v.

10/4/2022
CCHMC Sepsis Algorithm
CONCERN FOR SEPSIS
Clinical Concern Positive Screen (ED, PICU, CICU) SA Huddle Discussion Algorithms guide care but
are not intended to replace
clinical judgement, nor
capture all nuances of
SITUATION AWARENESS HUDDLE or ED SEPSIS HUDDLE critical care.

Evaluate for Signs of Shock: Altered Perfusion

• Cool extremities
• Delayed capillary refill (> 2 sec); diminished pulses; mottling
• Flushed; warm extremities; bounding pulses; flash capillary refill (< 1 sec)
• Altered mental status (confusion, sleepiness, fussiness)
• Hypotension (late finding)

Altered
Perfusion?

SEPTIC SHOCK RED PATHWAY SUSPECTED SEPSIS YELLOW PATHWAY

GOALS: Reverse shock, antibiotics within 60 minutes GOALS: Expedite diagnostic evaluation, recognize developing shock
Sepsis Algorithm

Utilize CCHMC or Unit-Specific Septic Shock Order Set* Utilize CCHMC or Unit-Specific Septic Shock Order Set*
Initiate monitors (Q15 minute vital signs) Initiate monitors (Q15 minute vital signs)
Rapid IV access; IO if PIV cannot be obtained quickly IV access
Oxygen as needed Consider rapid bolus of NS or LR 10-20 mL/kg** (Push pull bolus
Rapid bolus of NS or LR 10-20 mL/kg** (Push pull bolus or rapid or rapid infuser)
infuser) STAT CBC, blood culture, BMP, blood gas, lactic acid. Other labs
STAT CBC, blood culture, BMP, blood gas, lactic acid. Other labs as indicated to assess for organ dysfunction (see back)
as indicted to assess for organ dysfunction (see back) Consider additional labs & imaging to identify source of infection
Order antibiotics STAT Consider Watcher status, Specify MRT criteria
Designate Watcher status/MRT criteria; Activate MRT if indicated Evaluate for developing shock
30 min

**Smaller volumes if clinically indicated *Populations with protocols for antibiotics for fever (GI, CBDI, CVL,
etc.) should have antibiotics initiated within those timeframes
Reassess **Smaller volumes if clinically indicated 1 hr
Vital signs q15 minutes
Response to fluid & for signs of fluid overload (rales, new/worse
hypoxemia) Move to RED Yes
Signs of persistent shock Signs of shock?
Pathway
Consider additional fluid boluses, up to 40-60 mL/kg total over the
1st hour (10-20 mL/kg per bolus) until shock resolves or signs of No
fluid overload develop
Reassess
Vital signs
Continued No Monitor Response to fluid & for signs of fluids overload (rales, new/worse
signs of shock? closely, hypoxemia)
ongoing care When indicated, antibiotics should be ordered STAT &
administered ASAP
Yes
Consider need for additional fluid boluses (10-20 mL/kg per bolus)
Ongoing Resuscitation Evaluate for developing shock
1 hr
Administer antibiotics within 60 min of shock recognition
Reassess response to fluid & for signs of fluid overload (rales,
60min new/worse hypoxemia) Move to RED Yes
Signs of shock?
Pathway

Continued No Monitor No 33hrs

hrs
signs of shock? closely,
ongoing care Ongoing care, Monitor closely
Administered antibiotics as soon as indicated & within 3
Yes hours of initial suspicion of sepsis* (if indicated)
Ongoing monitoring & reassessments for clinical deterioration
Ongoing Resuscitation & Sepsis Care*
Initiate epinephrine or norepinephrine if shock persists after
40-60mL/kg (sooner if signs of fluid overload develop)
When available, assess cardiac function; consider epinephrine if *Septic Shock Order Sets
there is myocardial dysfunction
Airway management: consider trial of noninvasive ventilation if Ensures comprehensive sepsis management, including indicated
ARDS & responding to resuscitation; consider intubation for labs, & that antibiotics are ordered STAT
resistant shock, avoid etomidate; utilize high PEEP
Early infectious source control (including surgical) • Septic Shock Algorithm (used on acute care units)
Avoid hypoglycemia / address electrolyte abnormalities • ED Septic Shock Algorithm
Repeat lactic acid if abnormal • PICU Septic Shock Admission (or Abbreviated)
• Septic Shock Algorithm for GI
Other considerations: Invasive hemodynamic monitoring; • BMT Sepsis Order Set
Hydrocortisone for refractory shock (risk/benefit unclear); ECLS for • Sepsis Hem/Onc
refractory shock or oxygenation / ventilation failure (after addressing • CICU Septic Shock Abbreviated
other causes of shock & respiratory failure)

10
 Sepsis Algorithm

11
Antibiotic Recommendations
Previously
Healthy Ceftriaxone +/- Intra-Abdominal Cefepime/Flagyl
Unknown Source
Vancomycin* Source +/- Vancomycin*
Patient
BMT or Oncology Refer to CBDI GI Patient (Liver or Refer to GI Septic
small bowel transplant,
Medically Patient Guidelines or CVC
Shock Order Set
Complex History of Multi-Drug Non-CBDI Patients with
Patient Resistant Bacteria or Meropenem + a CVC or on Immuno- Cefepime +
Recent Exposure to Vancomycin suppresive Meds Vancomycin
Cefepime or Zosyn (e.g. Rheum)
*Vancomycin is indicated for children with MRSA risk factors or highly-resistant S. pneumoniae & when it is ordered, it should be
administered after the 1st antibiotic listed above.
• MRSA risk factors: bone/joint/deep tissue infection; personal history or family history of MRSA infection of recurrent boils
• Highly-resistant S. pneumoniae risk factors: recent B-lactam exposure, daycare attendance, unvaccinated
Additional Lab Recommendations
All patients: CBC, blood culture, BMP, blood gas, lactic acid
As needed to identify source/based on underlying conditions: UA/Urine culture, LFTs, HCG, CXR, and/or
CSF, viral, wound, trach studies
If signs of coagulopathy: PT/PTT, INR, Fibrinogen, type/screen
If concerned for osteomyelitis or septic joint: ESR, CRP
Advanced care as needed: Procalcitonin, additional or advanced imaging