Guidelines on management of sepsis and associated organ dysfunction in children

· We suggest against transfusion of RBCs if the blood hemoglobin concentration is greater than or equal to 7 g/dL in hemodynamically stabilized children with septic shock or other sepsis-associated organ dysfunction.

· We cannot make a recommendation regarding hemoglobin transfusion thresholds for critically ill children with unstable septic shock.

· We suggest against prophylactic platelet transfusion based solely on platelet levels in nonbleeding children with septic shock or other sepsis-associated organ dysfunction and thrombocytopenia

· We suggest against prophylactic plasma transfusion in nonbleeding children with septic shock or other sepsis-associated organ dysfunction and coagulation abnormalities

Plasma Exchange, Renal Replacement, and Extra Corporeal Support

· We suggest against using plasma exchange (PLEX) in children with septic shock or other sepsis-associated organ dysfunction without thrombocytopenia-associated multiple organ failure (TAMOF).

· We cannot suggest for or against the use of PLEX in children with septic shock or other sepsis-associated organ dysfunction with TAMOF.

· We suggest using renal replacement therapy to prevent or treat fluid overload in children with septic shock or other sepsis-associated organ dysfunction who are unresponsive to fluid restriction and diuretic therapy.

· We suggest against high-volume hemofiltration (HVHF) over standard hemofiltration in children with septic shock or other sepsis-associated organ dysfunction who are treated with renal replacement therapy.

· We suggest using venovenous ECMO in children with sepsis-induced PARDS and refractory hypoxia .

· We suggest using venoarterial ECMO as a rescue therapy in children with septic shock only if refractory to all other treatments.

Immunoglobulins

· We suggest against the routine use of IV immune globulin (IVIG) in children with septic shock or other sepsis-associated organ dysfunction.

Prophylaxis

· We suggest against the routine use of stress ulcer prophylaxis in critically ill children with septic shock or other sepsis-associated organ dysfunction, except for high-risk patients.

· We suggest against routine deep vein thrombosis (DVT) prophylaxis (mechanical or pharmacologic) in critically ill children with septic shock or other sepsis-associated organ dysfunction, but potential benefits may outweigh risks and costs in specific populations.

“A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research,” concluded the authors.