 2019, there is a high risk of diagnostic fixation or
anchoring bias that a child with cardiopulmonary dysfunction must have acute COVID-
19 illness. (Weiss, et al., 2020).
Organ dysfunctions triggered by severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) should be considered a phenotype of paediatric sepsis or septic shock.
More recently, there has been a surge in children presenting with hyper inflammatory
shock resembling atypical Kawasaki disease, Kawasaki-shock, and/or toxic shock
syndrome. In cases where SARS-CoV-2 is the most likely pathogen or has already
been confirmed, patients with COVID-19 are at risk for bacteraemia or other secondary
bacterial or viral co-infections (e.g. pneumonia) (Weiss, et al., 2020).
Corticosteroids (SSCGC Recommendations 44-45)
SSCGC Recommendation 44 We suggest against using IV hydrocortisone to treat children with septic shock if fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 45 We suggest that either IV hydrocortisone or no hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability Quality/level of evidence: low + Strength of recommendation: Weak
Implementation point 13 (Recommendations 45-46) Hydrocortisone may be required if adequate fluid resuscitation and vasopressor
therapy are not able to restore hemodynamic stability, this is most often provided in a
critical care setting not in the immediate resuscitation phase.
If corticosteroids are given, refer to local hospital children’s formulary.
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3.1.9 Endocrine and Metabolic (SSCGC Recommendations 46-50)
SSCGC Recommendation 46 We recommend against insulin therapy to maintain a blood glucose target at or below 140 mg/dL (7.8 mmol/L) Quality/level of evidence: moderate + Strength of recommendation: Strong
SSCGC Recommendation 47 We were unable to issue a recommendation regarding what blood glucose range to target for children with septic shock or other sepsis-associated organ dysfunction. However, in our practice, there was consensus to target blood glucose levels below 180 mg/dL (10 mmol/L) but there was not consensus about the lower limit of the target range.
SSCGC Recommendation 48 We were unable to issue a recommendation as to whether to target normal blood calcium levels in children with septic shock or sepsis-associated organ dysfunction. However, in our practice, we often target normal calcium levels for children with septic shock requiring vasoactive infusion support.
SSCGC Recommendation 49 We suggest against the routine use of levothyroxine in children with septic shock and other sepsis-associated organ dysfunction in a sick euthyroid state. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 50 We suggest either antipyretic therapy or a permissive approach to fever in children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: moderate + Strength of recommendation: Weak
Implementation point 14 (Recommendations 46-47)Hypoglycaemia:Children with septic shock are at risk for hypoglycaemia; rapid blood glucose should
be measured as IV access is obtained. If present, hypoglycaemia should be
corrected by rapid IV infusion 2mLs/kg of Dextrose 10% (ALSG, 2016).
A continuous maintenance infusion of dextrose 5% to 10% in addition to
resuscitation fluids is a reasonable option to prevent the occurrence of
hypoglycaemia (Weiss & Pomerantz, Septic shock in children: Rapid recognition and
initial resuscitation (first hour), 2020).
After initial hypoglycaemia is reversed, the clinician should continue to monitor blood
glucose levels. Maintaining a blood glucose <180 mg/dL (8.33 mmol/L) is desirable.
Hypoglycaemia may also be an indicator of adrenal insufficiency in predisposed
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children and those with refractory septic shock (Weiss & Pomerantz, Septic shock in
children: Rapid recognition and initial resuscitation (first hour), 2020).
Hyperglycaemia: Sepsis can induce a hyperglycaemic stress response. Defining hyperglycaemic
parameters that may require insulin is based on adult guidelines, however the SSCGC
guidelines consider an upper blood glucose target of 180 mg/dL (10 mmol/L) to
reasonably require insulin therapy with a caveat of continuous monitoring for
hypoglycaemia.
In an Irish context, hyperglycaemic control should only be considered in the ICU setting.
Implementation point 15 (Recommendation 50) Antipyretics The decision to administer antipyretics is based on senior clinician advice, degree of
pyrexia and the overall condition of child. Refer to local age-related guidelines for
antipyretic therapy.
In febrile children, the basal heart rate may be calculated by deducting approximately
10 beats per minute for every 1°C (1.8°F) elevation in temperature. However,
tachycardia should resolve when the temperature returns to normal; persistent
tachycardia is a sensitive indicator of circulatory dysfunction and should not be
overlooked (Weiss & Pomerantz, Septic shock in children: Rapid recognition and initial
resuscitation (first hour), 2020).
Fever is a complex physiologic response associated with sepsis, and it remains
unclear whether fever is a beneficial or a harmful response to infection. Potential
benefits include inhibiting the growth of some pathogens and increased neutrophil
production and lymphocyte proliferation. Conversely, fever is associated with an
increased metabolic rate (which may or may not have detrimental effects in patients
with sepsis) and may impair some components of immune function.
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3.1.10 Nutrition (SSCGC Recommendations 51-64)
SSCGC Recommendation 51 We were unable to issue a recommendation regarding early hypocaloric/trophic enteral feeding followed by slow increase to full enteral feeding versus early full enteral feeding in children with septic shock or sepsis-associated organ dysfunction without contraindications to enteral feeding. However, in our practice, there is a preference to commence early enteral nutrition within 48 h of admission in children with septic shock or sepsis-associated organ dysfunction who have no contraindications to enteral nutrition and to increase enteral nutrition in a stepwise fashion until nutritional goals are met.
SSCGC Recommendation 52 We suggest not withholding enteral feeding solely on the basis of vasoactive-inotropic medication administration.
SSCGC Remarks: Enteral feeding is not contraindicated in children with septic shock after adequate hemodynamic resuscitation who no longer require escalating doses of vasoactive agents or in whom weaning of vasoactive agents has started. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 53 We suggest enteral nutrition as the preferred method of feeding and that parenteral nutrition may be withheld in the first 7 days of PICU admission in children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: moderate + Strength of recommendation: Weak
SSCGC Recommendation 54 We suggest against supplementation with specialized lipid emulsions in children with septic shock or other sepsis-associated organ dysfunction Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 55 We suggest against the routine measurements of gastric residual volumes (GRVs) in children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 56 We suggest administering enteral feeds through a gastric tube, rather than a postpyloric feeding tube, to children with septic shock or other sepsis-associated organ dysfunction who have no contraindications to enteral feeding. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 57 We suggest against the routine use of prokinetic agents for the treatment of feeding intolerance in children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
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SSCGC Recommendation 58 We suggest against the use of selenium in children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 59 We suggest against the use of glutamine supplementation in children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 60 We suggest against the use of arginine in the treatment of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 61 We suggest against using zinc supplementation in children with septic shock and other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 62 We suggest against the use of ascorbic acid (vitamin C) in the treatment of children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 63 We suggest against the use of thiamine to treat children with sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 64 We suggest against the acute repletion of vitamin D deficiency (VDD) for treatment of septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: very low + Strength of recommendation: Weak
Implementation point 16 (Recommendation 51-52) Enteral Nutrition
It is generally recommended that enteral nutrition (EN) be initiated in all critically ill
children, unless contraindicated, within 24-48 hours. The use of institutional EN
guidelines and stepwise algorithms to advance feeding and optimize progress is also
recommended (ASPEN Guidelines, 2020) (Mehta, et al., 2017).
Implementation point 17 (Recommendation 53)
Individual assessment is required to determine whether parenteral nutrition is a)
indicated b) viable and c) beneficial. PICU should have access to a dedicated dietitian
or nutrition support team (ASPEN Guidelines, 2020) (Mehta, et al., 2017). Care should
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be taken to ensure that nutrition support is not entirely withheld from extremely
vulnerable children (Koletzko et al, 2017). Any decision to withhold nutrition support
should be revisited daily.
3.1.11 Blood Products (SSCGC Recommendations 65-68)
SSCGC Recommendation 65 We suggest against transfusion of RBCs if the blood haemoglobin concentration is greater than or equal to 7 g/dL in hemodynamically stabilized children with septic shock or other sepsis-associated organ dysfunction. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Remarks: According to the 2018 Transfusion and Anemia Expertise Initiative (TAXI) guidelines, for the purposes of RBC transfusion, “hemodynamically stabilized” is defined as a MAP higher than 2 sds below normal for age and no increase in vasoactive medications for at least 2 h.
SSCGC Recommendation 66 We cannot make a recommendation regarding haemoglobin transfusion thresholds for critically ill children with unstable septic shock.
SSCGC Recommendation 67 We suggest against prophylactic platelet transfusion based solely on platelet levels in nonbleeding children with septic shock or other sepsis-associated organ dysfunction and thrombocytopenia Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 68 We suggest against prophylactic plasma transfusion in nonbleeding children with septic shock or other sepsis-associated organ dysfunction and coagulation Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Remarks: Prophylactic plasma transfusion refers to situations in which there is an abnormality in laboratory coagulation testing but no active bleeding.
Implementation point 18 (Recommendations 65-66) Haemoglobin is the primary determinant of blood oxygen carrying capacity and,
therefore, of tissue oxygen delivery. Thus, maintaining adequate haemoglobin levels
is an important aspect of managing children with ongoing septic shock.
The challenge of treating critically ill children with unstable shock is less clear as there
is insufficient data available to guide RBC transfusion therapy in these children.
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For children with sepsis or septic shock who are hemodynamically stable (defined as
mean arterial blood pressure higher than two standard deviations below normal for
age and no increase in vasoactive medications for at least two hours), we recommend
following the TAXI guidelines.
TAXI (Transfusion and Anemia Expertise Initiative) guidelines state “not administering
a RBC transfusion if the haemoglobin concentration is greater than or equal to 7 g/dL
in haemodynamically stable critically ill children with a diagnosis of severe sepsis or
septic shock” (Muszynski JA, (TAXI), & Pediatric Critical Care Blood Research
Network (Blood Net), 2018).
3.1.12 Plasma exchange, renal replacement, and extracorporeal support (SSCGC Recommendations 69-74)
SSCGC Recommendation 69 We suggest against using plasma exchange (PLEX) in children with septic shock or other sepsis-associated organ dysfunction without thrombocytopenia-associated multiple organ failure (TAMOF) Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 70 We cannot suggest for or against the use of PLEX in children with septic shock or other sepsis-associated organ dysfunction with TAMOF.
SSCGC Recommendation 71 We suggest using renal replacement therapy to prevent or treat fluid overload in children with septic shock or other sepsis-associated organ dysfunction who are unresponsive to fluid restriction and diuretic therapy. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 72 We suggest against high-volume hemofiltration (HVHF) over standard hemofiltration in children with septic shock or other sepsis-associated organ dysfunction who are treated with renal replacement therapy. Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Recommendation 73 We suggest using venovenous ECMO in children with sepsis-induced PARDS and refractory hypoxia. Quality/level of evidence: very low + Strength of recommendation: Weak
SSCGC Recommendation 74 We suggest using venoarterial ECMO as a rescue therapy in children with septic shock only if refractory to all other treatments. Quality/level of evidence: very low + Strength of recommendation: Weak
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3.1.13 Immunoglobulins (SSCGC Recommendation 75)
SSCGC Recommendation 75 We suggest against the routine use of IV immune globulin (IVIG) in children with septic shock or other sepsis-associated organ dysfunction Quality/level of evidence: low + Strength of recommendation: Weak
SSCGC Remarks: Although routine use of IVIG is not recommended, select patients may benefit from such treatment.
3.1.14 Prophylaxis (SSCGC Recommendations 76-77)
Recommendation 76 We suggest against the routine use of stress ulcer prophylaxis in critically ill children with septic shock or other sepsis-associated organ dysfunction, except for high-risk patients Quality/level of evidence: very low + Strength of recommendation: Weak
Remarks: Although routine stress-ulcer prophylaxis is not recommended, some high-risk patients may benefit from stress ulcer prophylaxis. Studies have supported benefit of stress-ulcer prophylaxis when baseline rate of clinically important bleeding is approximately 13%.
Recommendation 77 We suggest against routine deep vein thrombosis (DVT) prophylaxis (mechanical or pharmacologic) in critically ill children with septic shock or other sepsis-associated organ dysfunction, but potential benefits may outweigh risks and costs in specific populations. Quality/level of evidence: low + Strength of recommendation: Weak
Implementation point 19 (Recommendation 76) Rather than routine, universal administration of stress-ulcer prophylaxis, individual
patients should be assessed for the presence of risk factors of clinically important
gastrointestinal bleeding. These include multiple organ dysfunction, prolonged
mechanical ventilation (> 48 hr), coagulopathy, persistent shock, and treatment with
corticosteroids and nonsteroidal anti-inflammatory agents. The risk of GI bleeding is
also reduced by mucosal protection introduced by gastric feeding. Early enteral
nutrition could therefore be a viable alternative to pharmacological stress-ulcer
prophylaxis.
Stress ulcer prophylaxis should not be routinely administered to children with septic
shock or other sepsis-associated organ dysfunction, as evidence for benefit is lacking
and may increase risk of adverse effects, such as pneumonia or C. difficile infection.
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Implementation point 20 (Recommendation 77) Healthcare providers should follow local hospital guidelines regarding CVC care
bundles and remain vigilant for the signs and symptoms of an evolving VTE as patients
with sepsis and septic shock are likely to have an increased risk of this complication
if CVCs are inserted (Radulescu, 2015).
3.2 Rehabilitation and post-discharge care
Survival from sepsis is not without its complications. Some sepsis survivors
experience a variety of physical, psychological and emotional problems while
recovering. This is known as Post Sepsis Syndrome (PSS) and usually lasts between
6 and 18 months, sometimes longer. In infants, symptoms of post-sepsis syndrome
may not be spotted until they reach school age and find themselves academically
behind their peers, or until it appears that they are not developing normally. (Als, et
al., 2013) One paediatric study by Brooner et al (2009) showed that 44% of the sepsis
survivors overall had problems with their cognitive function (Bronner, et al., 2009).
Awareness of the long-term sequelae of sepsis and septic shock should be promoted
amongst healthcare providers, patients, parents/carers and teachers.
Mobilisation and physical rehabilitation should start as early as clinically possible
during hospital stay, basing rehabilitation goals on the clinical assessment of
healthcare professionals experienced in critical care and rehabilitation.
Sepsis information booklets should be made available to the parents/carers and
relatives of patients admitted to a critical care area with sepsis.
3.3 Parental considerations
“When a child is suddenly admitted to hospital, parents are in a state of panic and
shock. They need to know, in layman's terms, what has happened to their child
(potential medical diagnosis) and the required treatment”. Lesley Richards, parent
representative.
As healthcare professionals we need to establish standardised practices around
these conversations to ensure parents emotional needs are met. With an acute
presentation to hospital, the emergency management of the child is the initial priority
for healthcare professionals who may not be in a position to provide detailed
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information on progress and prognosis immediately. Ideally, identification of a liaison
person from the team to communicate with the parents/carers, will facilitate timely
conversations at differing stages of diagnosis and treatment. Key to supporting
parents during a sudden event, is the ability to establish an open relationship,
allowing adequate time to understand, discuss and process the information
regarding their child's diagnosis and prognosis.
It is vital that healthcare professionals collaborate with parents in their child’s care,
as much as possible, which helps relieve both parental and patient anxiety.
Being present at the child’s bedside gives parents a greater understanding of the
severity of illness and the opportunity to advocate for their child.
Acknowledgements: A special word of thanks to our parent representative, Lesley Richards,
who reinforced the integral part a parent plays in their child’s care and
highlighted the importance of tenderness, compassion and empathy, when caring
for sick children and their families.
We gratefully acknowledge the support and endorsement by Prof. Mark
Peters, European Co-chair of the Paediatric Surviving Sepsis Campaign,
Great Ormond St. Hospital, who externally reviewed this document.
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Section 4. Appendices
Appendix 1: National Sepsis Steering Committee membership – 2019 /2020
Name Name Job Title and Affiliation Dr Fidelma Fitzpatrick Chair Dr Martina Healy National Sepsis Clinical lead Ciara Hughes Programme Manager National Sepsis Programme – Oct
2020 Mary Bedding Group Sepsis ADoN RCSI Hospital Group Karn Cliffe Group Sepsis ADoN/M Dublin Midlands Hospital Group Celine Conroy Group Sepsis ADoN Ireland East Hospital Group Yvonne Young Group Sepsis ADoN University Limerick Hospital Group Fidelma Gallagher Group Sepsis ADoN Saolta Hospital Group Sinead Horgan Group Sepsis ADoN South/South West Hospital Group Nuala Clarke Group Sepsis ADoN CHI Hospital Group Elaine Browne Representative from Acute Hospitals Division Dr Vida Hamilton Representative from NCAGL office Ger Shaw Representative from ONMSD Jacqui Hurley Representative from Health Pricing Office Collette Tully Representative from National Office Clinical Audit Dr Gerry McCarthy/Fiona Mc Daid
Representative for Emergency Medicine
Prof Ellen Crushell Representative for Paediatrics Prof Gary Courtney Representative for Acute Medicine Dr Michael Power Representative for Critical Care Avilene Casey Representative for Deteriorating Patient Dr Diarmuid Quinlan Representative for General Practitioner Brian Power Representative Pre-Hospital Emergency Care Council Barbara Egan Patient representatives x 2 Anne Mc Cabe Representative for NASCCRS (National Ambulance
Service and critical care and retrieval services)
Awaiting confirmation of representatives from the Health Pricing Office, the Integrated Care Programmes, the HSE Health Intelligence Unit, the National HPSC Office, the National Ambulance Service and Public Health Nursing.
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Appendix 2: National Sepsis Programme Team (NSP)
Name Name Job Title and Affiliation Martina Healy National Sepsis Clinical lead Ciara Hughes Programme Manager National Sepsis Programme – Oct
2020 Mary Bedding Group Sepsis ADoN RCSI Hospital Group Karn Cliffe Group Sepsis ADoN/M Dublin Midlands Hospital Group Celine Conroy Group Sepsis ADoN Ireland East Hospital Group Yvonne Young Group Sepsis ADoN University Limerick Hospital Group Fidelma Gallagher Ronán O Cathasaigh
Group Sepsis ADoN Saolta Hospital Group – Nov 2020 Group Sepsis ADoN Saolta Hospital Group – Jan 2021
Sinead Horgan Group Sepsis ADoN South/South West Hospital Group Nuala Clarke Group Sepsis ADoN CHI Hospital Group
Appendix 3: National Implementation Plan Development Group (NIPDG)
Name Name Job Title and Affiliation Dr Martina Healy National Sepsis Clinical Lead Ciara Hughes Programme Manager National Sepsis to Oct 2020 Nuala Clarke Group Sepsis ADON CHI Celine Conroy Group Sepsis ADON Ireland East Hospital Group Dr Laura Melody Consultant, Paediatric Emergency Medicine, CHI @
Crumlin Dr Regina Cooke Consultant Paediatrician, Portiuncula Dr Robert Cunney Consultant Microbiologist, CHI @ Temple St Dr Turlough Bolger Consultant in Paediatric Emergency Medicine, CHI
@ Tallaght Dr Niamh O Sullivan Consultant Microbiologist Kara Tedford Antimicrobial Pharmacist, CHI @ Crumlin Dr Julie Lucey Consultant Paediatrician, Waterford Dr Roisin McNamara Consultant, Paediatric Emergency Medicine, CHI @
Temple St Joan Broderick CNM3, ED, CHI @ Temple St Helen Flynn CNM3, UCC, CHI@ Blanchardstown Susan Keane Clinical Practice Coordinator, CHI @ Temple St Linda Farren RO, CHI @ Crumlin Experts co opted David Menzies & Ricky Ellis PHECC Jessica Sheppard Paediatric Dietitian, PICU , CHI @ Crumlin External Experts Prof. Mark Peters, ESICM / SSC GOSH, UK Lesley Richards Parent/patient representative
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Appendix 4: National Paediatric Sepsis Form Development Group 2019
Name Name Job Title and Affiliation
Dr Martina Healy National Sepsis Clinical Lead Ciara Hughes Programme Manager National Sepsis to Oct 2020 Nuala Clarke RO, CHI @ Tallaght Hospital Celine Conroy Group Sepsis ADON Ireland East Hospital Group Dr Roisin McNamara Consultant in Paediatric Emergency Medicine, CHI
@ Temple St Dr Regina Cooke Consultant Paediatrician, Portiuncula Jean Donnelly Consultant Paediatrician, CHI @ Crumlin Linda Farren RO, CHI @ Crumlin Turlough Bolger Consultant in Paediatric Emergency Medicine, CHI
@ Tallaght Helen Flynn CNM3, UCC , CHI@ Blanchardstown Susan Keane Clinical practice coordinator , CHI @ Temple St
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Appendix 5: Glossary of Terms and Abbreviations
Glossary of Terms
Child/Children: Refers to an infant, child or adolescent admitted to inpatient paediatric services
Clinician: A registered nursing/midwifery, medical or health and social care professional.
Escalation of Care: the point at which a clinician successfully contacts/calls for a more senior clinical review - nursing or medical - of a patient
EWS: Early Warning System
Infant: A child, from birth to one year of age.
PEWS: Paediatric Early Warning System
Sepsis is lifethreatening organ dysfunction caused by a dysregulated host response to infection
Septic Shock defined as severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication, or impaired perfusion)
Sepsis-associated organ dysfunction defined as severe infection leading to cardiovascular and/or noncardiovascular organ dysfunction.
SIRS Systemic Inflammatory Response Syndrome
SEPSIS 6 is the name given to a bundle of medical therapies designed to reduce mortality in patients with sepsis (Take 3 and Give 3). Sepsis 6 was developed by The UK Sepsis Trust (Daniels, Nutbeam, McNamara, & Galvin, 2011) as a practical tool to help healthcare professionals deliver the SSCG 1 hour bundle.
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Abbreviations
ALT: Alanine transaminase
ASPEN: American Society for Parenteral and Enteral Nutrition
AvLOS: Average Length of Stay
BIA: Budget Impact Analysis
BPS: Best Practice Statement
CDC: Centre for Disease Control
CDI: Clinical Design and Innovation
CDST: Clinical Decision Support Tool
CNS: Central Nervous System
CPAP: Continuous Positive Airway Pressure
CPG: Clinical Practice Guideline
CRRT: Continuous Renal Replacement Therapy
CVP: Central Venous Pressure
DIC: Disseminated Intravascular Coagulation
DoH: Department of Health
DON: Director of Nursing
DRG: Diagnostic Related Group
DVT: Deep Vein Thrombosis
Dx1: Primary Diagnosis
Dx2: Secondary Diagnosis
ECMO: Extracorporeal membrane oxygenation
ED: Emergency Department
EM: Emergency Medicine
EGDT: Early Goal-Directed Therapy
EMT: Emergency Medicine Technician
ESBL: Extended-Spectrum B- lactamase
ESRI: The Economic and Social Research Institute
FEAST: Fluid expansion As Supportive Therapy
GCS: Glasgow Coma Scale
GI: Gastrointestinal
GP: General practitioner
GRADE: Grading of Recommendations
Assessment, Development and Evaluation
GRV: Gastric Residual Volume
HCAI: Healthcare-Associated Infection
HCW: Healthcare Worker/healthcare staff
HDU: High Dependency Unit
HES: Hydroxyethyl starches
HFOV: High Frequency Oscillatory Ventilation
Hg: Mercury
HIPE: Hospital Inpatient Enquiry
HIQA: Health Information and Quality Authority
HPA: Health Protection Agency
HPO: Healthcare Pricing Office
HPSC: Health Protection Surveillance Centre
HSCP: Health and Social Care Professionals
HSE: Health Service Executive
HVHF: High Volume Haemofiltration
ICD: International Classification of Disease
ICU: Intensive Care Unit
ICTS: Irish Children’s Triage System
IPATS: Irish Paediatric Acute Transfer service
IVIG: Intravenous Immunoglobulin
IDSA: Infectious Disease Society of America (IDSA)
iNO: inhaled nitric oxide
IO: intraosseous
IPC(T): Infection prevention and control (team)
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Abbreviations (continued)
ISBAR: Identify, Situation, Background, Assessment, Recommendation
IV: Intravenous
LMWH: Low Molecular Weight Heparin
LOS: Length of stay
MAP: Mean Arterial Pressure
MDRO: Multidrug Resistant Organisms
MIC: Minimum Inhibitory Concentration
MRSA: Methicillin-Resistant Staphylococcus Aureus
N/A: Not Applicable
NCEC: National Clinical Effectiveness Committee
NCG: National Clinical Guideline:
NSP: National Sepsis Programme
NEWS: National Early Warning System
NICE: National Institute for health and Care Excellence
NIP: National Implementation Plan
NIV: Non-Invasive Ventilation
NNTP: National Neonatal Transport Service
NOCA: National Office Clinical Audit
ONMSD: The Office of the Nursing and Midwifery Services
OPD: Out-patient Department
PaCO2: Partial Pressure of Carbon Dioxide
PARDS: Paediatric Respiratory Distress Syndrome
PDSA: Plan, Do, Study, Act
PE: Pulmonary Embolism
PED: Paediatric Emergency Department
PEEP: Positive End Expiratory Pressure
PEWS: Paediatric Early Warning System
PHECC: Pre- Hospital Emergency Care Council
PICO: Population, Intervention, Comparison and Outcomes.
PICU: Paediatric intensive Care Unit
PIVC: Peripheral Intravenous Catheter
PLEX: Plasma Exchange
POC: Point Of Care
POD: Paediatric Observation Department
PPI’s: Proton Pump Inhibitors
PSS; Post Sepsis Syndrome
QA: Quality Assurance
RBC: Red Blood Cell
RCT: Randomised Controlled Trial
RCPI: Royal College of Physicians, Ireland
RRT: Renal Replacement Therapy
SAC: Scientific Advisory Committee
SCCM: Society of Critical Care Medicine
SD: Standard Deviation
ScvO2: Central Venous Oxygen Saturation
SIRS: Systemic Inflammatory Response Syndrome
SOFA: Sequential Organ Failure Assessment
SSC: Surviving Sepsis Campaign
SSCGC: Surviving Sepsis Campaign Guideline for Children
TAMOF: Thrombocytopenia-Associated Multiple Organ Failure
TAXI: Transfusion and Anemia Expertise Initiative
UCC: Urgent Care Centre
UFH: Unfractionated Heparin
UK: United Kingdom
US: United States
VAP: Ventilator Associated Pneumonia
VDD: Vitamin D Deficiency
VTE: Venous Thromboembolism
WHO: World Health Organisation
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Appendix 6: Guideline search strategy for Paediatric
Sepsis Guidelines Searched
1. Up To Date – Systemic inflammatory response syndrome (SIRS) and
sepsis in children: Definitions, epidemiology, clinical manifestations, and
diagnosis
https://www.uptodate.com/contents/systemic-inflammatory-response-
syndrome-sirs-and-sepsis-in-children-definitions-epidemiology-clinical-
manifestations-and-
diagnosis?search=sepsis&source=search_result&selectedTitle=3~150&usage
_type=default&display_rank=3#H2892990901
2. BMJ Best Practice – Sepsis in children
https://bestpractice.bmj.com/topics/en-gb/1201/guidelines
3. Other guideline databases searched:
NICE, (National Institute Clinical Effectiveness);
GINN, (Guidelines International Network);
TRIP (Turning Research into Practice) and
American Clearing House.
Databases Searched (Using the search strategy in table 3)
Web of Science – Hits 9
PubMed – Hits 143
Scopus – Hits 297
Embase – Hits 132
Google Scholar Hits 148
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Appendix 7: Paediatric Sepsis Awareness
Leaflets
Video/social media campaign
Posters
80
What to do if you think your child might have sepsis …
For further information on sepsis please visit www.hse.ie/sepsis
Watch for early symptoms (see inside this leafl et)
Get urgent medical assistance
Call 999 or 112
Go to your local GP (doctor) or your nearest Emergency Department
ChildhoodInfection
Don’t be afraid to ask …Could this be sepsis?
National Clinical& Integrated Care ProgrammesPerson-centred, co-ordinated care
Sepsis is the most common avoidable cause of death in children
SepsisKnow the
symptoms, save lives
200129 ChildSepsis_flyer_flip v6.indd 1-2200129 ChildSepsis_flyer_flip v6.indd 1-2 31/01/2020 15:5031/01/2020 15:50
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App
endi
x 8:
Ena
bler
s an
d B
arrie
rs to
impl
emen
ting
the
NIP
Tabl
e 20
. (D
raft)
Impl
emen
tatio
n Pl
an fo
r Int
erna
tiona
l Clin
ical
Gui
delin
e fo
r the
man
agem
ent o
f sep
tic s
hock
and
sep
sis-
asso
ciat
ed o
rgan
dys
func
tion
in c
hild
ren
Gui
delin
e re
com
men
datio
n or
nu
mbe
r(s)
Impl
emen
tatio
n ba
rrie
rs /
enab
lers
/ ga
ps
Act
ion
/ int
erve
ntio
n /
task
to im
plem
ent
reco
mm
enda
tion
Lead
re
spon
sibi
lity
for
deliv
ery
of th
e ac
tion
Tim
efra
me
for
com
plet
ion
Expe
cted
ou
tcom
e an
d ve
rific
atio
n
GEN
ERA
L E
nable
rs
•S
creenin
g tool p
ilote
d11/2
0 s
ites
•P
ublic
aw
are
ness
leafle
ts/p
op u
ps
•T
rain
the tra
iner
work
shops
x 3
B
arr
iers
•
Challe
nges
inre
cognis
ing s
epsi
searly-
Gaps
inkn
ow
ledge/e
duca
tion
•9 o
uts
tandin
g s
ites
topilo
t.
•Lack
of IT
sys
tem
s to
captu
re in
form
atio
nLack
of in
tegra
tion
acr
oss
IT
sys
tem
s
Deve
lop c
om
munic
atio
n,
dis
sem
inatio
n a
nd s
take
hold
er
engagem
ent w
ith 2
020 S
CC
guid
elin
es
Dis
sem
inatio
n
of
audit
findin
gs
with
hosp
ital m
anagem
ent
Educa
tion:
•D
eve
lop a
n e
-learn
ing
paedia
tric
sepsi
spro
gra
mm
e•
Addre
ss c
urr
ent
know
ledge g
aps
•T
arg
ete
d e
duca
tion o
nuse
of cl
inic
al d
eci
sion-
maki
ng tools
– d
eve
lop
scenarios
Identif
y re
quirem
ents
fro
m IT
sy
stem
s (E
HR
) to
captu
re s
epsi
s data
Im
pro
ve d
ata
captu
re w
ith
colla
bora
tion fro
m IT
exp
ert
s
Sepsi
s N
atio
nal C
linic
al
Pro
gra
mm
e
Paedia
tric
Work
ing G
roup
Paed S
epsi
s A
DO
N
Educa
tion L
eads
acr
oss
dis
ciplin
es
ICT
engagem
ent
To b
e d
eci
ded
Out
com
e
Impro
ved a
ware
ness
and
know
ledge o
f paedia
tric
se
psi
s guid
elin
e a
nd
acc
om
panyi
ng tools
.
Verif
icat
ion
Ack
now
ledgem
ent fr
om
hosp
ital l
eads
upon
rece
ipt of guid
elin
e.
Monito
ring a
nd A
udit
feedback
.
SCR
EEN
ING
, D
IAG
NO
SIS,
AN
D
SYST
EMA
TIC
M
AN
AG
EMEN
T O
F SE
PSIS
R
eco
mm
endatio
ns
1-4
Enable
rs
•A
udit
and feedback
Cham
pio
ns
identif
ied
•S
upport
fro
mH
osp
ital S
enio
rM
anagem
ent
•Loca
l Sepsi
sC
om
mitt
ees
•P
aed S
epsi
s A
DO
N
Deve
lopm
ent of netw
ork
of
cham
pio
ns
– m
edic
al a
nd
nurs
ing a
cross
all
site
s
Deve
lop a
nd u
se a
udit
tools
and
audit
schedule
s
Natio
nal S
epsi
s T
eam
Paedia
tric
Work
ing
Gro
up
ED
engagem
ent
Paed S
epsi
s A
DO
N
To b
e d
eci
ded
Out
com
e M
ore
cham
pio
ns.
E
ngagem
ent w
ith
guid
elin
e, le
adin
g to
impro
ved o
utc
om
es
for
patie
nts
. Im
pro
ved a
ccess
to
sepsi
s data
and h
osp
ital.
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Barr
iers
•E
D s
peci
fic p
ath
way
for
scre
enin
g tool
lack
ing
•Lack
of cl
arity
regard
ing
medic
al/n
urs
ing
cham
pio
ns
on s
om
esi
tes
Advo
cate
fo
r m
aki
ng
sepsi
s e-
learn
ing m
andato
ry i
n a
ll hosp
ital
gro
ups
Deliv
ery
of
loca
l educa
tion,
as
required
(by
AD
ON
s,
AN
Ps,
C
linic
al
leads,
N
atio
nal
Clin
ical
Lead)
Hosp
ital S
epsi
s C
om
mitt
ees
com
pariso
ns
of m
ort
alit
y data
for
child
ren.
Verif
icat
ion
Audit
and a
nnual r
eport
s.
Report
ing fro
m S
epsi
s A
DO
N.
Feedback
fro
m H
osp
ital
Sepsi
s C
om
mitt
ees.
F
eedback
fro
m h
osp
ital
gro
up.
AN
TIM
ICR
OB
IAL
THER
APY
R
eco
mm
endatio
ns
5-1
4
SOU
RC
E C
ON
TRO
L R
eco
mm
endatio
ns
15-1
6
Enable
rs
•Loca
l Sepsi
sC
om
mitt
ees
•S
epsi
s to
ols
/alg
orith
m•
Loca
l antim
icro
bia
lguid
elin
es
•C
onsu
ltant
Mic
robio
logis
ts•
Antim
icro
bia
lst
ew
ard
ship
•C
HI cr
oss
site
antib
iotic
guid
elin
e
Barr
iers
•
Lack
of kn
ow
ledge
•Lack
of equip
ment to
measu
re la
ctate
Conduct
gap a
naly
sis
on
equip
ment
for
poin
t-of-
care
la
ctate
s.
Educa
tion:
e-learn
ing tool
Lect
ure
/PP
T
Sim
ula
tion
IPC
invo
lvem
ent
Sepsi
s pre
ventio
n
for d
evi
ces
Feedback
fro
m a
udits
: •
com
plia
nce
with
tool
•so
urc
e/p
ath
ogen
identif
ied
Invo
lve s
urg
ical s
peci
alit
ies
early
for
sourc
e c
ontr
ol.
Sepsi
s A
DO
Ns
Hosp
ital S
epsi
s C
om
mitt
ees
Antim
icro
bia
l pharm
aci
sts/
infe
ctio
n
Pharm
aci
sts
To b
e d
eci
ded
Out
com
e Im
pro
ved a
ccess
to
equip
ment.
Impro
ved a
dhere
nce
to
loca
l antim
icro
bia
l guid
elin
e.
Verif
icat
ion
Revi
ew
of H
osp
ital
Antim
icro
bia
l C
onsu
mptio
n
Revi
ew
of devi
ce r
ela
ted
infe
ctio
ns.
FLU
ID T
HER
APY
R
eco
mm
endatio
ns
17-2
3
HEM
OD
YNA
MIC
M
ON
ITO
RIN
G
Reco
mm
endatio
ns
24-2
7
The
NIP
dev
elop
men
t gr
oup
have
pro
vide
d im
plem
enta
tion
poin
ts a
fter
each
rec
omm
enda
tion
or g
roup
of
reco
mm
enda
tions
, to
guid
e im
plem
enta
tion
of th
e SS
C In
tern
atio
nal G
uide
lines
for c
hild
ren
in Ir
elan
d.
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VASO
AC
TIVE
M
EDIC
ATI
ON
S R
eco
mm
endatio
ns
28-3
3
VEN
TILA
TIO
N
Reco
mm
endatio
ns
34-4
3
CO
RTI
CO
STER
OID
S R
eco
mm
endatio
ns
44-4
5
END
OC
RIN
E A
ND
M
ETA
BO
LIC
R
eco
mm
endatio
ns
46-5
0
NU
TRIT
ION
R
eco
mm
endatio
ns
51-6
4
BLO
OD
PR
OD
UC
TS
Reco
mm
endatio
ns
65-6
8
PLA
SMA
EX
CH
AN
GE,
REN
AL
REP
LAC
EMEN
T,
AN
D
EXTR
AC
OR
POR
EAL
SUPP
OR
T R
eco
mm
endatio
ns
69-7
4
IMM
UN
OG
LOB
ULI
NS
Reco
mm
endatio
n 7
5
PRO
PHYL
AXI
S R
eco
mm
endatio
n 7
6
The
NIP
dev
elop
men
t gr
oup
have
pro
vide
d im
plem
enta
tion
poin
ts a
fter
each
rec
omm
enda
tion
or g
roup
of
reco
mm
enda
tions
, to
guid
e im
plem
enta
tion
of th
e SS
C In
tern
atio
nal G
uide
lines
for c
hild
ren
in Ir
elan
d.
National Implementation Plan for SSCGC Paediatric Sepsis Guidelines
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Appendix 9: Paediatric Sepsis Form Draft
84
☐ Inappropriate tachypnoea i.e. does not respond with simple measures☐ Altered functional status (e.g. severe leg pain, or inability to weight-bear or decreased activity)☐ Healthcare professional concern ☐ Parental concern☐ Increasing PEWS ☐ Other:
≥1 Amber Flag
Start Sepsis 6 within 1hrTime:
Yes NoSigns of Shock 3hr window for diagnostic
work up - see “take 3”Suspicion Time:
YesSuspected SepsisWorking Diagnosis:
Review within:
Sepsis NOT likely at this time
Addressograph
Paediatric Sepsis FormFor early recognition, treatmentand referral (ALWAYS USE CLINICAL JUDGEMENT)
PAEDIATRIC PATIENTS(from 4 weeks (or 4 wkscorrected age)to 16 years)
There are separate sepsis criteria formaternity patients and adults
Ver
sion
5 -
12/0
8/20
21
Complete this form if there is a clinical suspicion of infection and the child appears unwell. When complete, sign and place in child’s healthcare record. Seek senior expert help early if sepsis is suspected.
Page 1 of 2, continue overleaf
Doctor (Print Name): Doctor Signature:
MCRN: Date: Time:
Print name:Signature:
Role:NMBI or MCRN:
Date: Time:
Is Sepsis likely at this time?
Urgent medical review if ≥1 Amber Flag +/- Risk Factor(s)
Certain conditions will increase risk of sepsis and should lower threshold for initiation of Sepsis 6. These include:☐ Immunocompromised (follow national haematology/oncology guidelines for children with cancer)☐ Age ≤3 months ☐ Chronic disease☐ Recent surgery ☐ Break in skin (including chickenpox)☐ Indwelling line/device ☐ Signs of infection in a wound (including chickenpox) ☐ Incomplete vaccination record ☐ Other:
Risk Factor(s)
No Red FlagYes
Immediate medical review
☐ Altered mental status- P or U on AVPU ☐ Hypotension ☐ Prolonged central capillary re�ll☐ Tachycardia unexplained by fever/crying ☐ Non-blanching rash ☐ Clinical deterioration as in-patient
≥1 Red Flag
COULD THIS BE SEPSIS?
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Look for signs of septic shock (following administration
of �uid bolus of up to 40ml/kg)
☐ Hypotension
☐ Prolonged central CRT
☐ Core to peripheral temperature gap ≥30C
☐ Unexplained metabolic acidosis
☐ Oliguria: ≤1ml/kg/hour up to 11 years or ≤0.5ml/kg/hour in the 12+ age group
☐ Need for inotropic support
☐ This is SEPTIC SHOCK
Time:
In addition to senior clinical support at the bedside early involvement of PICU support is encouraged. Where PICU support is not on site a national 24-hour hotline is available for urgent referrals providing advice and arranging transfer – 1800 222 378.
Tick samples taken:☐ Blood cultures ☐ FBC☐ Glucose ☐ Blood gas☐ Coag screen incl �brinogen☐ Lactate☐ U&E ☐ LFTs☐ CRP☐ Urinalysis☐ PCRs if available
☐ Urine output assessment/measurement
☐ Early senior input (essential) as per local escalation policy
Time Sepsis 6 completed:
Name: MCRN:
GIVE 3TAKE 3
☐ IV access Time or ☐ IO access Time
Paediatric Sepsis FormOngoing clinical review and interpretation of results (ALWAYS USE CLINICAL JUDGEMENT)
Mo
chua
Pri
nt &
Des
ign
| ww
w.m
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uap
rint
.ie
Page 2 of 2
File this document in the child’s healthcare record.
Doctor (Print Name): Doctor Signature:
MCRN: Date: Time:
Reassess the child as clinically indicated and complete formwithin 1 hour of initiating the Sepsis 6 bundle
☐ Oxygen to achieve saturations ≥94% titrating to e�ect or as appropriate in chronic lung or cardiac disease
☐ IV/IO �uids- Titrate 10-20mls/kg Hartmann’s Solution over 5-10min, 0.9% NaCL is
an acceptable alternative – repeat as per clinical response- Call critical care/anaesthesia in haemodynamic collapse- Consider early inotropic support- Assess for �uid overload, monitor for crepitations or
hepatomegaly
☐ IV/IO Antimicrobials according to the site of infection and following local antimicrobial guidelines.Drug name: Dose: Time given:
Paediatric Sepsis 6 – complete within 1 hour
Look for signs of new organ dysfunction after the Sepsis 6 bundle has been given or from blood test results – any one is su�cient:Cardiovascular☐ Lactate ≥4 after 20mls/kg �uid
therapy
Central Nervous System☐ Glasgow coma score (GCS) ≤11 or
poorly responsive☐ Acute change in mental status
with a decrease in GCS ≥3 points from usual baseline
Haematological☐ Platelet count ≤80,000/mm3
Coagulation☐ International normalised ratio ≥2
Respiratory ☐ Increasing need for Oxygen to
maintain saturations ≥ 94% titrating to e�ect or as appropriate in chronic lung or cardiac disease
☐ Need for nonelective invasive or noninvasive mechanical ventilation
Renal ☐ Serum creatinine ≥2 times upper limit
of normal for age or 2-fold increase in baseline creatinine
Liver ☐ Total bilirubin Bilirubin ≥ 38 µmol/L
(micromoles/L) not applicable for newborn
☐ ALT 2 times upper limit of normal for age
Any new organ dysfunction due to infection: ☐ This is SEPSISInform Consultant and Anaesthesia/PICU. Time:Reassess frequently in the �rst hour. Consider other investigations and management +/- source control if child does not respond to initial therapy.No new organ dysfunction due to infection: ☐ This is NOT SEPSIS If infection is diagnosed, proceed with usual treatment pathway for that infection.
Addressograph
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Appendix 10: Supporting tools
National Sepsis Programme www.hse.ie/sepsis
HSELand: https://www.hseland.ie/
Global Sepsis Alliance: https://www.global-sepsis-alliance.org/
Surviving Sepsis Campaign: https://www.sccm.org/SurvivingSepsisCampaign/Home
UK Sepsis Trust https://sepsistrust.org/
National Acute Medicine Programme: https://www.hse.ie/eng/about/who/cspd/ncps/acute-medicine/national-early-warning-score/
National Clinical Programmes: https://www.rcpi.ie/national-clinical-programmes/
NCG No. 11 Clinical Handover in Acute and Children’s Hospital Services: https://www.gov.ie/en/collection/006e63-clinical-handover-in-acuteand-childrens-hospital-services/
NCG No. 12 PEWS: https://www.rcpi.ie/paediatric-early-warning-system/
IPATS drug calculators: http://www.nasccrs.ie/IPATS/Calculators/
Model of care for Adult Critical care: https://www.hse.ie/eng/about/who/cspd/ncps/critical-care/moc/
Conversion websites: http://www.conversion-website.com/pressure/centimeter-of-water-to-millimeter-of-
mercury.html
https://www.sensorsone.com/mmhg-to-kpa-conversion-table/
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Appendix 11: Flowchart of implementation of SSCGC recommendations within the Irish acute healthcare sector
All paediatric hospitals and acute hospitals with paediatric units are required to have a Sepsis Committee whose role is to guide the implementation of the SSCGC recommendations and this NIP in their hospital. This committee oversees the coordination of sepsis education, introduction and utilisation of the sepsis form and reviews audit feedback to inform this process.
Implementation Plan
IDENTIFY LOCAL IMPLEMENTATION LEADS TO
COORDINATE IMPLEMENTATION OF SEPSIS
GUIDELINE (NIP)
LOCAL SEPSIS COMMITTEE (Adult committee should have
representation from Children’s service)
Membership should include: • Medical and Nursing
grades• Quality & Risk• Audit• Education personnel
/practice development• Hospital management• Pharmacy• Microbiology /IPC• Sepsis ADON• PEWS representative
Sepsis champions on each site Educational material
Sepsis form utilisation Audit process
NATIONAL SEPSIS TEAM SEPSIS ADON
Annual process audits National Sepsis report Educational material
Sepsis Guideline
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Appendix 12: Start Smart and then Focus’ approach for antimicrobial therapy 2012
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Appendix 13: Irish Paediatric Acute Transport Service (IPATS)
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Appendix 14: SSCGC Initial Resuscitation Algorithm for Children
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Appendix 15: SSCGC Fluid and Vasoactive-Inotrope Management Algorithm for children
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Appendix 16: PHECC CPG for Septic Shock – Paediatric ≤ 15yrs (2021)
92
Abnormal physiology?Source of infection considered
If septic shock suspected and not responsive to IV fluids consider
Repeat prn
P
APPatient generally unwell with suspected infection
(Temperature < 36 or > 38.5oC)
Oxygen therapy
Consider 2nd fluid bolus
No
Request
ALS
If infection advise Triage nurse
EMT
Clinical status improving
Pre-alert ED if;• sepsis• septic shock• meningitis suspected• at risk of neutropenia
Indication for antibioticSeptic shockSepsisMeningitis suspectedAt risk of neutropenia
Yes Sepsis Red Or Amber Flag +/- risk factors No
Monitor clinical condition; re-evaluate for possible sepsis if clinically indicated
Evidenceof inadequate
perfusion
Yes
SpO2, BP, RR, ETCO2 & ECG monitoring
No
Adrenaline 0.1 mcg/kg IV/IO
Sepsis – Paediatric 4/5/6.13.20Version 5, 03/2021
If temperature > 38.5oC consider
orParacetamol
>1 mth to <1 year: 80mg PR1 to 3 years: 180mg PR4 to 8 years: 360mg PR
orParacetamol
≤1 year – 7.5mg/kg IV>1 year – 15mg/kg IV
NaCl (0.9%) 20mL/kg IV/IO
Ceftriaxone 1 month – 11 years: 50mg/kg IV/IO/IM> 11 years: 2g IV/IO/IM
Sepsis Red Flag (≥ 1 item)- Altered mental status (P or U on AVPU)- Inappropriate tachycardia- Prolonged central capillary refill- Non-blanching rash- Hypotension- Clinical deterioration
High Consequence Infectious Disease (HCID) ensure appropriate PPE is worn;• Long sleeve gown• Facemask• Eye protection
Sepsis Amber Flag (≥ 1 item)- Inappropriate tachypnoea- Altered functional status- Practitioner concern- Parental concern- Vital signs deterioration
Risk Factor(s) +/-- Immunocompromised- Age ≤ 3 months- Chronic disease- Recent surgery- Break in skin (including chicken pox)- Indwelling line/device- Signs of infection in wound- Incomplete vaccination record
Yes
Titrate SpO2 > 94%
Paracetamol 15mg/kg PO
YesNaCl (0.9%) 20 mL/kg IV/IORepeat prn
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Appendix 17: Surviving Sepsis Campaign References The SSCGC references that are cited in this document are numbered as per the SSCGC document.
1. Singer M, Deutschman CS, Seymour CW, et al: The Third International Consensus Definitions for Sepsis and SepticShock (Sepsis-3). JAMA 2016; 315:801–81011. Dellinger RP, Levy MM, Carlet JM, et al; International Surviving Sep- sis Campaign Guidelines Committee; AmericanAssociation of CriticalCare Nurses; American College of Chest Physicians; American College of Emergency Physicians;Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society ofIntensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for AcuteMedicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine;Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine: Surviving SepsisCampaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296– 32712. Dellinger RP, Levy MM, Carlet ,JM, et al; International Surviving Sepsis Campaign Guidelines Committee; AmericanAssociation of CriticalCare Nurses; American College of Chest Physicians; American College of Emergency Physicians;Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society ofIntensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for AcuteMedicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine;Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine: Surviving SepsisCampaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296– 32713. Guyatt GH, Oxman AD, Kunz R, et al: GRADE guidelines: 2. Framing the question and deciding on importantoutcomes. J Clin Epidemiol 2011; 64:395–40014. World Health Organization: Guideline (2016) Updates on paediatric emergency triage, assessment and treatment:care of Critically-Ill children. Geneva, Switzerland, World Health Organization. https ://www. ncbi.nlm.nih.gov/books/NBK35 0523/. Accessed 18 Aug 201917. Peake SL, Delaney A, Bailey M, et al: Goal-directed resuscitation for patients with early septic shock. N Engl J Med.2014;371(16): 1496–150620. Levy MM, Dellinger RP, Townsend SR, et al; Surviving Sepsis Campaign: The Surviving Sepsis Campaign: results ofan international guidelinebased performance improvement program targeting severe sepsis. Crit Care Med 2010;38:367–37422. Cecconi M, De Backer D, Antonelli M, et al: Consensus on circulatory shock and hemodynamic monitoring. Taskforce of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1795–181523. Eskesen TG, Wetterslev M, Perner A: Systematic review including re-analyses of 1148 individual data sets of centralvenous pressure as a predictor of fluid responsiveness. Intensive Care Med 2016; 42:324–332 18241. Murphy DJ, Ogbu OC, Coopersmith CM: ICU director data: using data to assess value, inform local change, andrelate to the external world. Chest 2015; 147:1168–117842. Black MD, Schorr C, Levy MM: Knowledge translation and the multifaceted intervention in the intensive care unit. CritCare Med 2012; 40:1324–132855. Weiss CH, Persell SD, Wunderink RG, et al: Empiric antibiotic, mechanical ventilation, and central venous catheterduration as potential factors mediating the effect of a checklist prompting intervention on mortality: an exploratoryanalysis. BMC Health Serv Res 2012; 12:198183. Maitland K, Kiguli S, Opoka RO, FEAST Trial Group et al (2011) Mortality after fluid bolus in African children withsevere infection. N Engl J Med 364:2483–2495
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Appendix 18: National Implementation Plan References
Advanced Paediatric Life Support Group. (2016). Advanced Paediatric Life Support; A practical approach to emergencies. Chichester: Blackwell Publishing Group Ltd.
Als, L., Nadel, S., Cooper, M., Pierce, C., Sahakian, B., & Garralda, E. (2013). Neuropsychological function three to six months following admission to paediatric intensive care. Critical Care Medicine, 4(41), 1094-1103.
ALSG. (2016). Advanced Paediatric Life Support- A practical approach to emergencies. Chichester: Willey Blackwell.
ASPEN Guidelines. (2020, Dec 4). https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Guidelines/. Retrieved from www.nutritioncare.org: https://www.nutritioncare.org
Bronner, M., Knoester, H., Sol, J., Bos, A., Heymans, H., & Grootenhuis, M. (2009). An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock. Paediatric critical care, 636-42.
Brun-Buisson, C., Doyon, F., Carlet, J., Dellamonica, P., Gouin, F., Lepoutre, A., . . . Regnier, B. (1995). Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA, 968-974.
Chang, D., Tseng, T., & Shapiro, M. (2015). Rehospitalizations Following Sepsis: Common and Costly. Critical Care Medicine, 2085-2093.
Daniels, R., Nutbeam, T., McNamara, G., & Galvin, C. (2011). The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J, 507-12.
Department of Health. (2017). Ireland’s National Action Plan on Antimicrobial Resistance 2017-2020. (iNAP). Dublin: Department of Health.
Goldstein, B., Giroir, B., & Randolph, A. (2005). International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Paediatric critical care medicine, 2-8.
HSE. (2009). Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. Dublin: HSE. HSE. (2016a). The Irish Paediatric Early Warning System (PEWS) NCG no.12. Dublin:
HSE. HSE. (2016b). Irish Children’s Triage System: National Emergency Medicine Programme.
Dublin: HSE. HSE. (2018). National Guideline for Nursing and Midwifery Quality care-metrics data
measurement in Children's services 2018. Dublin: HSE. HSE. (2019). Draft National Sepsis Report. Dublin: HSE. HSE. (2020, Dec 12). Antibiotic Prescribing. Retrieved from www.hse.ie:
https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing HSE. (2020). Sepsis Management National Clinical Guideline No. 6 . Dublin: HSE. HSE Health Protection Surveillance Centre. (2009). Guidelines for Antimicrobial
Stewardship in Hospitals in Ireland. Dublin: HSE. HSE Model of Care for Paediatric Critical Care. (2019). Model of Care for Paediatric
Critical Care;National Clinical Programme for Critical Care& National Clinical Programme for Paediatrics. Dublin: HSE.
HSE, Critical Care Programme. (2014, December 8). Model of care for Adult Critical Care. Dublin: HSE. Retrieved from www.hse.ie: https://www.hse.ie/eng/about/who/cspd/ncps/critical-care/moc/
HSE, National Clinical Programme for Critical Care. (2019). Model of Care for Paediatric Critical Care. Dublin: HSE.
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HSE,National Clinical programme for Anaesthesia. (2015). Model of Care for Paediatric Anaesthesia. Dublin: HSE.
Hsu, H., Abanyie, F., Agus, M., Balamuth, F., Brady, P., Brilli, R., . . . Rhee, C. (2019). A National Approach to Pediatric Sepsis Surveillence. Paediatrics, 1-12.
Koletzko, B., Goulet, O., Jochum, F., & Shamir, R. (2017). Use of parenteral nutrition in the pediatric ICU,should we panic because of PEPaNIC? Current Opinion in Clinical Nutrition and Metabolic Care, 201-203.
Lin, J., Spinella, P., Fitzgerald, J., Tucci, M., Bush, J., Nadkarni, V., . . . Network, S. S. (2017). New or Progressive Multiple Organ Dysfunction Syndrome(NPMODS) in Pediatric Severe Sepsis: A Sepsis Phenotype with Higher Morbidity and Mortality. Pediatr Crit Care Med., 8-16.
Martin, G., Mannino, D., Eaton, S., & Moss, M. (2003). The Epidemiology of Sepsis in the United States from 1979 through 2000. New England J Med, 1546-1554.
Mehta, N., Skillman, H., Irving, S., Coss-Bu, J., Vermilyea, S., Farrington, E., . . . Braunschweig, C. (2017). Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Paediatric Critical Care Medicine, 675-715.
Menon, K., Schlapbach, L., Akech, S., Argent, A., Chiotos, K., Chisti, M., . . . Sorce, L. (2020). Pediatric Sepsis Definition—A Systematic Review Protocol by the Pediatric Sepsis Definition Taskforce. Critical Care Explorations:, e0123.
Muszynski JA, G. N., (TAXI), P. C., & Pediatric Critical Care Blood Research Network (Blood Net), a. t. (2018). Recommendations on RBC Transfusions for Critically Ill Children With Nonhemorrhagic Shock From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med., S121-S126.
Novasad, S., Sapiano, M., Grigg, C., Lake, J., Robyn, M., Dumyati, G., . . . Epstein, L. (2016). Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. Atlanta: CDC - MMWR Morb Mortal Wkly.
Ospina-Tascon, G. C.-T. (2020). Inodilators in septic shock: should these be used? Ann Transl Med, 796.
Phua, J., Ngerng, W., See, K., Tay, C., Kiong, T., Lim, H., . . . Mukhopadhyay, A. (2003). Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Critical Care, R202.
Radulescu, V. (2015). Management of venous thrombosis in the pediatric patient. Pediatric Health, Medicine and Therapeutics, 6, 111-119.
RCPI. (2012). 'Start Smart, Then Focus' - An Antibiotic Care Bundle for Hospitals. Dublin: RCPI.
Roland, D., Jones, C., Neill, S., Thompson, M., & Lakhanpaul, M. (2014). Safety netting in healthcare settings: what it means, and for whom? Arch Dis Child Educ Pract Ed , 48-53.
Royal College of Nursing. (2017). STANDARDS FOR ASSESSING, MEASURING AND MONITORING VITAL SIGNS. London: Royal College of Nursing.
Royal College of Physicians of Ireland. (2020, December 18). Start-Smart-Then-Focus-An-Antibiotic-Care-Bundle-for-Hospitals. Retrieved from www.rcpi.ie: https://www.rcpi.ie/news/publication/start-smart-then-focus-an-antibiotic-care-bundle-for-hospitals/
Samaraweera, S. A.–1.-0.-2.-9. (n.d.). Samaraweera, S., Gibbons, B., Gour, A., & Sedgwick, P. (2017). Arterial versus venous
lactate: a measure of sepsis in children. Eur J Paediatrics, 1055-1060. SARI by HSE Health Protection Surveillance Centre. (2009). Guidelines for Antimicrobial
Stewardship in Hospitals in Ireland. Dublin: HSE.
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Schlapbach, L., Straney, L., Bellomo, R., MacLaren, G., & Pilcher, D. (2018). Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital infection admitted to the intensive care unitmortality among children with suspected . Intensive Care Med , 179-188.
Scott, H., Donoghue, A., Gaieski, D., Marchese, R., & Mistry, R. (2012). The Utility of Early Lactate Testing Inflammatory Response Syndrome in Undifferentiated Pediatric Systemic. Academic Emergency Medicine, 1276-1280.
Singer, M., Deutschman, C., & Seymour, C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3). JAMA, 801-810.
The Department of Health. (2016). The Irish Paediatric Early Warning System (PEWS). Dublin: Department of Health.
van Waardenburg, D., Jansen, T., Vos, G., & Buurman, W. (2006). Hyperglycemia in children with meningococcal sepsis and septic shock: the relation between plasma levels of insulin and inflammatory mediators. J Clin Endocrinol Metab(91), 3916-3921.
Verhoeven, J. B., Hokken-Koelega, A., Hazelzet, J., & Jooster, J. (2011). Pathophysiological aspects of hyperglycemia in children with meningococcal sepsis and septic shock: a prospective, observational cohort study. Critical Care(15).
Weiss, s., & Pomerantz, J. (2020, June 3). Septic shock in children: Rapid recognition and initial resuscitation (first hour). Retrieved August 5, 2020, from https://www.uptodate.com/contents/septic-shock-in-children-rapid-recognition-and-initial-resuscitation-first-hour
Weiss, S., Fitzgerald, J., Pappachan, J., Wheeler, D., Jaramillo-Bustamante, J., Salloo, A., . . . Thomas, N. (2015). Global Epidemiology of Pediatric Severe Sepsis: The Sepsis Prevalence, Outcomes, and Therapies Study. American Journal of Respiratory and Critical Care Medicine, 1147-1157.
Weiss, S., Peters, M., Agus, M., Alhazzani, W., Choong, K., Flori, H., . . . Nadael, S. N. (2020). Perspective of the Surviving Sepsis Campaign on the Management of Pediatric Sepsis in the Era of Coronavirus Disease 2019. Paediatric Critical care Med, 1-7.
Weiss, S., Peters, M., Alhazzani, W., Agus, M., Flori, H., Inwald, D., . . . Tissieres, P. (2020). Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med, 46 (Suppl 1):S10–S67.
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