Guidelines on management of sepsis and associated organ dysfunction in children

Screening, Diagnosis, and Systematic Management of Sepsis

· In children who present as acutely unwell, we suggest implementing systematic screening for timely recognition of septic shock and other sepsis-associated organ dysfunction.

· We were unable to issue a recommendation about using blood lactate values to stratify children with suspected septic shock or other sepsis-associated organ dysfunction into low- versus high-risk of having septic shock or sepsis.

· We recommend implementing a protocol/guideline for management of children with septic shock or other sepsis-associated organ dysfunction (BPS).

· We recommend obtaining blood cultures before initiating antimicrobial therapy in situations where this does not substantially delay antimicrobial administration (BPS).

· In children with septic shock, we recommend starting antimicrobial therapy, within 1 hour of recognition.

· In children with sepsis-associated organ dysfunction but without shock, we suggest starting antimicrobial therapy after appropriate evaluation, within 3 hours of recognition.

· We recommend empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (BPS).

· Once the pathogen(s) and sensitivities are available, we recommend narrowing empiric antimicrobial therapy coverage (BPS).

· If no pathogen is identified, we recommend narrowing or stopping empiric antimicrobial therapy according to clinical presentation, site of infection, host risk factors, and adequacy of clinical improvement in discussion with infectious disease and/or microbiological expert advice (BPS).

· In children without immune compromise and without high risk for multidrug-resistant pathogens, we suggest against the routine use of empiric multiple antimicrobials directed against the same pathogen for the purpose of synergy.

· In children with immune compromise and/or at high risk for multidrug-resistant pathogens, we suggest using empirically multi-drug therapy when septic shock or other sepsis-associated organ dysfunction is present/suspected.

· We recommend using antimicrobial dosing strategies that have been optimized based on published pharmacokinetic/pharmacodynamic principles and with consideration of specific drug properties (BPS).

· In children with septic shock or sepsis-associated organ dysfunction who are receiving antimicrobials, we recommend daily assessment (e.g., clinical, laboratory assessment) for de-escalation of antimicrobial therapy (BPS).

· We recommend determining the duration of antimicrobial therapy according to the site of infection, microbial etiology, response to treatment, and ability to achieve source control (BPS).

· We recommend that emergent source control intervention be implemented as soon possible after a diagnosis of an infection amenable to a source control procedure is made (BPS).

Source Control

· We recommend that emergent source control intervention be implemented as soon possible after a diagnosis of an infection amenable to a source control procedure is made (BPS).

· We recommend removal of intravascular access devices that are confirmed to be the source of sepsis or septic shock after other vascular access has been established and depending on the pathogen and the risks/benefits of a surgical procedure.

Fluid Therapy

· In healthcare systems with availability of intensive care, we suggest administering up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour, titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction.

· In healthcare systems with no availability of intensive care and , we recommend against bolus fluid administration while starting maintenance fluids

· In healthcare systems with no availability of intensive care, we suggest administering up to 40 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour with titration to clinical markers of cardiac output and discontinued if signs of fluid overload develop.

· We suggest using crystalloids, rather than albumin, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction.

· We suggest using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction.

· We recommend against using starches in the acute resuscitation of children with septic shock or other sepsis-associated organ dysfunction.

· We suggest against using gelatin in the resuscitation of children with septic shock or other sepsis-associated organ dysfunction.

Hemodynamic Monitoring

· We were unable to issue a recommendation about whether to target mean arterial blood pressure (MAP) at the 5th or 50th percentile for age in children with septic shock and other sepsis-associated organ dysfunction. However, in our practice, we target MAP to between the 5th and 50th percentile or greater than 50th percentile for age.

· We suggest not using bedside clinical signs in isolation to categorize septic shock in children as "warm" or "cold."

· We suggest using advanced hemodynamic variables, when available, in addition to bedside clinical variables to guide the resuscitation of children with septic shock or other sepsis-associated organ dysfunction.

· We suggest using trends in blood lactate levels, in addition to clinical assessment, to guide resuscitation of children with septic shock and other sepsis-associated organ dysfunction.

Vasoactive Medications

· We suggest using epinephrine, rather than dopamine, in children with septic shock.

· We suggest using norepinephrine, rather than dopamine, in children with septic shock.

· We were unable to issue a recommendation for a specific first-line vasoactive infusion for children with septic shock. However, in our practice, we select either epinephrine or norepinephrine as the first-line vasoactive infusion guided by clinician preference, individual patient physiology, and local system factors.

· We were unable to issue a recommendation about initiating vasoactive agents through peripheral access in children with septic shock. However, in our practice, we often or sometimes administer a dilute concentration of the initial vasoactive medication through a peripheral vein if central venous access is not readily accessible.

· We suggest either adding vasopressin or further titrating catecholamines in children with septic shock who require high-dose catecholamines.

· We were unable to issue a recommendation about adding an inodilator in children with septic shock and cardiac dysfunction despite other vasoactive agents. However, in our practice, we sometimes use inodilators in children with septic shock and evidence of persistent hypoperfusion and cardiac dysfunction despite other vasoactive agents.