Triage Trigger or Concern for Sepsis
Identifying children at risk for severe sepsis/septic shock
Use clinical suspicion to identify patients at risk for severe sepsis or septic shock. Patients with severe sepsis/septic shock have an infection which triggers an exaggerated immune response that causes inadequate tissue perfusion leading to organ failure. Hypotension is a late finding. Early recognition and goal directed therapy improves patient outcomes.
Use the following criteria to identify children with history, symptoms suggestive of infection and inadequate tissue perfusion:
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Temperature Abnormality |
Fever > 38.5°C or < 36°C |
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Heart Rate Abnormality |
See table below |
PLUS ONE OF THE FOLLOWING:
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Mental Status Abnormality |
Anxiety, restlessness, agitation, irritability, inappropriate crying |
|
Perfusion Abnormality |
Cool extremities, capillary refill > 3 seconds, diminished pulses, mottling or |
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High Risk Conditions |
< 56 days of age Central line presence BMT or solid organ transplants Malignancy Immune compromised Asplenia, Sickle Cell Disease Immunosuppressive therapy Static encephalopathy Petechial, purpuric rash Erythroderma |
|
Age |
Tachycardia ( > 95th percentile ) |
|
1 mo to 1 yr |
> 180 |
|
> 2 - 5 yrs |
> 140 |
|
> 6 - 12 yrs |
> 130 |
|
> 13 - 18 yrs |
> 120 |
Remember, heart rate is affected by pain, anxiety, medications and hydration status.
Goldstein B. Pediatr Crit Care Med, 2005;6
Retrieved from: http://www.chop.edu/clinical-pathway/sepsis-severe-triage-clinical-pathway-emergency
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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. |