Risk stratification tool for children aged under 5 years with suspected sepsis

Transcription

1 Risk stratification tool for children aged under 5 years with suspected sepsis Category Age Behaviour No response to social cues Appears ill to a healthcare professional Does not wake, or if roused does not stay awake Weak high-pitched or continuous cry Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity Parent or carer concern that child is behaving differently from usual Responds normally to social cues Content or smiles Stays awake or awakens quickly Strong normal cry or not crying Grunting Apnoea Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Oxygen saturation of less than 91% in air or increased oxygen requirement over baseline Nasal flaring Respiratory Under 1 year rate: 60 breaths per rate: breaths per moderate to high risk 1 2 years rate: 50 breaths per rate: breaths per 3 4 years rate: 40 breaths per rate: breaths per

2 Bradycardia: heart rate less than 60 beats per Capillary refill time of 3 seconds or more Reduced urine output For catheterised patients, passed less than 1 ml/kg of urine per hour Circulation and hydration Under 1 year Rapid heart rate: 160 beats per Rapid heart rate: beats per moderate to high risk 1 2 years Rapid heart rate: 150 beats per Rapid heart rate: beats per 3 4 years Rapid heart rate: 140 beats per Rapid heart rate: beats per Mottled or ashen appearance Skin Cyanosis of skin, lips or tongue Normal colour Non-blanching rash of skin Less than 36ºC Temperature Under 3 months 38 C or more 3 6 months 39 C or more Other Leg pain Cold hands or feet high to moderate risk This table is adapted from NICE s guideline on fever in under 5s.

3 Risk stratification tool for children aged 5 11 years with suspected sepsis Category Age Moderate to high risk criteria Behaviour Objective evidence of altered behaviour or mental state Appears ill to a healthcare professional Does not wake or if roused does not stay awake Not behaving normally Decreased activity Parent or carer concern that the child is behaving differently from usual Behaving normally Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline Respiratory Aged 5 years Aged 6 7 years rate: 29 breaths per rate: 27 breaths per rate: breaths per rate: breaths per moderate to high risk criteria met Aged 8 11 years rate: 25 breaths per rate: breaths per Circulation and hydration Heart rate less than 60 beats per Capillary refill time of 3 seconds or more Reduced urine output For catheterised patients, passed less than 1 ml/kg of urine per hour moderate to high risk Aged 5 years Raised heart rate: 130 beats per Raised heart rate: beats per

4 Aged 6 7 years Aged 8 11 years Raised heart rate: 120 beats per Raised heart rate: 115 beats per Raised heart rate: beats per Raised heart rate: beats per Skin Mottled or ashen appearance Cyanosis of skin, lips or tongue Non-blanching rash of skin Other Leg pain Cold hands or feet No high or moderate to high risk

5 Risk stratification tool for adults, children and young people aged 12 years and over with suspected sepsis Category History from patient, friend or relative of new onset of altered behaviour or mental state History Objective evidence of new altered mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Normal behaviour Trauma, surgery or invasive procedures in the last 6 weeks Respiratory rate: 25 breaths per New need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) rate: breaths per moderate to high risk Blood pressure Systolic blood pressure 90 mmhg or less or systolic blood pressure more than 40 mmhg below normal Systolic blood pressure mmhg moderate to high risk Circulation and hydration Raised heart rate: more than 130 beats per Not passed urine in previous 18 hours. For catheterised patients, passed less than 0.5 ml/kg of urine per hour Raised heart rate: beats per (for pregnant women beats per ) or new onset arrhythmia Not passed urine in the past hours For catheterised patients, passed ml/kg of urine per hour moderate to high risk Temperature Tympanic temperature less than 36 C Skin Non-blanching rash of skin Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound No non-blanching rash

6 Person with possible infection Think could this be sepsis? if they present with signs or symptoms that indicate infection, even if they do not have a high temperature. Be aware that people with sepsis may have non-specific, non-localising presentations (for example, feeling very unwell. Pay particular attention to concerns expressed by the person and family/carer. Take particular care in the assessment of people who might have sepsis who are unable, or their parent/carer is unable, to give a good history (for example, young children, people with English as a second language, people with communication problems) ASSESSMENT Assess people with suspected infection to identify: likely source of infection risk factors (see righthand box) Indicators of clinical of concern such as abnormalities of behaviour, circulation or respiration. Healthcare professionals performing a remote assessment of a person with suspected infection should seek to identify factors that increase risk of sepsis or indicators of clinical concern. People more vulnerable to sepsis the very young (under 1 year) and older people (over 75 years) or very frail people recent trauma or surgery or invasive procedure (within the last 6 weeks) Impaired immunity due to illness or drugs (for example, people receiving steroids, chemotherapy or immunosuppressants) Indwelling lines / catheters / intravenous drug misusers, any breach of skin integrity (for example, any cuts, burns, blisters or skin infections). If at risk of neutropenic sepsis - refer to secondary care Additional risk factors for women who are pregnant or who have been pregnant, given birth, had a termination or miscarriage within the past 6 weeks -gestational diabetes, diabetes or other co-morbidities; needed invasive procedure such as caesarean section, forceps delivery, removal of retained products of conception, prolonged rupture of membranes, close contract with someone with group A streptococcal infection, have continued vaginal bleeding or an offensive vaginal discharge). Sepsis not suspected no clinical cause for concern no risk factors. SUSPECT SEPSIS If sepsis is suspected, use a structured set of observations to assess people in a face-to-face setting. Consider using early warning scores in hospital settings. Parental or carer concern is important and should be acknowledged. Use clinical judgment to treat the person, using NICE guidance relevant to their diagnosis when available. Stratify risk of severe illness and death from sepsis using algorithm appropriate to age and setting

7 Managing suspected sepsis in children aged under 5 years - outside an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for children aged under 5 years Behaviour: No response to social cues Appears ill to a healthcare professional Does not wake, or if roused does not stay awake Weak high pitched or continuous cry Aged under 1 year: 160 beats per Aged 1 years: 150 beats per Aged 3 4 years: 140 beats per Heart rate less than 60 beats per at any age Aged under 1 year: 60 breaths per Aged 1 2 years: 50 breaths per Aged 3 4 years: 40 breaths per Grunting Apnoea Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Temperature: Aged under 3 months: 38 C or more Less than 36ºC Behaviour: Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity Parent or carer concern that child is behaving differently from usual Aged under 1 year: breaths per Aged 1 2 years: breaths per Aged 3 4 years: breaths per Oxygen saturation 91% or less in air or increased oxygen requirement over baseline Nasal flaring Aged under 1 year: beats per Aged 1 2 years: beats per Aged 3 4 years: breaths per Capillary refill time of 3 seconds or more Reduced urine output, or for catheterised patients passed less than 1 ml/kg of urine per hour Pale or flushed Pallor of skin, lips or tongue Temperature: Aged 3 6 months: 39 C or more Leg pain Cold hands or feet Responds normally to social cues Content or smiles Stays awake or awakens quickly Strong normal cry or not crying moderate to high risk Normal colour Provide information about symptoms to monitor and how to access medical care high risk Send patient urgently for emergency care (setting that has resuscitation facilities) Aged under 5 years and immunity compromised AND any moderate to high risk No Can definitive condition be diagnosed and treated in an out of hospital setting? Yes Treat definitive condition and / or provide information to safety net

8 Managing suspected sepsis in children aged under 5 years - in an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for children aged under 5 years Behaviour: No response to social cues Appears ill to a healthcare professional Does not wake, or if roused does not stay awake Weak high pitched or continuous cry Aged under 1 year: 160 beats per Aged 1 2 years: 150 beats per Aged 3 4 years: 140 beats per Heart rate less than 60 beats per at any age Aged under 1 year: 60 breaths per Aged 1 2 years: 50 breaths per Aged 3 4 years: 40 breaths per Grunting Apnoea Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Temperature: Less than 36ºC Aged under 3 months: 38 C or more 1 high risk criterion Arrange immediate review by senior clinical decision maker (paediatric or emergency care ST4 or above or equivalent). Carry out venous blood test for the following: blood gas including glucose and lactate measurement blood culture Full blood count C reactive protein Urea and electrolytes Creatinine Clotting screen Give i.v. antibiotics without delay, and at least within one hour. Discuss with consultant Behaviour: Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity Parent or carer concern that child is behaving differently from usual Aged under 1 year: breaths per Aged 1 2 years: breaths per Aged 3 4 years: breaths per Oxygen saturation of less than 91% in air or increased oxygen requirement over baseline Nasal flaring Aged under 1 year: beats per Aged 1 2 years: beats per Aged 3 4 years: breaths per Capillary refill time of 3 seconds or more Reduced urine output, or for catheterised patients passed less than 1 ml/kg of urine per hour Pale or flushed Pallor of skin, lips or tongue Temperature: Aged 3 6 months: 39 C or more Leg pain Cold hands or feet 2 or more moderate to high risk criteria Perform tests: venous blood for blood culture, FBC, CRP, U/E, creatinine, and blood gas for lactate Clinican review and results review within 1 hour Only 1 moderate to high risk criterion Clinician review and consider blood tests within 1 hour Responds normally to social cues Content or smiles Stays awake or awakens quickly Strong normal cry or not crying moderate to high risk Normal colour Suspected sepsis and no high risk or high to moderate criteria met Clinical assessment and manage according to clinical judgement Lactate > 4 mmol/l Give i.v. fluid (bolus injection) without delay Discuss with critical care Lactate 2 4 Give i.v. fluid (bolus injection) without delay Lactate < 2 Consider i.v. fluids (bolus injection) Carry out observations, at least every 30 s or continuous monitoring in ED. Consultant to attend if not already present if patient does not improve Lactate > 2 mmol / L OR assessed as having AKI* = escalate to high risk Lactate 2 mmol / L and no AKI* If no definitive condition identified, repeat structured assessment at least hourly Ensure review by a senior decision maker within 3 hours for consideration of antibiotics. Manage definitive condition / infection if diagnosed * See Acute kidney injury (NICE guideline CG169)

9 Managing suspected sepsis in children aged 5-11 years - outside an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for children aged 5 11 years Objective evidence of altered behaviour or mental state Appears ill to a healthcare professional Does not wake or if roused does not stay awake Aged 5 years: 29 breaths per Aged 6 7 years: 27 breaths per Aged 8 11 years: 25 breaths per Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Aged 5 years: 130 beats per Aged 6 7 years: 120 beats per Aged 8 11 years: 115 beats per Or heart rate less than 60 beats per at any age Not responding normally to social cues Decreased activity Parent or carer concern that the child is behaving differently from usual Aged 5 years: breaths per Aged 6 7 years: breaths per Aged 8 11 years: breaths per Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline Aged 5 years: beats per Aged 6 7 years: beats per Aged 8 11 years: beats per Or capillary refill time of 3 seconds or more Reduced urine output, or for catheterised patients passed less than 1 ml/kg of urine per hour Leg pain Cold hands or feet Normal behaviour moderate to high risk Provide information about symptoms to monitor and how to access medical care high risk Aged 5 11 years and impaired immune system AND any moderate to high risk Can definitive condition be diagnosed and treated in an out of hospital setting? Yes Send patient urgently for emergency care (setting with facilities for resuscitation) No Treat definitive condition and / or provide information to safety net

10 Managing suspected sepsis in children aged 5-11 years - in an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for children aged 5 11 years Objective evidence of altered behaviour or mental state Appears ill to a healthcare professional Does not wake or if roused does not stay awake Aged 5 years: 29 breaths per Aged 6 7 years: 27 breaths per Aged 8 11 years: 25 breaths per Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline Aged 5 years: 130 beats per Aged 6 7 years: 120 beats per Aged 8 11 years: 115 beats per Or heart rate less than 60 beats per at any age Not responding normally to social cues Decreased activity Parent or carer concern that the child is behaving differently from usual Aged 5 years: breaths per Aged 6 7 years: breaths per Aged 8 11 years: breaths per Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline Aged 5 years: beats per Aged 6 7 years: beats per Aged 8 11 years: beats per Or capillary refill time of 3 seconds or more Reduced urine output, or for catheterised patients passed less than 1 ml/kg of urine per hour Leg pain Cold hands or feet Normal behaviour moderate to high risk 1 high risk criterion 2 or more moderate to high risk criteria Only 1 moderate to high risk criterion high to moderate risk Arrange immediate review by senior clinical decision maker (paediatric or emergency care doctor ST4 or above) to assess patient and consider diagnosis and management. Cary out venous blood test for the following: blood gas for glucose and lactate blood culture full blood count C reactive protein urea and electrolytes creatinine clotting screen. Clinician to review person s condition and venous lactate results within 1 hour Carry out venous blood test for the following: blood gas for glucose and lactate blood culture full blood count C reactive protein urea and electrolytes creatinine clotting screen. Clinician review for clinical assessment and consider blood tests within 1 hour Clinical assessment and manage according to clinical judgement Give i.v. antibiotics without delay, and at least within one hour. Discuss with consultant Lactate > 2 mmol / L Lactate 2 mmol / L Lactate > 4 mmol/l Give i.v. fluid (bolus injection) within 1 hour Refer to critical care Lactate 2 4 Give i.v. fluid (bolus injection) within 1 hour Lactate < 2 Consider i.v. fluids (bolus injection) Carry out observations, at least every 30 s or continuous monitoring in ED. Consultant to attend if not already present if patient does not improve If no definitive condition identified, repeat structured assessment at least hourly Ensure review by senior clinical decision maker within 3 hours for consideration of antibiotics. Manage definitive condition. If appropriate discharge with information depending on setting.

11 Managing suspected sepsis in children and young people aged years - outside an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for adults, children and young people aged 12 years and over Objective evidence of new altered mental state 25 breaths per OR new need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) 130 beats per or above Systolic blood pressure 90 mmhg or less or systolic blood pressure more than 40 mmhg below normal Not passed urine in previous 18 hours or for catheterised patients, passed less than 0.5 ml/kg of urine per hour History from patient, friend or relative of new onset of altered behaviour or mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Trauma, surgery or invasive procedures in the last 6 weeks breaths per beats per (for pregnant women beats per ) OR new onset arrhythmia Systolic blood pressure mmhg Not passed urine in the past hours, or for catheterised patients passed ml/kg of urine per hour Tympanic temperature less than 36 C Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound Normal behaviour moderate to high risk criteria met No non blanching rash Provide information about symptoms to monitor and how to access medical care high risk Aged years and immunity compromised AND any moderate to high risk Can definitive condition be diagnosed and treated in an out of hospital setting? Yes Send patient urgently for emergency care No Treat definitive condition and/or provide information to safety net

12 Managing suspected sepsis in children and young people aged years - in an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for adults, children and young people aged 12 years and over Objective evidence of new altered mental state 25 breaths per OR new need for oxygen (more than 40% FiO 2 ) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) 130 beats per or above Systolic blood pressure 90 mmhg or less or systolic blood pressure more than 40 mmhg below normal Not passed urine in previous 18 hours, or for catheterised patients passed less than 0.5 ml/kg of urine per hour History from patient, friend or relative of new onset of altered behaviour or mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Trauma, surgery or invasive procedures in the last 6 weeks breaths per beats per (for pregnant women beats per ) OR new onset arrhythmia Systolic blood pressure mmhg Not passed urine in the past hours, or for catheterised patients passed ml/kg of urine per hour Tympanic temperature less than 36 C Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound Suspected sepsis, but: Normal behaviour moderate to high risk No non blanching rash 1 high risk criterion Arrange immediate review by senior clinical decision maker (paediatric or emergency care ST4 or above or equivalent). Carry out venous blood test for the following: blood gas including glucose and lactate measurement blood culture Full blood count C reactive protein Urea and electrolytes Creatinine Clotting screen Give i.v. antibiotics without delay, and at least within one hour. Discuss with consultant 2 or more moderate to high risk criteria OR SBP: mmhg Perform tests: venous blood for blood culture, FBC, CRP, U/E, creatinine, and blood gas for lactate Clinican review and results review within 1 hour Only 1 moderate to high risk criterion Clinician review and consider blood tests within 1 hour Suspected sepsis and no high risk or high to moderate Clinical assessment and manage according to clinical judgement Lactate > 4 mmol/l OR SBP < 90 mmhg Give i.v. fluid (bolus injection) without delay Discuss with critical care Lactate 2 4 Give i.v. fluid (bolus injection) without delay Lactate < 2 Consider i.v. fluids (bolus injection) Lactate > 2 mmol / L OR assessed as having AKI* = escalate to high risk Lactate 2 mmol / L and no AKI* If no definitive condition identified, repeat structured assessment at least hourly Ensure review by a senior decision maker within 3 hours for consideration of antibiotics. Manage definitive condition / infection if diagnosed * See Acute kidney injury (NICE guideline CG169) Carry out observations, at least every 30 s or continuous monitoring in ED. Consultant to attend if not already present if patient does not improve

13 Managing suspected sepsis in adults and young people aged 18 years and over - outside an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for adults, children and young people aged 12 years and over Objective evidence of new altered mental state 25 breaths per OR new need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) 130 beats per or above Systolic blood pressure 90 mmhg or less or systolic blood pressure more than 40 mmhg below normal Not passed urine in previous 18 hours, or for catheterised patients passed less than 0.5 ml/kg of urine per hour History from patient, friend or relative of new onset of altered behaviour or mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Trauma, surgery or invasive procedures in the last 6 weeks breaths per beats per (for pregnant women beats per ) OR new onset arrhythmia Systolic blood pressure mmhg Not passed urine in the past hours, or for catheterised patients passed ml/kg of urine per hour Tympanic temperature less than 36 C Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound Normal behaviour moderate to high risk Provide information about symptoms to monitor and how to access medical care high risk Can definitive condition be diagnosed and treated in an out of hospital setting? Yes Send patient urgently for emergency care (setting with resuscitation facilities) No Treat definitive condition and/or provide information to safety net

14 Managing suspected sepsis in adults and young people aged 18 years and over - in an acute hospital setting Stratify risk of severe illness and death from sepsis using the risk criteria in the stratification tool for adults, children and young people aged 12 years and over Objective evidence of new altered mental state 25 breaths per OR new need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) 130 beats per or above Systolic blood pressure 90 mmhg or less or systolic blood pressure more than 40 mmhg below normal Not passed urine in previous 18 hours, or for catheterised patients passed less than 0.5 ml/kg of urine per hour History from patient, friend or relative of new onset of altered behaviour or mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Trauma, surgery or invasive procedures in the last 6 weeks breaths per bets per (for pregnant women beats per ) OR new onset arrhythmia Systolic blood pressure mmhg Not passed urine in the past hours, or for catheterised patients passed ml/kg of urine per hour Tympanic temperature less than 36 C Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound Suspected sepsis, but: Normal behaviour moderate to high risk 1 high risk criterion Arrange immediate review by senior clinical decision maker (person authorised to prescribe antibiotics, such as CT3/ST3 and above or advanced nurse practitioner). Carry out venous blood test for the following: blood gas including glucose and lactate measurement blood culture full blood count C reactive protein urea and electrolytes creatinine clotting screen. Give intravenous antibiotics without delay, and at least within one hour of identification of high risk criteria. 2 or more moderate to high risk criteria OR SBP: mmhg Clinician to review person s condition and venous lactate results within 1 hour Carry out venous blood test for the following: blood gas including lactate measurement blood culture full blood count C reactive protein urea and electrolytes creatinine. Only 1 moderate to high risk criterion Clinician review within 1 hour and perform blood tests if indicated Suspected sepsis and no high risk or high to moderate risk Clinical assessment and manage according to clinical judgement Use an intravenous antimicrobial from agreed local formulary and in line with local (where available) or national guidelines. Discuss with consultant Lactate > 4 mmol/l OR SBP < 90 mmhg Give i.v. fluid (500 ml over less than 15 s) without delay Refer to critical care Lactate 2 4 Give i.v. fluid (500 ml over less than 15 s) without delay Lactate < 2 Consider i.v. fluids. Lactate > 2 mmol / L OR assessed as having AKI* = escalate to high risk Lactate 2 mmol / L and no AKI* If no definitive condition identified, repeat structured assessment at least hourly Ensure review by a senior decision maker within 3 hours for consideration of antibiotics. Manage definitive condition / infection if diagnosed Carry out observations, at least every 30 s or continuous monitoring in ED. Consultant to attend if not already present if patient does not improve * See Acute kidney injury (NICE guideline CG169)