An Emergency Department Septic Shock Protocol and Care Guideline for Children Initiated at Triage

Author:

Larsen Gitte Y.12,Mecham Nancy3,Greenberg Richard23

Affiliation:

1. Pediatric Critical Care, Department of Pediatrics, and

2. Department of Pediatrics, University of Utah, Salt Lake City, Utah

3. Pediatric Emergency Department, Primary Children's Medical Center, Salt Lake City, Utah; and

Abstract

BACKGROUND: Unrecognized and undertreated septic shock increases morbidity and mortality. Septic shock in children is defined as sepsis and cardiovascular organ dysfunction, not necessarily with hypotension. OBJECTIVE: Cases of unrecognized and undertreated septic shock in our emergency department (ED) were reviewed with a focus on (1) increased recognition at triage and (2) more aggressive treatment once recognized. We hypothesized that septic shock protocol and care guideline would expedite identification of septic shock, increase compliance with recommended therapy, and improve outcomes. METHODS: We developed an ED septic shock protocol and care guideline to improve recognition beginning at triage and evaluated all eligible ED patients from January 2005 to December 2009. RESULTS: We identified 345 pediatric ED patients (49% male, median age: 5.6 years), and 297 (86.1%) met septic shock criteria at triage. One hundred ninety-six (56.8%) had ≥1 chronic complex condition. Hypotension was present in 34% (n = 120); the most common findings were tachycardia (n = 251 [73%]) and skin-color changes (n = 269 [78%]). The median hospital length of stay declined over the study period (median: 181–140 hours; P < .05); there was no change in mortality rate, which averaged 6.3% (22 of 345). The greatest gains in care included more complete recording of triage vital signs, timely fluid resuscitation and antibiotic administration, and serum lactate determination. CONCLUSIONS: Implementation of an ED septic shock protocol and care guideline improved compliance in delivery of rapid, aggressive fluid resuscitation and early antibiotic and oxygen administration and was associated with decreased length of stay.

Publisher

American Academy of Pediatrics (AAP)

Subject

Pediatrics, Perinatology and Child Health

Reference18 articles.

1. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine [published correction appears in Crit Care Med. 2009;37(4):1536];Brierley;Crit Care Med,2009

2. Role of early fluid resuscitation in pediatric septic shock;Carcillo;JAMA,1991

3. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome;Han;Pediatrics,2003

4. Early goal-directed therapy in the treatment of severe sepsis and septic shock;Rivers;N Engl J Med,2001

5. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support;American Heart Association;Pediatrics,2006

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