uhl children’s hospital guideline b31/2016

ApprovedbyUHLP&GCommitteeMay2017.UHLTrustRef:B29/2016Version:2.3NextReviewMay2019Contact:Jeremy.Tong@uhl-

tr.nhs.ukNB:Papercopiesofthisdocumentmaynotbemostrecentversion.ThedefinitiveversionisheldintheUHLPoliciesandGuidelines

Library

UniversityHospitalsofLeicester NHSTrust

KetteringGeneralHospital NHSFoundationTrust

UHLChildren’sHospitalGuidelineB31/2016UHLPaediatricSepsisGuideline

PaediatricSepsisInitialScreeningandActionTool(PaediatricSepsis6)

ThisdocumentprovidesguidancetostaffontheinitialrecognitionandmanagementofsepsisinchildrenwithinUniversityHospitalsofLeicester.

1. Introduction

1.1. Sepsisisalife-threateningillnesscausedbythebody’sresponsetoaninfection.

1.2. Recognitionofsepsisinchildrenisoftenverydifficultasclinicalsignsandsymptomscanbesimilartoself-limitingorlesssevereconditions.Earlyrecognitioncoupledwithearlyantibioticadministrationandprotocolisedmanagementsaveslives,reducesmorbidity,andreduceshospitallengthofstay(1).

1.3. Bacterialinfectionsarebyfarthemostcommoncauseofsepsis,butitcanalsobecausedbyviralorfungalinfections.Commoncausesinclude:respiratorytractinfections,urinarytractinfections,congenitalinfections,bloodstreaminfections,abdominalinfections,infectedwoundsorindwellinglinesandcatheters,andcellulitis.

1.4. InchildrenSepsisisdefinedasasuspectedorproveninfectionassociatedwithaSystemicInflammatoryResponse(SIRS).SevereSepsisissepsiswithorgandysfunction.Septicshockissepsiswithcardiovasculardysfunction(e.g.raisedlactate,hypotension)(2).

1.5. Insimpleterms,SIRSisthepresenceofatleast2ofthefollowing,oneofwhichmustbeabnormaltemperatureorwhitecellcount:

• Coretemperature>38.5°Cor<36°C.

• Tachycardiaforageintheabsenceofexternalstimulus

• Tachypneaforageormechanicalventilationforanacuteprocess.

• Whitecellcountelevatedordepressed

1.6. AtUHLweexpecttoseeapproximately2-3casesofpaediatricsepsisperweek.Mortalityforsepsisinchildrenvariesbutcanbeashighas15–20%(PICUall-causemortality<3%).

Infection dysregulatedhostresponse life-threateningorgandysfunction

UHLPaediatricSepsisGuideline

ApprovedbyUHLP&GCommitteeMay2017.UHLTrustRef:B29/2016Version:2.3NextReviewMay2019Contact:[email protected]

NB:Papercopiesofthisdocumentmaynotbemostrecentversion.ThedefinitiveversionisheldintheUHLPoliciesandGuidelinesLibrary

Page2of20

2. Scope

2.1. ThisguidelineisrelevanttoallmedicalandnursingstaffemployedbyUHL,includingbank,agencyandlocumstaff.

2.2. ThisguidelineappliestoallinfantsandchildrenpresentingtoUHLasacuteadmissionsorasexistinginpatients,includingthePaediatricEmergencyDepartment(PED).

2.3. ThisguidelinedoesNOTapplytoneonateswithintheUHLMaternityServices(LabourWard,NeonatalUnits,PostNatalWard)

2.4. InfantsandChildrenwithcancersonchemotherapy,followingahaematopoieticstemcelltransplant(bonemarrowtransplant),orneutropenicsepsisshouldbetreatedusingthisguidancealongsideNICEclinicalguidanceonneutropenicsepsis(NICECG151)andtheUHLChildren’sOncologyUnitguidelines.

3. GuidelineStatements

3.1. Thisguidelineisbasedaround3practicetools:

• PaediatricSepsisScreening&ActionTool -AppendixA

• PaediatricAMBERFLAGSepsisTool -AppendixB

• PaediatricSepsisAntibioticCribCards -AppendixC

3.2. AnswerstoFrequentlyAskedQuestionsonPaediatricSepsisareavailable.–AppendixD

3.3. ThePaediatricSepsisScreeningandActionToolandAMBERFLAGSepsisToolarebasedon:

• Internationalguidelinesonthemanagementofpaediatricsepsis(3)

• NICE[NG51]Sepsis:recognition,diagnosisandearlymanagement(4)

• TheUKSepsisTrustPaediatricSepsis6Tool(5)

3.4. ThePaediatricSepsisAntibioticCribCardsarebasedonlocalmicrobialprevalenceandresistancepatterns,UHLantibioticprescribingpoliciesanddrugmonographs,andhasbeenapprovedbytheUHLAntimicrobialWorkingParty.




Library Page3of20

4. ThePaediatricSepsisScreeningandActionTool

4.1. Itistheresponsibilityoftheattendingclinicalteam(nurseordoctor)toidentifyandscreenforsepsisinchildren.

4.2. ItistheresponsibilityoftheattendingclinicalteamtodocumentallcareandtreatmentonthePaediatricSepsisScreeningandActionTool.Oncecomplete,thetoolshouldbefiledinthepatient’smedicalrecords.

4.3. ThePaediatricSepsisScreeningandActionToolprovidesdetailsofthepatientcare,monitoringandactionsthatarerequiredtorecogniseandtreatsepsis/severesepsis/septicshockinchildren.

4.4. ThePaediatricSepsisScreeningandActionToolshouldbeusedinALLchildrenwhomayhaveaninfection,havemedical/familyconcerns,orhaveabnormalobservations.Thetoolmustbeinitiatedassoonastheseconcernshavebeenidentified.

4.5. NotethatPOPSisusedintheEmergencyDepartment(PED)andPEWSinallotherareastohelpidentifyinfantsandchildrenwhoneedtobescreenedforsepsis.

4.6. AnyREDFLAGSignshouldpromptimmediatereviewbyaclinicianatST4levelorabove(ST4+),andhavethePaediatricSepsis6actionscompletedwithin1hourofTimeZero.

4.7. TimeZeroisthebookingintimeforPED/Children’sAssessmentUnit(CAU).Forinpatients,itisthetimewhenREDFLAGSepsissignsorobservationswerenoted.

4.8. Theclinicalteamshouldconsidercallingforadditionalassistancetoensurethetreatmenttimelineisadheredto,particularlyforsickchildren.

4.9. Ifthereistobeadelayinseniorreview(ST4+),thePaediatricSepsisSixactionsshouldbecommencedbytheclinicalteamassoonpossibletoenablecompletionwithin1hour.

4.10. Notethatde-escalationorvariationfromthePaediatricSepsis6isacceptable.Someconditionsmaymimicsepsis(e.g.bronchiolitis),andchildrenidentifiedashavingorbeingathighriskofsepsismaynotalwaysrequireall6elementsofSepsisSix.Thisassessmentanddecisionshouldbemadebyasenior(ST4+)andreasonsdocumentedonthetool.

4.11. Itisveryimportantforchildrenidentifiedashavingorathighriskofsepsistoreceiveantibioticswithin1hour.(NICE[NG51])

4.12. InfantsorchildrenwithREDFLAGsignsmusthaveobservationsincreasedtoevery15–30minutes,andhavetheirfluidbalancemonitored.FurtherinvestigationsmayberequiredandshouldbediscussedwiththereviewingclinicianatST4levelorabove.

4.13. IftheinfantorchilddoesnothaveREDFLAGsigns,theymaystillbeatMediumRiskforSepsis–usetheAMBERFLAGSepsisTool.Theresponsibleclinicianshouldbemadeaware.

4.14. InfantsandChildreninAMBERFLAGcategoryshouldhaveobservationsincreasedtoeveryhourwithre-assessmentforREDFLAGsigns.Urineoutputshouldbemonitored.




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5. TheChildren’sSepsisBox

5.1. TheChildren’sSepsisBoxesareavailableonallchildren’swardsandcontainappropriateantibioticsandequipmenttocarryoutthePaediatricSepsis6actions.ThiswasdesignedtoaidindeliveringthePaediatricSepsis6actionswithin1hour.Wheneverpossible,thesepsisboxshouldbeutilisedtocompleteactions.

5.2. ModifiedversionsoftheChildren’sSepsisBoxareavailableinPED.Theseonlycontainantibioticsasotheritemsareavailableatthebedside.

5.3. PaediatricSepsisAntibioticCribCardsareavailablewithintheChildren’sSepsisBoxes.

5.4. ForChildrenwhoarealreadyonanantibiotic,considerwhetherachangeisneeded-discusswiththemostexperiencedavailablePaediatricianorMicrobiologist.

6. EducationandTraining

6.1. Trainingandraisingawarenessareongoingprocesses.Ongoingawarenessispromotedthroughthewardbasedsepsischampions,whoserolewillbetopromotetimely,effectivesepsiscarethroughuseofthePaediatricSepsisScreening&ActionTool,thePaediatricSepsisAntibioticCribCards,andthePaediatricSepsisBox.

6.2. Trainingisprovidedformedicalstaffduringlunchtimeteachingandothersessions,andatjuniordoctors’inductiontraining.

6.3. NursingeducationissupportedbythePracticeDevelopmentteams,andbywardbasedsepsischampions.




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7. Monitoringandauditcriteria

KeyPerformanceIndicator MethodofAssessment Frequency Lead

Infantsandchildrenwhomeetcriteriaarescreenedforsepsis.

ChildrenidentifiedashavingREDFLAGSepsisreceiveantibioticswithin1hour

DeliveryofPaediatricSepsis6componentswithin1hour.

AuditofchildrenwithPEWS/POPS³3foruseofthepaediatricsepsisscreeningandactiontool.

AuditofchildrenwithREDFLAGSignsforuseofthepaediatricsepsisscreeningandactiontoolandadministrationtimesforantibiotics.

Auditofchildrenwithsepsisagainstadherencetosepsiscarepathway.

PaediatricpatientsinEDareauditedseparatelyalongsideadultpatients

Quarterly

Quarterly

Quarterly

UHLPaediatricSepsislead



UHLPaediatricEmergencyDepartmentSepsislead

ContinuedinvolvementofPaediatricSepsischampions.

Annualconfirmationfromeachchampion.Toattendannualtrainingupdate.

Annual UHLPaediatricSepsislead

8. Legalliabilityguidelinestatement

GuidelinesorProceduresissuedandapprovedbytheTrustareconsideredtorepresentbestpractice.StaffmayonlyexceptionallydepartfromanyrelevantTrustguidelinesorProceduresandalwaysonlyprovidingthatsuchdepartureisconfinedtothespecificneedsofindividualcircumstances.Inhealthcaredelivery,suchdepartureshallonlybeundertakenwhereinthejudgementoftheresponsiblehealthcareprofessional,itisfullyappropriateandjustifiable-suchdecisiontobefullyrecordedinthepatient’snotes.

9. Keywords

Paediatricsepsis,PaediatricSepsis6,sepsis,septicchild,septicinfant,septicshock,severesepsis,septicaemia,children,infant,POPS,PEWS,antibiotic




Page6of20

10. References

1. PaulR,NeumanMI,MonuteauxMC,MelendezE.AdherencetoPALSSepsisGuidelinesandHospitalLengthofStay.Pediatrics.2012Aug;130(2):e273–80.

2. GoldsteinB,GiroirB,RandolphA,InternationalConsensusConferenceonPediatricSepsis.Internationalpediatricsepsisconsensusconference:definitionsforsepsisandorgandysfunctioninpediatrics.PediCriticCareMed.2005Jan;6(1):pp.2–8.

3. BrierleyJ,CarcilloJA,ChoongK,CornellT,DeCaenA,DeymannA,etal.Clinicalpracticeparametersforhemodynamicsupportofpediatricandneonatalsepticshock:2007updatefromtheAmericanCollegeofCriticalCareMedicine.CritCareMed.2009Feb;37(2):666–88.

4. NICGGuideline[NG51]Sepsis:recognition,diagnosisandearlymanagement.July2016https://www.nice.org.uk/guidance/ng51

5. TheUKSepsisTrustPaediatricSepsis6http://sepsistrust.org/clinical-toolkit/lastaccessed16Jun2016

11. ContactandReviewDetails

Author: DrJeremyTong,PICUConsultantDrRachelRowlands,PEDConsultant

CurrentVersion: 2.4

UHLTrustRef: B31/2016

Approvedby: UHLP&GCommittee

ApprovalDate: May2017

NextReviewDate: May2019

Versionhistory: 1.0JeremyTong-Jun2016 CompleteReviewofGuideline

2.0JeremyTong-Apr2017 UpdateofguidelineNewSepsisScreeningandActionTool(NICEcompliant)NewAmberFlagSepsisTool




Page7of20

SepsisScreeningcompleted by:PrintName

Sign Grade

Date Time

Highriskofsepsis � Tick

Thisisatimecriticalconditionandimmediateactionisrequired.ArrangeIMMEDIATE reviewbyST4orabove

StartPaediatricSepsisSixDiscussmanagementplanwithchild,parents,andfamily

Considerpossibilityofsepsismimics:e.g.asthma,anaphylaxis,DKA,bronchiolitis

Moderateriskofsepsis � Tick

Monitorandtreataspercondition/concerns.Ensurereviewwithin1hr forconsiderationoffurtherinvestigationortreatmentasperAMBER sepsisguideline


Lowriskofsepsis � Tick

Treataspercondition/concerns.

Documentsafetynetadvicegiven. � Tick

ANYofthefollowingredflagspresent?Age(yrs)

� Appearance any Appearsilltohealth careprofessionalLooksmottled/ashenCyanosisofskin,lipsortongueNon-blanchingrash

� Breathing any Grunting /ApnoeaSpO2 <90%inairorincreasedO2

requirementoverbaseline

<1 RR≥60/min

1- 2 RR≥50/min

3- 4 RR≥40/min

� Circulation any HR <60/min

<1 HR≥160/min

1- 2 HR≥150/min

3- 4 HR≥140/min

� Demeanor any NoresponsetosocialcuesDoesnotwakeIfroused,doesnotstayawakeWeakhigh-pitchedorcontinuouscry

� Exposure any Temp<36°C

<3months Temp>38°C

At leastoneofthefollowingpresent?� PEWSorPOPSscoring3ormore � Health careprofessionalconcern

� Parentalconcern of sepsis**Remember somechildrenareatincreasedriskofseriousinfection**

i.e.onchemotherapy,indwellinglinesorchronicdisease

Age<5yrs PaediatricSepsisScreening&ActionToolThistoolshouldbeusedinALLchildrenage<5yrs withabnormalphysiologyORclinicalconcerns(excludesneonatalunitsandpostnatalwards).

Name:

DateofBirth:

Hospitalnumber:

AffixhospitalLabelifavailable

N

Y

Y

Y

N

N

UniversityHospitalsofLeicesterNHSTrust

KetteringGeneralHospitalNHSFoundationTrust

THINK:couldthischildhave aninfection?Someexamplesofbacterialinfectionstoconsider:

- Pneumonia- UrinaryTractInfection- Abdominalpainordistension- Meningitis/meningococcalsepsis- Cellulitis/septicarthritis/infectedwound- Otherunknownsource

ApprovedbyWomen’s&Children’sQ&SBandEDHoS May2017.Contact:RachelRowlands(ED)JeremyTong(Paeds)TrustRef:C53/2004Reviewed2007,2009,2012,2015.LastReviewed:May2017.NextReview:May2019NB:Papercopiesofthisdocumentmaynotbemostrecentversion.ThedefinitiveversionisintheUHLPolicies&GuidelineLibrary

SND108aVersion205/17Page1of2

AppendixA




Page8of20

Usethedepartmentsepsisboxandworktogethertocompleteallelementswithin1hour.

Recordtimeofcompletionforeachactions.Takeobservationsevery15- 30min.

RecordTimeZero PED/CAU:bookingintime.Inpatients:timewhenredflagsepsissigns/obs develop.

PrintName Grade Sign Date

De-escalationorvariationfromtheSepsisSixisacceptableassomeconditionsmaymimicsepsis(e.g.bronchiolitis),andchildren

identifiedashavingorbeingathighriskofsepsismaynotalwaysrequireall6elementsofSepsisSix.Thisassessmentand decision

shouldbemadebyaseniorclinician(ST4andabove)andreasonsdocumentedhere:

PrintName Grade Sign Date Time

1 Administer supplementaryoxygen• Viarebreathingfacemask orequivalent.Titrateoxygenaiming forSpO2 >94%

Timestarted Name

2

ObtainIV/IOaccess&takebloodtestsa. Bloodculture

b. Bloodgasforglucose&lactate

c. FBC,CRP,coagulation,U&E

d. Lumbarpuncture unlesscontraindicatedin:

• lessthan1month

• 1- 3monthsandlooksunwellorhasWBC<5or>15x109

ConsiderfurtherinvestigationsbutDONOTDELAYTREATMENTforthese:

• e.g.urine,CSForlinecultures,MeningococcalPCR

TimeIV/IO

access

Name

Timeblood

culturetaken

Name

TimeLPtaken Name

3GiveIVorIOantibiotics• BroadspectrumcoverasperUHLpolicy(usesepsisbox)

• PrescribefirstdoseinSTATdosesectionanddocument time

Timegiven Name

4

ConsiderFluidresuscitation• Aimtorestorenormalcirculatingvolumeandphysiologicalparameters

• IfLactate>2mmol/l:

Give20ml/kg(10ml/kgif <1month)of0.9%SodiumChloride over5- 10

minutes,andrepeatifnecessary

• Beawareofriskoffluidoverload(esp.in<1month)

Timestarted Name

5Escalation• Review byaseniorclinicianST4oraboveorequivalent

• DiscusswithConsultantPaediatrician andPICUif:

• Lactate>4mmol/l

• Noclinicalimprovementfollowingsecondfluidbolus

Timeseen Name

6Considerinotropicsupportearly• Ifnormalphysiologicalparametersarenotrestoredafter40ml/kgfluids

• AdrenalineinfusionmaybegivenviaperipheralIVorIOaccess- askPICUforhelp

Timestarted Name

PaediatricSepsisSixBundle

SND108aVersion205/17

Page2of2

ApprovedbyWomen’s&Children’sQ&SBandEDHoS May2017.Contact:RachelRowlands(ED)JeremyTong(Paeds)

tRef:C53/2004Reviewed2007,2009,2012,2015.LastReviewed:May2017.NextReview:May2019

NB:Papercopiesofthisdocumentmaynotbemostrecentversion.ThedefinitiveversionisintheUHLPolicies&GuidelineLibrary




Page9of20

SepsisScreeningcompleted by:

PrintName

Sign Grade

Date Time


Thisisatimecriticalconditionand

immediateactionisrequired.

ArrangeIMMEDIATE reviewbyST4orabove

StartPaediatricSepsisSixDiscussmanagementplanwithchild,

parents,andfamily





ANYofthefollowingredflagspresent?Age(yrs)

� Appearance any Appearsilltohealth careprofessionalLooksmottled/ashenCyanosisofskin,lipsortongueNon-blanchingrash

� Breathing any SpO2 <90%inairorincreasedO2

requirementoverbaseline

5 RR≥29/min

6- 7 RR≥27/min

7- 11 RR≥25/min

� Circulation any HR <60/min

5 HR≥130/min

6- 7 HR≥120/min

7- 11 HR≥115/min

� Demeanor any ObjectiveevidenceofalteredbehaviourormentalstateDoesnotwakeorifrouseddoesnotstayawake

� Exposure any Temp<36°C


� Parentalconcern of sepsis

**Remember somechildrenareatincreasedriskofseriousinfection**


Age5- 11PaediatricSepsisScreening&ActionToolThistoolshouldbeusedinALLchildrenage5- 11withabnormalphysiology

ORclinicalconcerns(excludesneonatalunitsandpostnatalwards).

Name:

DateofBirth:

Hospitalnumber:


N

Y

Y

Y

N

N




UniversityHospitalsofLeicester

NHSTrust

KetteringGeneralHospital

NHSFoundationTrust

SND108bVersion205/17

Page1of2







Page10of20

Usethedepartmentsepsisboxandworktogethertocompleteallelementswithin1hour.

Recordtimeofcompletionforeachactions.Takeobservationsevery15- 30min.








Timestarted Name

2

ObtainIV/IOaccess&takebloodtestsa. Bloodcultureb. Bloodgasforglucose&lactatec. FBC,CRP,coagulation,U&EConsiderfurtherinvestigationsbutDONOTDELAYTREATMENTforthese:


TimeIV/IO

access

Name

Timeblood

culturetaken

Name

3GiveIVorIOantibiotics• BroadspectrumcoverasperUHLpolicy(usesepsisbox)• PrescribefirstdoseinSTATdosesectionanddocument time

Timegiven Name

4

ConsiderFluidresuscitation• Aimtorestorenormalcirculatingvolumeandphysiologicalparameters• IfLactate>2mmol/l:

Give20ml/kgof0.9%SodiumChloride (max.500ml)over5- 10minutes,andrepeatifnecessary

• Beawareofriskoffluidoverload

Timestarted Name

5Escalation• Review byaseniorclinicianST4oraboveorequivalent• DiscusswithConsultantPaediatrician andPICUif:

• Lactate>4mmol/l• Noclinicalimprovementfollowingsecondfluidbolus

Timeseen Name

6Considerinotropicsupportearly• Ifnormalphysiologicalparametersarenotrestoredafter40ml/kgor 2x500ml

fluid bolus• AdrenalineinfusionmaybegivenviaperipheralIVorIOaccess- askPICUforhelp

Timestarted Name


SND108bVersion205/17Page2of2


Trustref: B29/2016 reviewed2007,2009,2012,2015.LastReviewed:May2017.NextReview:May2019

NB:Papercopiesofthisdocumentmaynotbemostrecentversion.ThedefinitiveversionisintheUHLPolicies&GuidelineLibrary




Page11of20

SepsisScreeningcompleted by:PrintName

Sign Grade

Date Time


Thisisatimecriticalconditionandimmediateactionisrequired.ArrangeIMMEDIATE reviewbyST4orabove

StartPaediatricSepsisSixDiscussmanagementplanwithchild,parents,andfamily





ANYofthefollowingredflagspresent?

� Appearance AppearsilltohealthcareprofessionalLooksmottled/ashenCyanosisofskin,lipsortongueNon-blanchingrash

� Breathing Newneedforoxygen(inspired O2 >40%) tomaintainsaturation>92%

RR≥25/min

� Circulation sBP ≤90mmHg

sBP 40mmHgbelowusual

HR≥130/min

Notpassedurinepast18hrsorCatheterisedpassing<0.5ml/kg/hr

� Demeanor Objectiveevidenceofalteredbehaviourormentalstate

� Exposure Temp<36°C


� Parentalconcern of sepsis**Remember somechildrenareatincreasedriskofseriousinfection**


Age12yrs+PaediatricSepsisScreening&ActionToolThistoolshouldbeusedinALLchildrenage12+withabnormalphysiologyORclinicalconcerns(excludesneonatalunitsandpostnatalwards).

Name:

DateofBirth:

Hospitalnumber:


N

Y

Y

Y

N

N






SND108cVersion205/17Page1of2





Contact:[email protected]


Page12of20

Usethedepartmentsepsisboxandworktogethertocompleteallelementswithin1hour.Recordtimeofcompletionforeachactions.Takeobservationsevery15- 30min.








Timestarted Name

2

ObtainIV/IOaccess&takebloodtestsa. Bloodcultureb. Bloodgasforglucose&lactatec. FBC,CRP,coagulation,U&EConsiderfurtherinvestigationsbutDONOTDELAYTREATMENTforthese:


TimeIV/IO

access

Name

Timeblood

culturetaken

Name

3GiveIVorIOantibiotics• BroadspectrumcoverasperUHLpolicy(usesepsisbox)• PrescribefirstdoseinSTATdosesectionanddocument time

Timegiven Name

4

ConsiderFluidresuscitation• Aimtorestorenormalcirculatingvolumeandphysiologicalparameters• IfLactate>2mmol/l:

Give20ml/kgof0.9%SodiumChloride (max.500ml)over5- 10minutes,andrepeatifnecessary

• Beawareofriskoffluidoverload

Timestarted Name

5Escalation• Review byaseniorclinicianST4oraboveorequivalent• DiscusswithConsultantPaediatrician andPICUif:

• Lactate>4mmol/l• Noclinicalimprovementfollowingsecondfluidbolus

Timeseen Name

6Considerinotropicsupportearly• Ifnormalphysiologicalparametersarenotrestoredafter40ml/kg or 2x500ml

fluid bolus• AdrenalineinfusionmaybegivenviaperipheralIVorIOaccess- askPICUforhelp

Timestarted Name


SND108cVersion205/17Page2of2


TrustRef:B29/2016 reviewed2007,2009,2012,2015.LastReviewed:May2017.NextReview:May2019


ApprovedbyUHLP&GCommitteeMay2017.UHLTrustRef:B31/2016Version:2.3NextReviewMay2019Contact:[email protected]&GCommitteeMay2017.UHLTrustRef:B/2016Version:2.3NextReviewMay2019Contact:[email protected] NB:

PapNBer:Pcaoppeirecsoopifetshoifstdhioscduocmuemnetntmmayaynnoottbbeemmooststrerceecnetnvtervsieorns.ioThn.eTdehfeinidtievfeinvietrisvieonviesrhsielodninisthheelUdHiLnPtohliceiesUHLandPGoluiicdieleisneasnLidbrGuariydelinesLibrary

Page13of20

ModerateriskofsepsisPatientidentifiedasatModerateRiskof sepsisusingthePaediatricSepsisScreening&ActionTool


PaediatricAmberFlagSepsisToolThistoolshouldbeusedonALLchildrenatmoderateriskofsepsisidentifiedusingthePaediatricSepsisScreening&ActionTool.



Lactate< 2mmol/l

DoBloods:FBC,CRP,U&E,creatinineandbloodgas

Clinicianreviewchildandresultswithin1hour

ManagedefinitiveconditionSafetynetasneededPatientmaybedischarged

Lactate>2mmol/lor

evidenceofAKIin>12yrs

ClinicianreviewandCONSIDERbloodtestswithin1hour

Hourlyobservation

Seniorreviewwithin3hoursforconsiderationofantibiotics

YES

HowmanyAmberflagsarepresent?Usethetableprovidedoverleaf

TreatasREDFLAGSEPSIS

≥2flags

only1flag

NO

Definitivediagnosisreached?

AppendixB




Page14of20

PaediatricAmberSepsisCriteria

Age(years)<1

1-23-4

56-7

8-11>12

AppearancePallorofskin,lipsortongue

Decreasedactivity

BreathingRespiratory

rate≥50/m

in

≥40/min

≥35/min

≥24/min

≥22/min

≥21/min

Workofbreathing

Nasalflaring

SaturationsSpO

2 <91%inairorincreasedO

2 requirementoverbaseline

SpO2 <91%

inairorincreasedO2 requirem

entoverbaseline

CirculationHeartrate

≥150/min

≥140/min

≥130/min

≥120/min

≥115/min

≥91/min

Caprefilltime

≥3seconds

BloodpressureSystolicBP91-100

mmHg

Urineoutput

Reducedurineoutputor<1ml/kg/hrifcatheterised

Notpassed

urinefor>12hrsor0.5-

1ml/kg/hrifcatheterised

Dem

eanorOnly

wakesafterprolongedstim

ulation

Alteredresponsetosocialcues

Carerconcernedchildbehavingdifferently

Alteredbehaviourofmentalstate

(patient/carerreported)

AcuteDeteriorationinfunction

ExposureTem

p>39°C3-6m

onthsTem

p<36°C

Coldhandsandfeet

Legpain

Trauma,surgeryorinvasiveprocedureinthelast6w

eeks

Impairedim

munesystem

(duetoillnessordrugs,includingoralsteriods)

Signofinfectionatsurgicalsiteorwound

ApprovedbyUHLP&GCommitteeMay2017.UHLTrustRef:B31/2016Version:2.3NextReviewMay2019Contact:[email protected]:Papercopiesofthisdocumentmaynotbemostrecentversion.ThedefinitiveversionisheldintheUHLPoliciesandGuidelinesLibrary




Library Page15of20

Sepsis<1MonthageDosingandAdministrationinformation

Version2.1UHLAWG2015Review:May2017Authors:JTong/DHarris

GentamicinPostConceptionalage Dose Frequency Administration

28-37weeks 4mg/kg*Confirmwithpharmacy Slowbolus

(over3-5minutes)Plantomeasurelevelspre&postthirddose

38weeksto1month(upto7daysold) 3.5mg/kg 24hourly

38weeksto1month(over7daysold) 3.5mg/kg 12hourly

*Postconceptionage<38weeks-givefirstdoseandconfirmongoingfrequencywithpharmacist

Amoxicillin

Dose Frequency Administration

50mg/kg/doseIV 12hourly(under7daysold)8hourly(over7daysold)

250mgvialadd4.8mlwaterforinjection(50mg/ml)IVIover30minutes Flushwith0.9%sodiumchloride

**Consider100mg/kg/doseforListeriameningitis

CefoTAXime


50mg/kg/doseIV 12hourly(under7daysold)8hrly(7to20daysold)6hrly(over20daysold)

500mgvialadd1.8mlwaterforinjection(250mg/ml)IVbolusover3-5minutes Flushwith0.9%sodiumchloride

* Alwaysprescribe1stdoseinonceonly/statsectiononfrontofprescriptionchart

AppendixC




Page16of20

Sepsis1-3MonthageDosingandAdministrationinformation


Amoxicillin


50mg/kg/doseIV 8hourly 500mgvialadd9.6mlwaterforinjection(50mg/ml)IVIover30minutes Flushwith0.9%sodiumchloride

CefTRIAXone


80mg/kg/doseIV

(max2g)

Oncedaily 1gvialadd9.4mlwaterforinjection(100mg/ml)IVIover30minutes Flushwith0.9%sodiumchloride


Sepsis>3MonthageDosingandAdministrationinformation


CefTRIAXone


80mg/kg/doseIV

(max2g)

Oncedaily 1gvialadd9.4mlwaterforinjection(100mg/ml)IVIover30minutes Flushwith0.9%sodiumchloride





Library Page17of20

PaediatricHaematology/OncologySepsisDosingandAdministrationinformation


Piperacillin-Tazobactam


90mg/kg/doseIV

(max.4.5g)

Age>1month:6hourlyAge<1month:8hourly

Reconstitutewitha16.5mlofwaterforinjection.(225mg/ml)Maybefurtherdilutedwith0.9%sodiumchlorideor5%dextrose

Teicoplanin-refertoIVMonograph


Age>1month:10mg/kgIV

(max600mg)

12hourlyFORFIRST3DOSESONLYTHENDAILY

Slowlyaddtheprovidedampouleofwaterforinjection.Gentlyrollthevialtodissolveallthepowder.Avoidshakingasthismaycausefoaming.Ifthisoccursallowtostandfor15minutesbeforeusing.Finalconcentrationis400mgin3ml.MaybegivenbyIVbolusorfurtherdilutedwith0.9%sodiumchloride





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Frequentlyaskedquestionsaboutsepsisinchildren

WhenshouldachildbescreenedforSepsis?

• PEWSorPOPSscoreof3ormore.

• Ifyouareconcernedyourpatientlooksorisunwell.

• Ifyourpatient’sfamilyisconcernedtheirchildmayhavesepsis.

WhoshouldscreenchildrenforSepsis?

AllhealthcareprofessionalsreviewingpatientsormeasuringPEWSorPOPSshouldbeawareoftheabovecriteria.You

shouldbepreparedtoescalatequickly.

WhatisscreeningforSepsisinchildren?

AnassessmentofthechildusingthePaediatricSepsisScreeningandActionsToolavailablefromtheUHLintranet.

AnyREDFlagSignorObservationshouldpromptanimmediatereviewbyadoctoratmiddlegrade/registrar(ST4)level

oraboveinexperience.Ifthereistobeadelayinseniorreview,thePaediatricSepsisSixactionsshouldbecommenced

assoonpossibletoenablecompletionwithin1houroftimezero.

* Notenotallchildrenscreenedwillhavesepsis.Conditionssuchasasthma,anaphylaxis,DKA,bronchiolitisetc.may

mimicsignsofsepsis.Ifunsure,asksomeonemoreexperienced.

DoIneedtoscreenforsepsiseverytimemypatientscoresaPEWSof3ormore?

Yes,ifthereisachangeinclinicalconditionortheirPEWSistriggeringfordifferentparameters.

Ifitisobviousthatyourpatientistriggeringduetoon-goingoxygenrequirementsorotherchronicdisease,thenclinical

judgementshouldbeused.Thisdecisionshouldbemadebythemostseniorresidentdoctorandbedocumentedinthe

medicalrecord/NerveCentreas:“noevidenceofinfection/sepsis”

* Ensurethereisanappropriateescalationplandocumentede.g.ifthechildisknowntoscorehighthendocumentat

whatpointfurtheractionisrequired.

Whatistimezeroforredflagsepsis?

ForpatientsadmitteddirectlytoPEDorCAU:thebookingintime.

Forinpatientswithsignsofinfection:timewhenthepatientdevelopsredflagsepsissigns/observation(s)

EffectivecarerequiresthePaediatricSepsisSixtobecompletedwithin1hroftimezero.Useapaediatricsepsisboxand

worktogetherwithcolleaguestohelpmeetthisgoal.Patientsidentifiedassepsisandreceivingtreatmentshould

continuetobemonitored.Furtherdeteriorationrequirespromptreview.

HowdoIknowifmypatienthasaninfection?

Suspicionofinfectionrequires2ormorepiecesofevidence:e.g.symptoms,signs,whitecellcount,CRP,imaging,or

positivemicrobiologyresult.Araisedtemperatureisnotessentialtosuspectinfection.

UniversityHospitalsofLeicester NHSTrust

KetteringGeneralHospital NHSFoundationTrust

AppendixD




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Considersepsisiftheyhavebeenadmittedwithasuspected/proveninfectionsuchaspneumonia,urinarytractinfection,

appendicitis/abdominalinfection,cellulitis/septicarthritisorothersourcesofinfection.Lowerthethresholdofsuspicion

forchildrenunder3monthsage,withchronicdisease,recentsurgeryortheimmunocompromised.Consideriftheyhave

newsymptomsduringhospitalstay,e.g.woundredness/erythema,orabdominalpain.Considerinfectionsfrom

indwellinglinesordevices.

Thediagnosisofsepsisisuncertainandplanistoinvestigatefurther

Don’twait–sepsiscareisbasedonsuspicionofsepsis.

Patientswithredflag(s)shouldhavePaediatricSepsisSixstartedimmediately.Investigationsshouldoccuralongside

PaediatricSepsisSix.However,registrarreviewshouldtakeplaceassoonaspossible,asshouldinformingtheconsultant.

Consultantreviewmustoccurwithin14hours.

WhichantibioticsdoIgivetochildrenwithsepsis?

FollowUHLpaediatricantimicrobialguidelines.Appropriateagebasedantibioticchoicesanddirectionsfor

administrationareavailableinthepaediatricsepsisboxes.

Whatifmypatientisonantibioticsandtheytriggerforredflagsepsis?

Patientdeteriorationwithnewredflag(s)requiresescalationasperthepaediatricsepsissixcarebundle.Discuss

antibioticchangeswithmostexperiencedavailableregistrar/consultantpaediatrician/microbiologist.Anyoutstanding

elementsofthePaediatricSepsisSixshouldalsobecompleted.

DoallelementsofthePaediatricSepsisSixneedtobecarriedout?

Aclinicaldecisionshouldbemadebytheregistrarassessingthechildastowhetheritisappropriatetocarryouteach

elementofthePaediatricSepsisSix.De-escalationorvariationfromtheSepsisSixisacceptableassomeconditionsmay

mimicsepsis(e.g.bronchiolitis),andchildrenidentifiedashavingorbeingathighriskofsepsismaynotalwaysrequireall

6elementsofSepsisSix.Thisassessmentanddecisionshouldbemadebyaseniorclinician(ST4andabove)andreasons

documentedhere:

MypatientisDNARandistriggeringPEWSscores–whatshouldIdo?

Thesechildrenwillmostoftenbeforactivetreatmentofsepsis.Allescalationactions(PEWS/Sepsisetc)mustbe

adheredtounlessthereisaclearplanforlimitationoftreatmentdocumented.

Mypatientisonanendoflifecareplan–whatshouldIdo?

Themedicalteamwillneedtodecidewhatmanagementforsepsisisappropriate.

WheredoIputtheSepsisScreeningtool?

Fileitinthepatient’smedicalrecordplease.