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 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 ICU 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 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 ED Admit to Inpatient for Septic Shock 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