Skip to main content

Monitor and Vital Signs

Vital sign targets and clinical goals


Age-related vital sign targets

Age

Heart Rate*

Respiratory

Rate*

SBP**

MAP**

DBP**

Term NB

90-170

40-60

>60

>40

>30

0 to 30 days

110-180

30-50

>60

>40

>30

3 Mo

110-180

30-45

>65

>45

>30

6 Mo

110-180

25-35

>65

>45

>30

1 Yr

80-160

20-30

>70

>50

>35

2 Yrs

80-130

20-30

>75

>50

>40

4 Yrs

80-120

20-30

>75

>50

>40

6 Yrs

75-115

18-24

>85

>60

>45

8 Yrs

70-110

18-22

>85

>60

>45

10 Yrs

70-110

16-20

>85

>60

> 45

12 Yrs

60-110

16-20

>85

>60

> 45

14 Yrs to Adult

60-100

16-20

>90

>65

>50

*Heart rate and respiratory rate from Pediatric Early Warning Score (PEWS)

**Systolic blood pressure, mean arterial pressure (MAP) and diastolic blood pressure (DBP) values from Children’s Hospital of Philadelphia, Sepsis Critical Care Pathway—PICU (http://www.chop.edu/clinical-pathway/icu-clinical-pathway-infants-28-days-and-children-severe-sepsisseptic-shock-vital)

 

RN Assessment and vital sign documentation

Parameters to Assess

Capillary refill

Extremity temperature

Pulse strength

Mental status

Frequency

At time of pathway initiation

Every 15 minutes for the 1st hour

Every 30 minutes for the 2nd hour

Hourly until goals met

Discuss with the Resident, Nurse Practitioner, or Attending when to space out these assessments

 

 

Clinical goals for initial resuscitation

Parameter

Comment

Target

Heart Rate

Tachycardia can be a sign of hypovolemia or ongoing shock;

Bradycardia can be a sign of shock

Age-related (see table above)

Systolic Blood Pressure (SBP)

Arterial monitoring preferred

Age-related (see table above)

Diastolic Blood Pressure (DBP)

Arterial monitoring preferred

Age-related (see table above)

Mean Arterial Blood Pressure (MAP)

Arterial monitoring preferred

Age-related (see table above)

Urine Output (UOP)

Inadequate urine output is one sign of poor end-organ perfusion

< 30 kg: > 1 ml/kg/hr
≥ 30 kg: ≥ 30 ml/hr

Central Venous Pressure (CVP)

Most accurately measured from CVL with tip at the SVC-RA junction;
Femoral CVL, PICC and Broviac measurements less reliable, but trends may be useful

If CVP is high and the patient is not responding to fluid administration, consider not administering additional fluid boluses

Lactate

Elevated lactate > 4 mmol/L may be sign of shock with inadequate oxygen delivery (ref: Puskarich et al, Resuscitation, 2011 )

< 4 mmol/L or
≥ 10% decrease every 2 hours

Central venous oxygen saturation (ScvO2 or venous co-oximetry)

Most accurately measured from CVL with tip at the SVC-RA junction or long femoral line with tip near RA

≥ 70%
Note: Elevated ScvO2 (> 80%) may occur in sepsis due to "cytopathic hypoxia" despite ongoing shock

Hemoglobin

Hemoglobin is a primary determinant of O2 delivery; thus, anemia should be treated in shock. Patients NOT in shock may tolerate a lower Hgb level of 7

Hgb ≥ 10 g/dL (for patients in shock
- ScvO2 < 70%, lactate > 4 mmol/L)

Hgb > 7 g/dL (after resolution of shock)

Mental Status

Lethargy, confusion, agitation is one sign of poor end-organ perfusion

Alert and appropriate for age

Capillary Refill

Flash capillary refill can be seen in warm shock, delayed capillary refill can be seen in cold shock

< 2 seconds

 

Retrieved from http://www.chop.edu/clinical-pathway/icu-clinical-pathway-infants-28-days-and-children-severe-sepsisseptic-shock-vital

 

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.