Pre-retrieval care package for septic child
All patients should be taken to an agreed area for retrieval when initial resuscitation has been done
Ventilation
- Nasal endotracheal tube if possible
- End-tidal CO2 monitoring
- Insert orogastric tube
- CXR to confirm ETT position
- Mechanical ventilation with lowest appropriate FiO2
- Aim for tidal volumes of approximately 6-8 ml/kg or till appreciation of adequate chest wall movements if there is no facility to measure tidal volumes.
- Set respiratory rate according to age
- Minimum PEEP of 5 cm H2O
- Increase PEEP to an appropriate level if necessary to improve oxygenation. Sometimes a PEEP of up to 15cm H2O is required.
- Adjust ventilation according to arterial or capillary blood gases
Circulation
- IV access x2
- Consider central line/ arterial line. If central access needed but difficult to achieve, insert intraosseous needle.
- 0.45% saline with 5% Dextrose at 80% maintenance
- Fluid boluses to maintain circulation -early signs of hypovolaemia- tachycardia, prolonged capillary refill time, low peripheral pulse volume, low urine output
- FFP if deranged clotting
- Cryoprecipitate if low fibrinogen
- Blood transfusion if haemoglobin less than 8g/dl
- Consider whether vasopressors are needed to maintain BP (discuss with PICU consultant)
- Urinary catheter
Antibiotics
Cefotaxime or Ceftriaxone unless specific indication for another antibiotic
Sedation/analgesia
- Morphine10-20mcg/kg/hour and Midazolam 100-200mcg/kg/hour infusion
Lab Investigations
- Blood culture
- FBC, Coagulation profile, Cross Match
- Glucose and electrolytes
- Magnesium, Calcium, Phosphate, Liver function tests, CRP
- PCR for Meningococcus
- Urine Microscopy and culture
Documentation
- Clear history
- Copy of all notes, medication and observation charts
- X-rays to be sent with patients
- Documentation of the type and the amount of fluids given
Saqib Iqbal
July 2007