Septic Shock V9.0 Patient Flow Map

Septic Shock v9.0 Patient Flow Map

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

Patient presents to the ED with fever and/or concern for infection and ED sepsis score ≥ 6

! BPA fires Use the ED Suspected Septic Shock RN and Well-appearing patients should be placed pathway for all ill on the appropriate ED CSW pathway for Provider appearing patients their underlying condition (e.g. ED No including HemOnc/BMT, Huddle: HemOnc BMT Suspected Infection, ED Central Line Infection Is the patient ill Suspected Central Line Infection, ED and Neonates appearing? Neonatal Fever)

Yes

ED Septic Shock Pathway • Use ED Suspected Septic Shock Plan • Antibiotics and blood cultures for specific populations included

Inpatient Admit Criteria Does NOT meet Inpatient Admit Minute criteria • Resolution of hypotension and no • Admit to ICU ongoing signs of sepsis after ≤ 40 ml / 60 Huddle: YES NO • Follow ICU Septic Shock Pathway kg NS bolus Does patient meet • Use PICU/CICU Septic Shock Admit • First dose antibiotics administered Inpatient admit Plan • RISK to follow criteria? • Antibiotics, blood cultures for specific populations included in sub plans

Previously healthy > 30 days RISK RN to follow all • Admit to General Medicine patients admitted with • Follow Admit from ED Septic Shock concern for sepsis Pathway • Use Inpatient Septic Shock Plan ! Concern for evolving sepsis Previously healthy < 30 days Any • Admit to General Medicine admitted • Call RRT or Code Blue • Follow Neonatal Fever Pathway patient with • Follow Inpatient New Septic Shock • Use Inpatient Fever Neonatal 0-30 concern for new Pathway days Plan or evolving septic • Use Inpatient New Septic Shock Plan shock HemOnc/ BMT Suspected Infection • Admit to Cancer Care Unit Signs & Symptoms of • Follow Hemonc/BMT Suspected Sepsis Infection Pathway th • Use Hemonc Suspected Infection • Hypotension(MAP ≤ 5 Admit Plan percentile for age) • Tachycardia Central Line Infection • Poor perfusion • Admit to General Medicine/GI • Reduced urine output Transplant • Tachypnea/ new oxygen • Follow Central Line Infection Pathway requirement • Use Admit orders + Central Line • Mental status changes Infection Plan

For questions concerning this pathway, Last Updated: May 2021 contact [email protected] Next Expected Revision: December 2021 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Septic Shock v9.0 Suspected Septic Shock (ED) PHASE I Approval & Citation Explanation of Evidence Ratings Inclusion Criteria

Summary of Version Changes • Any patient with clinical concern Signs & Symptoms of for sepsis/septic shock OR Sepsis Urgent Care Transfer ED Sepsis Score of 6 or greater • Hypotension(MAP ≤ 5th Recommendations AND ED attending/fellow percentile for age) • Concern for septic shock assessment with concern for • Tachycardia • Initiate ALS transfer sepsis/septic shock • Poor perfusion • Provider to Provider handoff • Reduced urine output • Continue pathway while Exclusion Criteria • Tachypnea/ new oxygen waiting for transfer • None requirement • Mental status changes SHOCK TIME GOALS Activate Septic Shock Pathway ! • Assess airway, breathing, circulation Activate Time Zero = • Provide supplemental oxygen ED Sepsis ED Septic • Reassess vital signs every 5 minutes Internal Shock Pathway • Order appropriate antibiotics Response Activation Access/Labs Initial Fluid Resuscitation • EPOC: VBG, lactate, iCa • Place 2 large bore PIVs • POCT glucose • Administer 1st bolus of 20mL/kg normal if no central line • Electrolytes, Magnesium, saline rapidly over 20 minutes OR Phosphorus 15MIN LESS 15 • BUN, Creatinine ! • Consider PIV in patients Correct • Consider 5-10mL/kg boluses if • Blood cultures with central line glucose concern for fluid intolerance • CBC + diff ! and calcium (cardiac/renal dysfunction) • If 2 unsuccessful IV • CRP attempts; consider IO • Consider ABO/RhD and • Give stress dose steroids if known antibody adrenal insufficiency Administer Antimicrobials Ongoing Resuscitation • Previously healthy patients: ceftriaxone (+vancomycin if history • Administer 2nd and 3rd bolus * of 20mL/kg of/concern for MRSA) normal saline rapidly over 20 minutes • Appropriate antibiotics for specific populations: 30MIN OR LESS until perfusion improves or • HemOnc//BMT Suspected Infection (HOBSI) ! unless rales or hepatomegaly develop • Central Line Infection Notify • Order vasoactive/inotropic drips • Neonatal Fever (0-30 days) ICU • Consider blood products as indicated • Consider history of resistant organisms Consider ICU bed request * BMT patients: consider vasoactive / Initiate vasoactive/inotropic drips inotropic drips after 2nd NS bolus for Fluid Refractory Shock • Epinephrine for cold shock Bedside Huddle Respiratory Support (ED, ICU, +/- • Norepinephrine for warm shock • Consider ET intubation for ongoing 60MIN Hospitalist) •• TitrateTitrate drips drips toto resuscitationresuscitation goalsgoals respiratory distress or altered mental •• ConsiderConsider broadening broadening antibioticantibiotic status coveragecoverage asas indicated indicated

ICU Transfer Criteria • Recurrent hypotension despite > 40mL/kg fluid resuscitation in the last 12 hours Inpatient Admit Criteria • Fluid resuscitation includes either crystalloid or colloid • Hypotension (MAP ≤ 5th percentile for age) • Resolution of hypotension • Clinical situation not appropriate for ongoing fluid resuscitation AND no ongoing signs of • Defined as underlying cardiac disease, lung disease, existing fluid overload, sepsis after ≤ 40 ml / kg impaired renal function • First dose antibiotics • Lactate ≥ 4 or base excess < - 4 mmol administered • Sustained change in mentation or perfusion (>15 minutes) • RISK to follow • Patient requires continuous ICU monitoring or ICU level respiratory support

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

PHASE IIA

Inclusion Criteria, • Any patient admitted to the ICU with concern for septic shock

Exclusion Criteria • None

ICU Admission If the following have not already occurred: • IV fluid resuscitation: 40mL/kg or 2L in the first • Oxygen by face mask hour • Obtain 2 points of IV access • Order appropriate antibiotics for specific • Obtain laboratory studies per pathway populations • Assure 1st antibiotic infused within 1 hour of shock identification • Correct hypoglycemia, hypocalcemia

Monitor response vital vital sign sign targets targets & clinicalclinical goals ! ! ! 2020SepsisGuidelines Fluid Intubation Respiratory choice and and Sedation Support blood Medications Infection Repeat fluid products source contol boluses

Fluid Refractory Shock Consider central line, arterial line, Foley

Warm Shock Cold Shock; Low BP Cold Shock; Normal BP • Titrate norepinephrine • Titrate epinephrine • Titrate epinephrine • Consider epinephrine, vasopressin • Consider norepinephrine, dobutamine • Consider milrinone, dobutamine if • PRBC if Hgb <10g/dL • PRBC if Hgb <10g/dL SCvO2 <70% or lactate elevated • Consider intubation • Consider intubation, BNP, ECHO • PRBC if Hgb <10g/dL • Consider intubation, BNP, ECHO

Catecholamine Resistant Shock • Consider stress-dose hydrocortisone • Evaluate for: • Pericardial effusion Consider ECLS • Pneumothorax • Intra-abdominal hypertension • Primary cardiac dysfunction ICU to Inpatient Transfer Criteria • Weaned off of inotropic support • Not requiring ICU level of respiratory support Return to Flow • Hemodynamically stable

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

PHASE IIB

! ! Inclusion Criteria, • Any patient who is admitted Call to a service other than the code blue Call RRT for ICU on Septic Shock for imminent signs of sepsis that Pathway cardiac or require ICU presence pulmonary failure within 30 minutes Exclusion Criteria or neurologic emergency • None

Signs & Symptoms of Sepsis th Patient placed on RISK dashboard • Hypotension(MAP ≤ 5 • Vital signs Q 2 hours x 8 hours percentile for age) • Tachycardia • Poor perfusion • Reduced urine output • Tachypnea/ new oxygen requirement RISK Nurse Monitoring • Mental status changes • RISK dashboard monitoring • RISK nurse Inpatient evaluation • RISK nurse determines time on dashboard • RRT activation for signs of clinical deterioration

Continued Sepsis Care • Continue appropriate antibiotics for specific populations x 48 hours • Follow cultures daily, switch to narrow-spectrum antibiotics as indicated • Discontinue antibiotics after 48 hours if cultures negative and clinically improving • Advance diet as tolerated • Continue maintenance IV fluids if indicated

ICU Transfer Criteria • Recurrent hypotension despite > 40mL/kg fluid resuscitation in the last 12 hours • Fluid resuscitation includes either crystalloid or colloid • Hypotension (MAP ≤ 5th percentile for age) • Clinical situation not appropriate for ongoing fluid resuscitation • Defined as underlying cardiac disease, lung disease, existing fluid overload, impaired renal function • Lactate ≥ 4 or base excess < - 4 mmol • Sustained change in mentation or perfusion (>15 minutes) • Patient requires continuous ICU monitoring or ICU level respiratory support

Return to Flow Return to Phase I Return to Phase IIA

Approval & Citation PHASE IIC Explanation of Evidence Ratings

Signs & Symptoms Inclusion Criteria, Summary of Version Changes of Sepsis • Any patient who is admitted • Hypotension(MAP ≤ to a service other than the 5th percentile for age) ! ICU on Septic Shock • Tachycardia Call Pathway • Poor perfusion code blue • Reduced urine output for imminent Exclusion Criteria SHOCK • Tachypnea/ new cardiac or • None TIME oxygen requirement pulmonary failure GOALS • Mental status changes or neurologic emergency Time Zero = Inpatient Rapid Bedside Assessment New Septic Shock OFF PATHWAY Pathway Activation • Primary team huddle to Does • Assess airway, breathing, circulation activate Septic Shock pathway patient meet • Provide supplemental oxygen • Call RRT YES NO RRT • Place on continuous monitor, reassess vital ! • Appropriate antibiotics for specific criteria? signs every 15 minutes RRT population • AppropriateOrder appropriate antibiotics antibiotics for specific population

Labs Access/Initial Fluid Resuscitation • EPOC: Electrolytes, VBG, lactate, iCa • Consider PIV in patients with central line • Bedside Glucose if additional access is needed • Blood cultures 15 15MIN • CBC + diff ! • Administer 1st bolus of 20 mL/kg normal Correct saline rapidly over 20 minutes or less • CRP glucose • Magnesium, Phosphorus and calcium • Consider 5-10 mL/kg boluses if concern • BUN, Creatinine for fluid intolerance (cardiac/renal • Consider ABO/RhD and antibody dysfunction)

Administer Antimicrobials Ongoing Resuscitation • Previously healthy patients: ceftriaxone (+vancomycin if • Administer 2nd bolus * of 20mL/kg history of/concern for MRSA) normal saline rapidly over 20 minutes • AppropriateAntibiotics for antibiotics specific forpopulations: specific populations: ! OR LESS 30MIN • HemOnc//BMT Suspected Infection (HOBSI) Consider • Order vasoactive/inotropic drips as • Central Line Infection surgical indicated • Neonatal Fever (0-30 days) consult for • Consider blood products as indicated • Consider history of resistant organisms source control * BMT patients: consider vasoactive / inotropic drips after 2nd NS bolus

RISK Team Re-evaluation RRT Transfer to ICU • Initiate vasoactive/inotropic drips Debrief for Fluid Refractory Shock • Well-appearing patients, who do Does patient NO YES • Epinephrine for cold shock not meet ICU transfer criteria, may meet ICU 60MIN • Norepinephrine for warm shock stay on Inpatient unit and are transfer • Titrate drips to resuscitation goals placed on RISK dashboard for criteria? • Consider broadening antibiotic reassessment coverage as indicated

Return to Flow ICU Transfer Criteria • Recurrent hypotension despite > 40mL/kg fluid resuscitation in the last 12 hours Return to Phase I • Fluid resuscitation includes either crystalloid or colloid • Hypotension (MAP ≤ 5th percentile for age) • Clinical situation not appropriate for ongoing fluid resuscitation Return to Phase IIA • Defined as underlying cardiac disease, lung disease, existing fluid overload, impaired renal function Return to Phase IIB • Lactate ≥ 4 or base excess < - 4 mmol • Sustained change in mentation or perfusion (>15 minutes) • Patient requires continuous ICU monitoring or ICU level respiratory support

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Job Aid: Clinical Indication for Urgent Inotropic/ Vasoactive Support in the ED, PICU, and CICU

Fluid Refractory Shock / Inotropic Support Reference: CSW Septic Shock Pathway

Peripherally Acceptable Concentrations: • EPINEPHrine infusion 0.032 mg/mL • NORepinephrine infusion 0.032 mg/mL Access Type: Vasoactive/ PIV Access • DOPamine infusion 1.6 mg/mL CVL Access • PIV Inotropic (2 Preferred) • CVL Order

High-Risk Administer Lower Risk Extravasation Titration Range for PIV Infusions: Vasoactive/ Extravasation Infusions: EPINEPHrine: 0.01 – 0.1 mcg/kg/min MAX Inotropic Support Infusions: • EPINEPHrine NORepinephrine 0.01 – 0.1 mcg/kg/min MAX via CVL Milrinone • NORepinephrine DOPamine: 5 – 10 mcg/kg/min MAX • DOPamine

Every 15 Minutes Assessment PIV Assessment • Perform Vital Signs and Physical Every 1 Hour Assessment • Titrate vasoactive/inotropic medication to goal MAP • Assess PIV Site for signs and symptoms of an infiltration using Touch, Look, Compare Titration Frequency & Dose Change: (TLC) EPINEPHrine: 0.01 mcg every 5-10 min • For extravasation, administered ordered NORepinephrine 0.01 mcg every 5-10 min Phentolamine and refer to Intravenous (IV) DOPamine: 1-5 mcg every 5-10 min Line Infiltration and Extravasation Assessment and Treatment P&P IV Fluid • IV Fluid Carrier (KVO or at MIVF) • Ensure Standard IV Fluid Carrier with ! Vasoactive/Inotropic Infusion For Extravasation: RN Med Request Do Not Transition Phentolamine and Request IV HUDDLE REQUIRED IF: PIV Infusions/ Notify Provider For: Team to Administer • 6 hours of PIV Admin of Fluids to a CVL • Worsening Physical Assessment Findings Vasoactive/Inotropic line. • < 5th Percentile for MAP 5 Minutes After last Infusion Reached Recommend Titration • MAX dose reached setting up a new • Patient requires MAX dose via PIV Recommend CVL Placement line to prevent • PIV Infiltrate CLABSI risk.

Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Return to Flow Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Return to Flow Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Instructions for finding the “Individualized Antibiotic Plan”

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Return to Flow Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Septic Shock Approval & Citation

Approved by the CSW Septic Shock Team for 12/14/16 go-live date

CSW Sepsis/Septic Shock Team: Emergency Department, Owner Lori Rutman, MD ICU, Stakeholder Reid Farris, MD, MS ICU, Stakeholder Silvia Hartman, MD HemOnc, Stakeholder Kasey Leger, MD HemOnc, Stakeholder Jennifer Wilkes, MD HemOnc, Stakeholder Leah Kroon, CNS Emergency Department, CNS Sara Fenstermacher, CNS Emergency Department, CNS Elaine Beardsley, CNS Clinical Pharmacy Rochelle Legg, PharmD Pharmacy Informatics Rapheus Villanueva, PharmD Medical Unit, CNS Coral Ringer, MN, CNS Emergency Department, Stakeholder Eileen Klein, MD, MPH Emergency Department, Stakeholder Ron Kaplan, MD ICU, Stakeholder Jerry Zimmerman, MD RISK team/ICU Stakeholder Joan Roberts, MD Central Line Infection Pathway Owner Mathew Kronman, MD Antimicrobial Stewardship Committee Dan Pak, MD, Scott Weissman, MD Pediatric Chief Residents, Stakeholder Allison LaRoche, MD

Clinical Effectiveness Team: Consultant Darren Migita, MD Project Manager Pauline Ohare, MBA, RN CE Analyst Holly Clifton, MPH CIS Informatician Mike Leu, MD, MS, MHS Troy McGuire, MD CIS Analyst Heather Marshall Librarian Jackie Morton, MLIS Program Coordinator Kristyn Simmons

Clinical Effectiveness Leadership:

Medical Director: Darren Migita, MD Operations Director: Karen Rancich Demmert, BS, MA

Retrieval Website: http://www.seattlechildrens.org/pdf/septic-shock-pathway.pdf

Please cite as: Seattle Children’s Hospital, Rutman, L., Robert, J., Beardsley, E., Farris, R., Fenstermacher, S., Leu, M., Marshall, H., Migita, D., O’hare, P., Ringer, C., 2016 December. Septic Shock Pathway. Available from: http://www.seattlechildrens.org/pdf/septic-shock-pathway.pdf

Return to Flow To Bibliography Evidence Ratings

This pathway was developed through local consensus based on published evidence and expert opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):

Quality ratings are downgraded if studies: • Have serious limitations • Have inconsistent results • If evidence does not directly address clinical questions • If estimates are imprecise OR • If it is felt that there is substantial publication bias

Quality ratings are upgraded if it is felt that: • The effect size is large • If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR • If a dose-response gradient is evident

Guideline – Recommendation is from a published guideline that used methodology deemed acceptable by the team.

Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE criteria (for example, case-control studies).

To Bibliography Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Summary of Version Changes

Version 1.0 (10/7/2015): Go live Version 2.0 (2/12/2016): Clarification of clinical findings indicative of warm vs. cold shock added; updates to hypotension and resuscitation goals to reflect hospital standards; clarification of indication for RRT vs. code blue Version 3.0 (12/14/2016): New Septic Shock Inpatient Plan update; Revision of Septic Shock Score Trigger; Inclusion of BMT in Hem/Onc Suspected Infection pathway (renamed Hem/Onc/BMT Suspected Infection - HOBSI) Version 4.0 (5/22/2017): Updated MAP to include Normotension Median for Age (50 % ile). Added verbiage “Resolution of hypotension = Two blood pressure measurements obtained 15 minutes apart with MAP >10 %ile” Version 4.1 (6/12/2017): PHASE IIA ICU - Catecholamine Resistant Shock: replace “give stress dose hydrocortisone”, with, “consider stress dose hydrocortisone”. Version 5.0 (5/18/2018): Updated the recommendations for empiric therapy from pip/tazo to cefepime. Version 6.0 (9/5/2018): Updated PHASE IIA to separate PICU/CICU Sepsis/Septic Shock Plan, including peripheral pressors. Version 7.0 (10/16/2019): Cefotaxime is no longer available and has been replaced with ceftazidime. Sepsis Antibiotic Chart updated. Version 8.0 (7/14/2020): Age range updated from <>30 days to <> 28 days on Sepsis Antibiotic Chart. Version 9.0 (5/18/2021): Updated to reflect Epic change to ED Sepsis Score. Updated MAP table and added 2020-Sepsis Guidelines. Removed RRT K-Card.

Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither the authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are encouraged to consult with their health care provider before making any health care decision.

Return to Flow

Return to Phase I Return to Phase IIA Return to Phase IIB Return to Phase IIC Bibliography

Search Methods, Sepsis, Clinical Standard Work

Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Jackie Morton. Searches were performed in April, 2015. The following databases were searched – on the Ovid platform: Medline (2012 to date), Cochrane Database of Systematic Reviews (2012 to date); elsewhere – Embase (2012 to date), Clinical Evidence, National Guideline Clearinghouse, TRIP (2012 to date) and Cincinnati Children’s Evidence-Based Care Guidelines.

Retrieval was limited to humans (any age) and English language. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Concepts searched were sepsis and specific laboratory diagnostic procedures or antibiotic therapeutics. Additional searches for concepts not specific to sepsis were Rapid Sequence Intubation (RSI) and sedation, anesthetic, paralytic or pain agents and lastly the use and number of peripheral intravenous lines. All retrieval was further limited to certain evidence categories, such as relevant publication types, Clinical Queries filters for diagnosis and therapy, index terms for study types and other similar limits. An additional consensus document was identified by team members and added to results. Identification 233 records identified 1 additional record identified through database searching through other sources

Screening

234 records after duplicates removed

234 records screened 167 records excluded

Eligibility 56 full-text articles excluded, 5 did not answer clinical question 67 records assessed for eligibility 46 did not meet quality threshold 4 removed for other reasons 1 was a duplicate Included

11 studies included in pathway

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Return to Flow To Bibliography, Pg 2 Bibliography

Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med [Sepsis Original]. 2013;41(2):580-637. Accessed 20130128; 4/1/2015 5:54:20 PM. http://dx.doi.org/10.1097/ CCM.0b013e31827e83af. Lin SG, Hou TY, Huang DH, et al. Role of procalcitonin in the diagnosis of severe infection in pediatric patients with fever and neutropenia--a systemic review and meta-analysis. Pediatr Infect Dis J [Sepsis Original]. 2012;31(10):e182-8. Accessed 20120917; 4/1/2015 5:54:20 PM. http://dx.doi.org/10.1097/INF.0b013e31825da45d. Phillips R, Hancock B, Graham J, Bromham N, Jin H, Berendse S. Prevention and management of neutropenic sepsis in patients with cancer: Summary of NICE guidance. BMJ [Sepsis Original]. 2012;345:e5368. Accessed 20120920; 4/1/2015 5:54:20 PM. http://dx.doi.org/ 10.1136/bmj.e5368. Rodriguez L, Ethier MC, Phillips B, Lehrnbecher T, Doyle J, Sung L. Utility of peripheral blood cultures in patients with cancer and suspected blood stream infections: A systematic review. Support Care Cancer [Sepsis Original]. 2012;20(12):3261-3267. Accessed 20121025; 4/1/ 2015 5:54:20 PM. http://dx.doi.org/10.1007/s00520-012-1471-2. Texas Children's Hospital Evidence-Based Outcomes Center. Recognition and Initial Management Septic Shock Review Summary. . Updated 2015 JanuaryPDF. Wacker C, Prkno A, Brunkhorst FM, Schlattmann P. Procalcitonin as a diagnostic marker for sepsis: A systematic review and meta-analysis. Lancet Infect Dis [Sepsis Original]. 2013;13(5):426-435. Accessed 20130426; 4/1/2015 5:54:20 PM. http://dx.doi.org/10.1016/ S1473-3099(12)70323-7.

Return to Flow Return to Bibliography, Pg 1