Guidelines on management of sepsis and associated organ dysfunction in children

· We were unable to issue a recommendation about whether to intubate children with fluid-refractory, catecholamine-resistant septic shock. However, in our practice, we commonly intubate children with fluid-refractory, catecholamine-resistant septic shock without respiratory failure.

· We suggest not to use etomidate when intubating children with septic shock or other sepsis-associated organ dysfunction.

· We suggest a trial of noninvasive mechanical ventilation (over invasive mechanical ventilation) in children with sepsis-induced pediatric ARDS (PARDS) without a clear indication for intubation and who are responding to initial resuscitation.

· We suggest using high positive end-expiratory pressure (PEEP) in children with sepsis-induced PARDS.

· We cannot suggest for or against the use of recruitment maneuvers in children with sepsis-induced PARDS and refractory hypoxemia.

· We suggest a trial of prone positioning in children with sepsis and severe PARDS.

· We recommend against the routine use of inhaled nitric oxide (iNO) in all children with sepsis-induced PARDS.

· We suggest using iNO as a rescue therapy in children with sepsis-induced PARDS and refractory hypoxemia after other oxygenation strategies have been optimized.

· We were unable to issue a recommendation to use high-frequency oscillatory ventilation (HFOV) versus conventional ventilation in children with sepsis-induced PARDS. However, in our practice, there is no preference to use or not use HFOV in patients with severe PARDS and refractory hypoxia.

· We suggest using neuromuscular blockade in children with sepsis and severe PARDS.

Corticosteroids

· We suggest against using IV hydrocortisone to treat children with septic shock if fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.

· We suggest that either IV hydrocortisone or no hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.

Endocrine and Metabolic

· We recommend against insulin therapy to maintain a blood glucose target at or below 140 mg/dL (7.8 mmol/L).

· We were unable to issue a recommendation regarding what blood glucose range to target for children with septic shock or other sepsis-associated organ dysfunction. However, in our practice, there was consensus to target blood glucose levels below 180 mg/dL (10 mmol/L) but there was not consensus about the lower limit of the target range.

· We were unable to issue a recommendation as to whether to target normal blood calcium levels in children with septic shock or sepsis-associated organ dysfunction. However, in our practice, we often target normal calcium levels for children with septic shock requiring vasoactive infusion support.

· We suggest against the routine use of levothyroxine in children with septic shock and other sepsis-associated organ dysfunction in a sick euthyroid state.

· We suggest either antipyretic therapy or a permissive approach to fever in children with septic shock or other sepsis-associated organ dysfunction.

Nutrition

· We were unable to issue a recommendation regarding early hypocaloric/trophic enteral feeding followed by slow increase to full enteral feeding versus early full enteral feeding in children with septic shock or sepsis-associated organ dysfunction without contraindications to enteral feeding. However, in our practice, there is a preference to commence early enteral nutrition within 48 hours of admission in children with septic shock or sepsis-associated organ dysfunction who have no contraindications to enteral nutrition and to increase enteral nutrition in a stepwise fashion until nutritional goals are met.

· We suggest not withholding enteral feeding solely on the basis of vasoactive-inotropic medication administration.

· We suggest enteral nutrition as the preferred method of feeding and that parenteral nutrition may be withheld in the first 7 days of PICU admission in children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against supplementation with specialized lipid emulsions in children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against the routine measurements of gastric residual volumes (GRVs) in children with septic shock or other sepsis-associated organ dysfunction.

· We suggest administering enteral feeds through a gastric tube, rather than a postpyloric feeding tube, to children with septic shock or other sepsis-associated organ dysfunction who have no contraindications to enteral feeding

· We suggest against the routine use of prokinetic agents for the treatment of feeding intolerance in children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against the use of selenium in children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against the use of glutamine supplementation in children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against the use of arginine in the treatment of children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against using zinc supplementation in children with septic shock and other sepsis-associated organ dysfunction.

· We suggest against the use of ascorbic acid (vitamin C) in the treatment of children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against the use of thiamine to treat children with sepsis-associated organ dysfunction.