The prevention of mortality due to pediatric septic shock requires a team-centered approach in the Emergency Department (ED). Nurses and providers must work closely together to recognize septic shock early, treat it quickly, and do so consistently. The following case demonstrates the successful utilization of a national pediatric sepsis protocol and its criteria for identifying systemic inflammatory response and septic shock.
A 9-year-old female presented to the University of Minnesota Masonic Children’s Hospital ED with a history of cough for 5 days, fever for 3 days, and post-tussive emesis. Over the previous 24 hours, the patient experienced increased difficulty in breathing, left-side chest pain, fatigue, and decreased oral intake of solids and liquids. There was no recent history of a barky cough, sore throat, neck pain, or skin rashes. At triage, the vitals were temperature 102oF, heart rate 140 beats per minute, respiration rate 22 breaths per minute, pulse oximeter 91%, and blood pressure 110/65. She appeared tired, weak, and had poor eye contact. Her heart tones were normal; there were no extra heart sounds or murmurs. Her white blood cell count was 25,500. A lung exam revealed crackles in the lower left lung field. Capillary refill was delayed at 5 seconds.
Based on the patient’s vital signs, the nurse diagnosed septic shock. The resuscitation team was paged out, and the patient was escorted to the resuscitation room. Oxygen was provided via face mask, 2 large-bore IV catheters were placed, and a 20 ml/kg bolus of normal saline (NS) was given with a rapid infuser. Vancomycin and ceftriaxone were also ordered. Her blood pressure after the first bolus was 90/65. After a second NS bolus was infused over 15 minutes, the blood pressure was 90/40. As the third NS bolus was started, an epinephrine infusion was ordered. As the third NS bolus was completed, the blood pressure was 85/40. An epinephrine drip was started. A chest radiograph showed a left lingula pneumonia (Figure 1). As the patient was being transferred to the critical care unit, her blood pressure was 90/50. In the unit, she was placed on BiPaP. Over 24 hours she was weaned off of epinephrine. After 48 hours, she had a normal temperature. She was transitioned from BiPaP to nasal cannula at 4 L oxygen flow and transferred to the hospital service. She was discharged in 2 days with prescribed oral antibiotics.
The diagnosis of septic shock begins with identifying whether the patient has systemic inflammatory response syndrome (SIRS), the body’s response to infection. A diagnosis of SIRS is confirmed when 2 of 4 indicators are present: temperature instability (younger than 3 months: <96.8oF or >101.3oF; older than 3 months <96.8oF or >100.4oF), a heart rate above or below normal for age, respiration rate above or below normal for age, and/or an abnormal white blood cell count (above 4,500 to 11,000 ml.) With these indicators, the clinician can then presume sepsis and examine for signs of septic shock: Urinary output < 1 ml/kg/hour, altered mental status, or any of the following: cold shock (capillary refill >3 seconds), warm shock (flash capillary refill), or mottled skin. Hypotension is not necessary for the diagnosis of septic shock; however, its presence confirms it.
This patient’s vital signs—her elevated heart and respiration rates and high white cell count—led to a diagnosis of SIRS. Signs of SIRS and a suspected respiratory infection supported a diagnosis of sepsis, and septic shock was confirmed by the patient’s prolonged capillary refill rate and lethargy.
From triage to administration of first fluids and antibiotic, total time to treatment was 45 minutes. Best practice recommends 60 minutes.
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