Those who undergo major surgical procedures or who have certain medical hardware placed, such as a central line, are at increased risk for infection and subsequent septic shock. Despite the growing knowledge of this problem, overall recognition in pediatric patients remains relatively low among physicians. To address this issue, my colleagues and I published a study in the May 16, 2011 issue ofPediatrics to describe strategies that have been effective at our institution to improve the management of pediatric septic shock.
Recognizing & Treating Septic Shock Early
Studies have shown that early recognition and early, aggressive, goal-directed treatment can improve clinical outcomes for children with septic shock. For each additional hour of persistent shock, the mortality risk increases twofold. It’s critical that clinicians become aware of the warning signs of pediatric septic shock. For example, they should be on the lookout for key vital signs, such as age-appropriate heart rate, respiratory rate, and blood pressure. Signs and symptoms include fever, tachycardia, tachypnea, altered mental status, and poor perfusion that may be manifested by cool skin or decreased capillary refill. Hypotension would be a late finding.
Developing Protocols for Septic Shock
Each hospital should develop its own systems and protocols for recognizing pediatric patients with septic shock. A key note from our study in Pediatrics was that all patients presenting to the ED who met criteria for three or more of the above symptoms or who met any one item and had low blood pressure met our protocol for septic shock. Although most patients in the protocol did not have septic shock, we wanted to cast a wide net to be able to identify as many patients with septic shock as possible.
“It’s important to gauge your hospital’s current outcomes in cases of pediatric septic shock.”
Once the potential for septic shock was identified, patients were placed in a room with the goal of obtaining a physician assessment within 15 minutes, placing patients on pulse oximetry and cardiac monitors, and placing them on oxygen regardless of oxygen saturation level. Patients then had labs drawn, including complete blood counts, blood cultures, and serum lactate measurements performed at bedside. We then provided rapid administration of an IV fluid bolus with frequent reassessment and administered a second or third bolus quickly if needed. Perhaps the most important component of our protocol was to get nurses involved from triage. In many situations, attending physicians won’t see patients until they are placed in a room, and that can occur hours after the initial triage.
Expectations on the effect of implementing our protocol into other organizations will depend upon existing systems. It’s important to gauge your hospital’s current outcomes in cases of pediatric septic shock. Ultimately, using our protocol helped us achieve a statistically significant decrease in length of stay and hospital costs. Improvements were also seen in complete recording of triage vital signs, timely fluid resuscitation, initiation of antibiotic treatment, and serum lactate measurements. Organizations that implement this protocol can expect much of the same and may see a decrease in morbidity and mortality. Outcomes are likely to improve as greater efforts are made to recognize and aggressively treat pediatric patients with septic shock.
Readings & Resources (click to view)
Larsen G, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011 May 16 [Epub ahead of print]. Available at http://pediatrics.aappublications.org/content/early/2011/05/11/peds.2010-3513.abstract.
Lawrence K. Pediatric sepsis and multiorgan dysfunction syndrome: progress and continued challenges.Crit Care Nurs Clin North Am. 2011;23:323-337.
Lodha R, Oleti T, Kabra S. Management of septic shock. Indian J Pediatr. 2011;78:726-733.
Simpson J, Teach S. Pediatric rapid fluid resuscitation. Curr Opin Pediatr. 2011;23:286-292.