EMERGENCY PAEDIATRIC SEVERE SEPSIS PATHWAYRecognition is the key to successful treatment

ARE THERE SIGNS OF TOXICITY?–

Alterations of alertness or activity, weak/absent cry

Respiratory distress, tachypnoea or grunting breathing

Pallor and/or mottled Colour/Poor capillary refill, Cool peripheries, Persistent tachycardia, bounding pulses or wide pulse pressure

High fevers, rigors

Non- blanching rash?

Known high or low White blood Cell counts?

Line associated infection/swelling redness/pain?

ONCE IDENTIFIED, THE PRIORITY IS EARLY RESUSCITATION AND ANTIBIOTIC ADMINSTRATION

Mortality increases every hour that septic shock remains untreated

A – Ensure patent airway

B - Ensure SpO2 remains >95% - administer O2 as required

C – Achieve vascular access NOW.

No more than 2 attempts by most experienced immediately available clinician; if 2 x failed attempts at IV access in toxic child, insert Intraosseous access NOW

Check glucose

Collect FBC, UEC, LFT, Blood culture, VBG (lactate and glucose), CRP as per Sepsis policy

Initiate fluid resuscitation bolus 20ml/kg IV/IO Normal Saline

If hypoglycaemic (BSL <3.0mmol/L), administer 2mL/kg IV/IO 10% Glucose

D – Assess conscious level using Alert, Voice, Pain, Unresponsive (AVPU) scale

E – Evaluate for likely source of sepsis with rapid focussed history and examination

Administer IV antibiotics within 60 minutes based upon most likely source –

Source unknown – IV/IO Cefotaxime 50mg/kg up to 2g q6hrly AND Gentamicin 7.5mg/kg ideal body weight (1-12yr max dose 320mg, 12-16 max dose 560mg) AND Vancomycin 15mg/kg actual body weight up to 750mg q6hrly

Urinary source – IV/IO Gentamicin 7.5mg/kg ideal body weight (1-12yr max dose 320mg, 12-16yr max dose 560mg) AND Ampicillin 50mg/kg up to 2 g q6hrly

Comm. Acq. Pneumonia – IV/IO Cefotaxime 50mg/kg up to 2g q6hrly AND Vancomycin 15mg/kg actual body weight up to 750mg q6hrly. If significant concerns regarding atypical infection ADD IV/IO Azithromycin 10mg/kg up to 500mg daily

Meningitis/Encephalitis – IV/IO dexamethasone 0.15mg/kg prior to antibiotics. (Do NOT give if encephalitis thought highly likely) THEN IV/IO Cefotaxime 50mg/kg up to 2g q6hrly AND Vancomycin 15mg/kg actual body weight.

IF encephalitis thought to be likely ADD IV/IO Aciclovir (age 1mth-5yr 20mg/kg q8hrly, age >5 15mg/kg q8hrly)

IF at risk of Listeria, ADD IV/IO Ampicillin 50mg/kg up to 2g q6hrly

Intra-abdominal – IV/IO Gentamicin 7.5mg/kg ideal body weight (1-12yr max dose 320mg, 12-16 max dose 560mg) AND Ampicillin 50mg/kg up to 2 g q6hrly AND Metronidazole 12.5mg/kg up to 500mg q12hrly

For other scenarios, click here for CEC guideline or discuss with on-call Infectious Disease team

Consider additional specimen collection as needed eg CSF, urine, swabs, viral culture if not already attended to

F – Fluid in/out – Monitor inputs and outputs. Consider urinary catheter.

MONITOR AND RE-ASSESS

Has there been improvement in Alertness, Breathing parameters or Circulation (perfusion, colour, cap refill, tachycardia)?

If NOT administer further fluid bolus 20ml/kg IV/IO Normal Saline

G – Glucose – check BSL (or re-check if required glucose 10%), and correct with further 2ml/kg IV/IO 10% glucose if required

If persisting failure to demonstrate improvement with -

Ongoing tachypnoea (red/yellow zone) Persistent tachycardia (red/yellow zone) and/or hypotension/poor capillary refill Persistent pallor/mottling/cool peripheries Persistent altered mental state/alertness Poor urine output <1ml/kg/hour Persisting acidosis/elevated lactate Hypoglycaemia/leukopenia/abnormal coagulation studies

ESCALATE to Senior Emergency and Paediatric Medical staff and/or NETS NOW to arrange for definitive care, source control, and potential transfer to a Paediatric ICU

Consider and anticipate need for –

Further 20ml/kg bolus fluid; 2nd IV access; Initiation of vasopressor Respiratory support (e.g. HFNP O2) or Intubation