"Time Zero"

The first point at which anyone considers that a child might be septic.

1. Concern for shock - Besides fever, tachycardia, and hypotension, some patients present initially only with altered mental status and decreased perfusion (delayed or flash capillary refill) – refer to RAPID SEPSIS ASSESSMENT TOOL

2. Call Rapid Response Team or move to resuscitation room.

3. Place oxygen on all patients - min. 2 L NC to keep SpO2 > 94%!

4. Initiate attempts at IV access and lab testing (OK to use Broviac/central line): POC tests - blood gas, glucose, lytes, lactate. Also CBC, Chem 8, blood cultures)

5. Know IO equipment location.

0-15 Minutes - START

First Interval

1. If no IV access by 5 minutes, consider IO (TODO: Ideal: link to IO video and/or protocol) (TODO: Timer to pop up: "5 minutes have passed. Place IO if no IV access obtained")

2. PUSH fluids (NS by hand over 5 minutes if possible, not on a pump, 20 ml/kg IV, repeat until perfusion improves unless rales or hepatomegaly develop, maximum 60 ml/kg IV. Assess liver margin after each NS bolus. Fluid resuscitation will take longer than 15 minutes, but initiate here )

3. Assess point of care results and treat hypoglycemia ideal:link to hypoglycemia protocol) and hypocalcemia ionized Ca < 1 - confirm with CHRCO physician control) ideal:link to calcium replacement protocol). Consider NaHCO₃ 1 mEq/kg for pH < 7.0.

4. Order antibiotics ideal:link to antibiotic algorithm with antibiotic and dosing recommendations, e.g. 0-28 days ampicillin 50 mg/kg and cefotaxime 50 mg/kg IV; < 28 days: ceftriaxone 50 mg/kg IV up to 2 gm. Do not administer with calcium, etc.) and give ASAP Goal for first dose to be in by 30 minutes )

5. Order inotropes to bedside, use if BP low and 2nd IV available, MAY give inotropes through PIV or IO, even on the ward (TODO: Link to lookup: dopamine) first up to 10 mcg/kg/min then...

   1. ...if cold extremities add epinephrine 0.01-0.3 mcg/kg/min

   2. ...if warm extremities add norepinephrine 0.01-0.3 mcg/kg/min

15-60 Minutes - REASSESS

Second Interval

1. Consider hydrocortisone for potential adrenal insufficiency! (slow IV push: 25 mg IV up to 6 months, 50 mg IV up to 10 years, 100 mg IV if older than 10 years)

2. Reconsider need for inotropes if not already being given.

3. Reassess:

   1. Appropriate cultures have been drawn (min. 1 mL blood)

   2. Antibiotics given

   3. Sufficient fluid resuscitation given

1-4 Hours - REASSESS

Third Interval

1. Consider need for more fluid boluses (up to 200 ml/kg).

2. Consider adjusting inotropes upwards or adding vasopressors (norepinephrine or vasopressin (TODO: link to norepinephrine and vasopressin protocols).

3. May need blood transfusion. (Surviving Sepsis Guidelines suggest goal Hgb 10).

4. Consider pericardial effusion, pneumothorax, and increased intra-abdominal pressure. Treat if found. (TODO: link to protocols for treatment)

5. May require central line for access and/or monitoring CVP.

6. Consider repeating POC blood gas, electrolytes and glucose.

Rapid Sepsis Assessment