What to do when you suspect septic shock
When faced with a septic pediatric patient, what you do can affect whether this seriously ill child survives.
"The child's ongoing care is always determined with respect to the child's response to the initial resuscitation measures," says Dana Jundt, MSN, C-PNP, an ED nurse practitioner at Children's Hospital of Orange County (CA).
"It is literally a minute-by-minute assessment, reassessment, and management adjustment," says Jundt. "If serious problems are not addressed immediately, it may adversely affect the overall success of any resuscitation."
For example, a child who is hypoglycemic but not given a glucose solution is at risk for seizure, and child who is hypothermic may progress from compensated shock to decompensated shock if thermoregulation is not addressed, says Jundt.
"A child whose blood pressure is abnormally low and not given proper fluid resuscitation will continue a downward spiral to cardiovascular collapse," she says. "A child who has a critically low blood pressure and who is in hypovolemic shock may need pressors initiated."
The rate of survival for a child suffering a respiratory arrest is 40% and the rate of survival for a child suffering a cardiac arrest is less than 1%, adds Jundt. "It is so important to initiate proper resuscitative measures in children before they suffer either a respiratory or cardiac arrest," she says. Here are tips to improve care of pediatric septic shock patients:
- Control and maintain airway and breathing, and identify circulatory deficits.
This step should be your first priority, says Linda Pierog, FNP, an ED nurse practitioner at Children's. "Hypotension is a late sign. Skin signs are apparent earlier," she says. Remember that core temperature regulation is more difficult in infants due to larger surface area, small glycogen stores, and thin skin, she says. "Larger surface areas make them susceptible to dehydration," says Pierog.
- Understand the stages of septic shock.
Your plan of care must consider "where the patient is" in the continuum of the evolving shock state, says Jundt. During the hyperdynamic phase capillary refill is near normal, and peripheral pulses are easily palpated, although bounding with moderate tachycardia, she adds.
The hypodynamic phase is similar to uncompensated and irreversible shock, with altered mentation, lethargy, pale mottled skin, and weak thready pulse, she says. "The vascular volume is misplaced in septic shock, and a widespread response in initiated in response to the infecting organism," says Jundt.
- Assist with fluid resuscitation.
Fluid resuscitation is always done with normal saline or lactated ringers, with boluses calculated based on the child's weight, says Jundt. "Each fluid bolus is 20 cc/kg and can be repeated three times for most children," she says. "Children with underlying cardiac or renal disease may deserve special attention or less volume depending on the circumstances."
Obtain immediate intravenous access, using a 22 gauge or larger, using the intraosseous route if the percutaneous route is unsuccessful, says Jundt. "Calculating fluid volumes are the same whether they are given intraosseous or peripherally," she says.
Jundt advises you to have the following equipment available: oxygen, normal saline, intravenous pumps and catheters, bedside glucose monitoring system, dextrose solution to give if the child is hypoglycemic, cardiopulmonary/respiratory monitor, pulse oximetry, and a radiant warmer.
Correct pre-existing or present intravascular volume through rate of administration and amount of fluid infused, says Jundt. "Use warmed fluids any time a child's temperature is critically low," she says. "Newborns and infants with normal temperatures can be cold stressed easily when given IV fluids which have been stored at room temperature."
Accurately record fluids administered and communicated to all patient care team members, says Jundt. Document time of insertion; device used; number of attempts; site of insertion; type of fluid started and rate; vital signs before and after each fluid bolus, or more frequently as indicated; and urine output, she advises.
- Monitor the patient's response.
Quick and accurate communication about the child's respiratory status, vital signs, urine output, level of consciousness, and response to each fluid bolus is critically important, says Nicole Herriott, also an ED nurse practitioner at Children's. "It is this key responsibility of the emergency nurse that facilitates a successful outcome," she says.
For more information on interventions for pediatric septic shock, contact:
- Dana Jundt, MSN, C-PNP, Children's Hospital of Orange County, Orange, CA. Phone: (714) 771-8000, ext. 18113. Fax: (714) 744-8527. E-mail: firstname.lastname@example.org.