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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:

Temperature Abnormality

Fever > 38.5°C or < 36°C

Heart Rate Abnormality              

See table below


Mental Status Abnormality

Anxiety, restlessness, agitation, irritability, inappropriate crying
Drowsiness, confusion, lethargy, obtundation

Perfusion Abnormality

Cool extremities, capillary refill > 3 seconds, diminished pulses, mottling or
Flushed, warm extremities, bounding pulses, flash capillary refill

High Risk Conditions

< 56 days of age

Central line presence

BMT or solid organ transplants


Immune compromised

Asplenia, Sickle Cell Disease

Immunosuppressive therapy

Static encephalopathy

Petechial, purpuric rash




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:

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.