Respiratory Support
Continue to monitor clinical goals following resolution of shock
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Wean FiO2 to keep Sp)2 92-97%
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Continue lung protective strategies
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Consider diuretics or dialysis if fluid overload > 10-15%
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PRBCs if Hgb < 7g/dL
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Wean hydrocortisone when vasoactive infusions no longer required
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Monitor culture results and reassess antibiotic coverage
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Consult ID if culture negative sepsis to determine negative sepsis to determine antibiotic duration PT/OT consult, consider PM&R consult
Respiratory support
Begin age-appropriate oxygen therapy regardless of SpO2
Indications for intubation:
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Hypoxemia or inadequate oxygen delivery
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Left heart failure or refractory shock
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To facilitate safety during invasive catheter placement
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Initial respiratory assessment |
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Respiratory rate Pulse oximetry Work of breathing (WOB) Breath sounds |
Goals: Normal for age SpO2 92-97% Minimal, normal Normal |
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SpO2 < 92% Increased WOB Inadequate gas exchange |
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Consider:
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Gas exchange: Monitor ABG or noninvasive TcPCO2 |
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Respiratory reassessment |
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Monitor all assessment items in Initial Respiratory Assessment plus: Venous SCVO2 Lactate |
Goals: > 70% < 4 mmol/L |
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SpO2 < 92% Increased WOB Arterial pH < 7.25 SCVO2 < 70% |
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Consider:
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Reassess mechanical ventilation goals |
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Pulse oximetry Arterial pH SCVO2 Lactate |
Goals: SpO2 92-98% > 7.25 > 70% < 4 mmol/L |
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Meets Goals? |
Yes |
Lung-Protective Strategy Tidal volume < 7 mL/kg PIP < 35 cm H2O FiO2 < 60% Wean FiO2 if SpO2 > 98% |
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Follow: |
Oxygenation Index (OI) PaO2 / FiO2 |
No |
Alternative Ventilator Strategies Airway Pressure Release Ventilation (APRV) High Frequency Oscillator Ventilation (HFOV) |
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Oxygenation Index (OI) Assesses the intensity of ventilator support required to maintain oxygenation (lower is better). |
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Pa02/FiO2 Ratio Indicates severity of arterial blood hypoxemia given FiO2 only, used in defining ARDS. |
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Interpretation of OI: Very good < 5 Medium 10-20 Poor > 25 |
Interpretation of Pa02/FiO2 Ratio: Normal 452 Mild ARDS 201-300 Moderate ARDS 101 - 200 Severe ARDS < 100 |
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OI calculator: |
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Reconceptualized from: http://www.chop.edu/clinical-pathway/severe-sepsisseptic-shock-icu-clinical-pathway-infants-28-days-and-children-7#lung
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These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times. |