Pediatric Sepsis Curriculum

1
Pediatric Sepsis Curriculum
2
Dear Medical Student, Resident, or Pediatric
Subspecialty Fellow,You are being invited to
participate in a voluntary research survey and
curriculum. Your participation is voluntary, but
greatly appreciated. The goal of the study is to
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and treating Pediatric Sepsis.The risks of
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time for the curriculum is one hour. In
September, you will be invited to take a
post-curriculum survey which is similar to the
pre-curriculum survey in nature and should also
take about 20 minutes to complete. Estimated
maximum length of time spent on this study is
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participating in the study are increased
knowledge and confidence diagnosing and treating
Pediatric Sepsis.By taking the pre- or
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MPHUCLA Pediatrics PGY-1310.825.6301pager 28224
3
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4
Sepsis Fact Sheet

• What Sepsis, Whats a Bundle, and What Should I
  Do?

5
What is Sepsis?

• Sepsis is a life threatening response to
  infection. It represents a continuum through
  SIRS, sepsis, and septic shock.
• SIRS systemic inflammatory response syndrome
  2 or more of the following high or low white
  count, tachycardia, tachypnea, high or low
  temperature
• Sepsis SIRS a suspected source of infection
  (ex., skin ulcer, pneumonia, central line)
• Septic Shock sepsis hypotension(or signs of
  poor perfusion)
• Signs of poor perfusion altered mental status,
  delayed cap refill, poor pulses, mesenteric
  ischemia (emesis, diarrhea), urine output lt
  1cc/kg/hr, hypoxia

6
Whats A Bundle?

• A bundle is a group of treatments that improve
  outcomes when given together rather than
  separately.
• Sepsis Resuscitation Bundle how to treat early
  sepsis 20cc/kg IVF boluses, broad spectrum IV
  antibiotics, blood culture, lactate within 1 hour
  of presentation. You may use up to 60cc/kg in the
  early phase of sepsis and move to pressors if
  vitals do not normalize.
• Sepsis Management Bundle how to direct fluids
  and pressors to markers of improved cardiac
  output
• markers of improved cardiac output normal
  mental status, UOP gt 1cc/kg/hr, cap refill lt2
  sec, normal MAP and CVP gt8, ScVO2 gt 70. There
  are several monitoring devices that can help with
  hemodynamic monitoring, and the PA catheter is
  the gold standard (though use of a PA catheter
  has not been shown to decrease mortality from
  sepsis). Reduction in serum lactate does not
  accurately reflect improved cardiac output.

7
What Should I Do?

• If blood pressure doesnt increase with fluids
  and pressors, consider CIRCI (Critical Illness
  Related Corticosteroid Insufficiency). A random
  cortisol level lt 15 is diagnostic and IV
  hydrocortisone can help. A ACTH stim test is not
  needed. CIRCI is especially relevant to those who
  have previously been on steroids.
• Do not wait to start pressors till central access
  is obtained. Dopamine can be started at low doses
  via peripheral IV.
• Mortality form sepsis almost doubles with delays
  in bundled therapy and increases by 8 per hour
  with delays in IV antibiotics. Source removal is
  the ultimate treatment for sepsis. Advocate for
  your patients! Push fluids and antibiotics early!

8
Case 1

• Outpatient Clinic

9
Case 1 History

• CC Fever
• Time 1050
• HPI Two year-old female presents to clinic with
  a two-day history of irritability, subjective
  fevers, and chills. She has been less active
  than usual, complaining of leg and joint pain.
  Her mother notes she is developing a rash and
  that she had two episodes of emesis on the way to
  clinic.
• PMH ex-full term infant with normal development,
  no allergies, no current medications, no
  surgeries, no hospitalizations. Delayed
  immunization schedule (missing one Inactivated
  polio and one Pneumococcal vaccine)
• SH Lives in apartment with mom, dad, sister,
  three cousins, and grandmother. No smokers, no
  pets. No recent travel. One cousin is a marine.

10
Case 1 Physical Exam

• Time 1100
• Vitals T 39.2, HR 156, RR 50, BP 95/68
• Physical Exam
• General ill-appearing
• Neuro rousable but intermittently lethargic, CN
  2-12 intact, 5/5 strength and sensation, antalgic
  gait, normal reflexes
• HEENT mucous membranes dry, TM clear, OP clear,
  nasal flaring
• CVS S1, S2, hyperdynamic precordium, 1/6
  systolic murmur LUSB, pedal pulses 1
• Resp CTA b/l, subcostal retractions
• Abdomen s/nt/nd, no hsm
• Extremities cool feet and hands, joints are
  free of warmth or effusion
• Skin small, diffuse, petechiae on arms, legs,
  and trunk, cap refill 2 sec,

11
Case 1 Assessment and Plan

• Time 1110
• Click on the next most appropriate step in
  management
• perform lumbar puncture
• disCharge home with return precautions and
  rheumatology referral
• place peripheral IV
• observe in clinic for 2 hours

12
Plan Lumbar Puncture

• Time 1125
• While setting up to perform your lumbar puncture,
  you notice that your patient becomes increasingly
  tachypneic. Her skin appears mottled and
  capillary refill is now 4 sec.
• Repeat vitals are as follows
• T 39, HR 160, RR 50, BP 70/48
• The most appropriate next step in management is
• place peripheral IV
• proceed with lumbar puncture

13
Plan Observe

• Time 1330
• After two hours of close observation, your
  patients condition continues to deteriorate.
  Her skin is mottled, she is increasingly
  lethargic, and capillary refill is now 4
  seconds.
• Repeat vitals are as follows
• T 39, HR 160, RR 50, BP 60/45
• You decide to transfer her to the UCLA emergency
  room for suspected septic shock. Upon arrival At
  UCLA, she is noted to have purpura and adrenal
  insufficiency, and she expires by early evening.
  Blood cultures are positive for neisseria
  meningitidis.
• click here to redo the case

14
Plan IV

• Time 1223
• Two- 20 gauge peripheral IVs are placed in each
  antecubital fossa.
• Select the next most appropriate step in
  management
• give 20cc/kg bolus normal saline
• observe the child in clinic for 2 hours.
• prescribe oral antibiotic discharge home with
  follow up appointment in 2-3 days

15
Plan Bolus

• Time 1230
• After placing a peripheral IV and giving a single
  20 cc/kg bolus, which is the most appropriate
  step in management
• repeat 20cc/kg normal saline bolus, draw blood
  cultures and lactate, and give broad spectrum IV
  antibiotics
• proceed with lumbar puncture
• close observation in clinic for 2 hours

16
Plan Lumbar Puncture

• Time 1300
• You decide to proceed with lumbar puncture.
  However, your patients blood pressure continues
  to drop, her skin becomes increasingly cool and
  mottled, and she loses consciousness.
• You call 911 and she is transferred to the UCLA
  emergency room in septic shock.
• She decompensates within hours. At UCLA, she is
  noted to have purpura and adrenal insufficiency,
  and she expires by early evening. Blood cultures
  are positive for neisseria meningitidis.
• click here to redo the case

17
Plan Lumbar Puncture

• Time 1300
• You decide to proceed with lumbar puncture after
  giving a single bolus of 20 cc/kg normal saline.
  However, your patients blood pressure continues
  to drop, her skin becomes increasingly cool and
  mottled, and she loses consciousness.
• You call 911 and she is transferred to the UCLA
  emergency room in septic shock.
• She decompensates within hours. At UCLA, she is
  noted to have purpura and adrenal insufficiency,
  and she is intubated and transferred to the PICU
  by early evening. Blood cultures grow neisseria
  meningitidis.
• click here to redo the case

18
Plan Rheumatology Referral

• Time 1930
• Your patient has an appointment to see
  rheumatology for the rash and joint pain in 5
  days, and she returns home with strong return
  precautions. Your patients mother follows your
  counseling regarding persistent emesis and fever,
  and brings her to the nearest Emergency
  Department in the early evening. Her childs
  condition is rapidly deteriorating.
• By 2125, the childs rash becomes purpuric, and
  she develops fulminant DIC. A random cortisol
  level is 5. She is diagnosed with adrenal
  insufficiency, and she expires from septic shock.
  Blood cultures drawn prior to death indicate that
  the source of sepsis was neiserria meningitidis.
• click here to redo the case

19
Plan Discharge

• Time 1930
• Your patient returns home with oral antibiotics
  and strong return precautions. By 1830, Your
  patients mother follows your counseling
  regarding persistent emesis and fever, and brings
  her to the nearest Emergency Department. Her
  childs condition is rapidly deteriorating.
• By 2125, she is diagnosed with DIC and adrenal
  insufficiency. She expires from septic shock,
  and blood cultures are positive for neiserria
  meningitidis.
• click here to redo the case

20
Plan IV

• Time 1123
• Two- 20 gauge peripheral IVs are placed in each
  antecubital fossa.
• Select the next most appropriate step in
  management
• give a 20cc/kg bolus of normal saline
• observe hemodynamics in clinic for 2 hours.
• prescribe oral antibiotic discharge home with
  follow up appointment in 2-3 days

21
Plan Bolus

• Time 1134
• After placing a peripheral IV and giving a single
  20 cc/kg bolus, which is the most appropriate
  step in management
• repeat 20cc/kg normal saline bolus, draw blood
  cultures and lactate to clinic lab, and start
  broad spectrum IV antibiotics
• proceed with lumbar puncture once hemodynamics
  have improved
• observe hemodynamics in clinic for 2 hours

22
Sepsis Resuscitation Bundle

• Time 1215
• Within an hour of presentation, you have
  successfully given your patient all four aspects
  of the Sepsis Resuscitation Bundle. You quickly
  recognized symptoms of SIRS (Systemic
  inflammatory response syndrome) and suspected
  that meningococcemia could be a source of this
  childs infection. By implementing a bundle, or a
  collection of plans given together to improve
  patient outcomes, you have changed this childs
  course with meningococcemia.
• The components of the Sepsis Resuscitation Bundle
  are listed below
• up to three- 20 cc/kg boluses of normal saline,
  directed to hemodynamics
• broad spectrum IV antibiotics within 1 hour of
  presentation
• baseline serum lactate
• serum blood culture
• Vitals currently are as follows
• Vitals T 38.7, HR 112, RR 23, BP 87/65
• You transfer her via ambulance to the UCLA
  Emergency Department for source control. Two
  additional IV fluid boluses are given in the
  ambulance, and vitals improve by time of arrival
  in the ED. She remains febrile with poor PO
  intake and is admitted to the ICU with
  meningococcemia and dehydration. She heals well,
  is transferred to the floor, discharged home
  after three days of IV antibiotics and
  hemodynamic monitoring.

23
Sepsis Resuscitation Bundle (Delayed)

• Time 1400
• Your patient successfully receives all four
  aspects of the sepsis resuscitation bundle, but
  due to late recognition of symptoms of SIRS
  (Systemic inflammatory response syndrome) and
  suspected sepsis, IV antibiotics and early fluids
  are delayed by 3 hours. The relative risk of
  mortality increases approximately 10 for every
  hour that bundle implementation is delayed.
• The 4 parts of the Sepsis Resuscitation Bundle
  are
• up to three- 20 cc/kg boluses normal saline,
  directed to hemodynamics
• broad spectrum IV antibiotics within 1 hour of
  presentation
• baseline serum lactate
• blood culture prior to antibiotic administration
• Vitals currently are as follows
• Vitals T 39, HR 130, RR 34, BP 90/65
• You transfer her via ambulance to the UCLA
  Emergency Department for higher level care and
  source control. Two additional IV fluid boluses
  are given in the ambulance, and vitals are
  improved by time of arrival in the ED. Due to
  delay in antibiotics, she remains in the ICU on
  IV antibiotics and is transferred to the floor
  after one week of supportive care.

24
BILBIOLOGRAPHY Bochud PY, Bonten M, Marchetti O,
et al. Antimicrobial therapy for patients with
severe sepsis and septic shock An evidence-based
review. Crit Care Med. 200432(Suppl.)S495S512.
  Booy R, Habibi P, Nadel S, et al. Meningococcal
research group reduction in case fatality from
meningococcal disease associated with improved
healthcare delivery. Arch Dis Child 2001
85386-390. Bone M, Diver M, Selby A, Sharples
A, Addison M, Clayton P. Assessment of adrenal
function in the initial phase of meningococcal
disease. Pediatrics. 2002 Sep110(3)563-9.   Bone
RC. Immunologic dissonance a continuation
evolution in our understanding of the systemic
inflammatory response syndrome (SIRS) and the
multiple organ dysfunction syndrome (MODS). Ann
Int Med 1996 125680-7.   Brierly J, Carcillo
JA, Choong K, et al. Clinical practice parameters
for hemodynamic support of pediatric and neonatal
patients in septic shock 2007 update from the
American College of Critical Care Medicine. Crit
Care Med. 200937(2)666-668.   Briegel J,
Vogeser M, Annane D, et al. Measurement of
cortisol in septic shock Interlaboratory
harmonization. Am Rev Respir Crit Care Med. 2007
175A436   Carcillo JA, Davis AL, Zaritsky A.
Role of early fluid resuscitation in pediatric
septic shock. JAMA. 1991 2601242-1245.   Casarte
lli CH, Garcia PCR, Piva JP, Branco RG.  Adrenal
insufficiency in children with septic shock. J
Pediatr (Rio J) 200379(Suppl 2)S169-S76 Delling
er, RP, Levy, MM, Carlet, JM, et al. Surviving
Sepsis Campaign International guidelines for
management of severe sepsis and septic shock
2008. Crit Care Med. 2008 published correction
appears in Crit Care Med. 2008 361394-1396
36296-327   Han YY, Carcillo JA, Dragotta MA,
et al. Early reversal of pediatric-neonatal
septic shock by community physicians is
associated with improved outcomes. Pediatrics.
112793-799. Herbert PC, Wells G, Blajchman MA,
Marshall J, Martin C, Pagliarello G, Tweeddale M,
Schweitzer I, Yetisir E. A multicenter,
randomized, controlled clinical trial of
transfusion requirements in critical care.
Transfusion Requirements in Critical Care
Investigators, Canadian Critical Care Trials
Group. N Engl J Med. 1999 Feb 11340(6)409-17. K
umar A, Roberts D, Wood KE, et al. Duration of
hypotension prior to initiation of effective
antimicrobial therapy is the critical determinant
of survival in human septic shock. Crit Care Med.
2006 341589-1596   Lemson J, Nusmeier A, Van
Der Hoeven JG. Advanced hemodynamic monitoring in
critically ill children. Pediatrics 2011 1283
560-571 Rivers E, Nguyen B, Havstad S, Ressler
J, Muzzin A, Knoblich B, Peterson E, Tomlanovich
M. Early goal directed therapy in the treatment
of severe sepsis and septic shock. N Engl J Med
2001 3451368-1377 Watson RS, Carcillo JA,
Linde-Zwirble WT et al The epidemiology of
severe sepsis in the United States. Am J Respir
Crit Care Med 2003 167695-701. Wiedemann HP,
Wheeler AP, Bernarnd GR et al. Comparison of two
fluid management strategies in acute lung injury
2006 3542564-2575.
25
Reminders...

• WHAT IS SEPSIS?
• Systemic Inflammatory Response Syndrome SIRS
  2 or more of the following high or low white
  count, tachycardia, tachypnea, high or low
  temperature
• Sepsis SIRS a suspected source of infection
  (ex., gangrenous toe, pneumonia, central line,
  mucositis)
• Septic Shock sepsis hypotension (or signs of
  poor perfusion).
• Signs of poor perfusion altered mental status,
  delayed cap refill, poor pulses, mesenteric
  ischemia (emesis, diarrhea), urine output lt
  1cc/kg/hr, hypoxia
• WHAT IS A BUNDLE a group of treatments that
  improve outcomes when given together
• Sepsis Resuscitation Bundle how to treat early
  sepsis
• 20cc/kg IVF boluses, broad spectrum IV
  antibiotics, blood culture, lactate within 1 hour
  of presentation. You may use up to 60cc/kg in the
  early phase of sepsis and move to pressors if
  vitals do not normalize.
• Sepsis Management Bundle how to direct fluids
  and pressors to markers of improved cardiac
  output
• normal mental status, UOP gt 1cc/kg/hr, cap
  refill lt2 sec, normal MAP and CVP gt8, ScVO2 gt
  70. There are several monitoring devices that
  can help with hemodynamic monitoring, and the PA
  catheter is the gold standard (though use of a PA
  catheter has not been shown to decrease mortality
  from sepsis). Reduction in serum lactate does not
  accurately reflect improved cardiac output.
• WHAT SHOULD I DO?
• If blood pressure doesnt increase with fluids
  and pressors, consider CIRCI (Critical Illness
  Related Corticosteroid Insufficiency). A random
  cortisol level lt 15 is diagnostic and IV
  hydrocortisone can help. A ACTH stim test is not
  needed. CIRCI is especially relevant to those who
  have previously been on steroids.
• Do not wait to start pressors till central access
  is obtained. Dopamine can be started at low doses
  via peripheral IV.
• Mortality form sepsis almost doubles with every
  hour delay in resuscitation bundle and increases
  by 8 per hour with delays in IV antibiotics.
  Source removal is the ultimate treatment for
  sepsis. Advocate for your patients! Push fluids
  and antibiotics early!

26
Case 2

• Inpatient Wards

27
History

• Time 1330
• HPI While on weekend call, you are asked to
  evaluate a a 12-year-old girl who is complaining
  of dizziness and shortness of breath. Your
  signout shows that she is day 45 from a bone
  marrow transplant. She has been afebrile for two
  weeks, and her WBC counts recovered enough
  earlier in the week to discontinue prophylactic
  antibiotics. Before they left, the primary team
  told you that they drained a 2-cm blood blister
  on the patients foot earlier in the day.

28
Physical Exam

• Time 1330
• Vitals T 37.8, HR 125, BP 105/75, RR 30, SpO2
  97RA
• Physical Exam
• General Thin girl lying in her hospital bed,
  mild distress
• Neuro Appears anxious, expresses concern she is
  going to faint, somewhat confused when answering
  your questions.
• HEENT Alopecia. MMM.
• CVS Tachycardic. Normal S1/S2. No M/R/G present.
  Very brisk capillary refill x4 extremities.
• Resp Good air movement. Mild tachypnea. Few
  scattered crackles heard in the lung bases.
• Abd Soft, NT/ND.
• Ext/Skin Warm throughout. Drained lesion on
  right foot is covered by a C/D/I dressing. There
  is some mild erythema surrounding that area and
  in the distal calf. She complains of tenderness
  to palpation of the calf of the affected side.

29
Initial Plan

• Time 1345
• Click on the next most appropriate step in
  management
• Tell the RN that you will check back on the
  patient soon and plan to send blood and urine
  cultures if she becomes febrile gt38C
• Place an additional IV, order an IVF bolus, and
  place on supplemental O2
• Order an EKG, ultrasound of the bilateral lower
  extremities, and CTA of the chest
• Using her portacath, send a CBC, BMP and coag
  panel and review her last CXR

30
Plan Rapid Response

• Time 1430
• You hear an overhead page for a rapid response to
  the patients room. Upon entering her primary
  nurse tells you that the patient fainted when
  trying to walk to the restroom. The fall was
  witnessed and she did not appear to have any head
  trauma, but since being placed back into her bed
  she appears to be very sleepy.
• Repeat vitals T 38.5, HR 140, BP 100/70, RR 38,
  SpO2 95RA
• The most appropriate next step in management is
  to
• Place an additional IV, order an IVF bolus, and
  place on supplemental O2
• Using her portacath, send a CBC and blood culture
• Order a STAT head CT and review her medication
  administration record for any possible medication
  reactions that could be causing her symptoms

31
Plan Refractory Shock

• Time 1530
• The lab calls you and tells you that her platelet
  count is 15. When you go to tell the patient that
  she will require a transfusion, you are not able
  to arouse her. Repeat vitals demonstrate T 40, HR
  150, BP 85/60. You note skin erythema that has
  spread from her foot up her left leg. You start
  to initiate treatment for septic shock but the
  patient remains hypotensive and within a few
  hours the patient is requiring mechanical
  ventilation in the PICU. She dies later that
  night and you learn that her blood cultures were
  positive for Pseudomonas.
• Restart the case

32
Plan Refractory Shock

• Time 1445
• Once arriving in the radiology suite the patient
  is found to be unresponsive. When the code team
  arrives she is found to be hypotensive. Sepsis is
  suspected and although appropriate treatments are
  initiated in the PICU, the patient dies within
  the next few hours. A blood culture obtained
  prior to death is found to be positive for
  Pseudomonas.
• Restart the case

33
Plan Awaiting Studies

• Time 1410
• You review the EKG and note only sinus
  tachycardia. The laboratory technician has not
  yet arrived for the ultrasound and you are told
  that it will be at least a few hours before the
  CTA can be arranged. The nurse tells you that the
  patient becomes febrile.
• The most appropriate next step in management is
  to
• Place an additional IV, order an IVF bolus, and
  place on supplemental O2
• Using her portacath, send a CBC and blood culture

34
Plan Awaiting Lab Results

• Time 1405
• Upon review of her CXR from yesterday, there is
  no evidence of infiltrates. While awaiting the
  lab results you hear an overhead page for a rapid
  response to the patients room. Upon entering her
  primary nurse tells you that the patient fainted
  when trying to walk to the restroom. The fall was
  witnessed and she did not appear to have any head
  trauma, but since being placed back into her bed
  she appears to be very sleepy.
• Repeat vitals T 38.5, HR 140, BP 100/70, RR 38,
  SpO2 95RA
• The most appropriate next step in management is
  to
• Place an additional IV, order an IVF bolus, and
  place on supplemental O2
• Order a STAT head CT and review her medication
  administration record for any possible medication
  reactions that could be causing her symptoms

35
Plan Bolus Infusing

• Time 1420
• The IV access is placed and the bolus starts
  infusing. The high flow nasal cannula is
  initiated and the patient appears slightly more
  comfortable, but is also starting to complain
  that she is very sleepy. Her repeat vital signs
  demonstrate T 38.5, HR 130, BP 100/70, RR 38,
  SpO2 98 10L HFNC. Her exam is significant for
  decreased responsiveness, brisk capillary refill,
  bounding pulses, and an unchanged respiratory
  exam. You check a point-of-care blood glucose
  level which is normal. STAT electrolytes and a
  CBC are pending.
• The most appropriate next step in management is
  to
• Order a STAT CXR, STAT head CT, and review her
  medication administration record for any possible
  medication reactions that could be causing her
  symptoms
• Repeat the fluid bolus

36
Plan Repeat Bolus

• Time 1440
• You repeat the fluid bolus two more times but her
  vital signs have not improved. She remains
  confused and difficult to arouse. The crackles
  you had heard on her initial exam are now more
  diffuse and her work of breathing has increased.
  Her laboratory results are still pending.
• The most appropriate next step in management is
  to
• Start broad spectrum antibiotics and begin an IV
  inotrope
• Order a STAT echocardiogram and consult cardiology

37
Plan Inotropes Initiated

• Time 1500
• Dopamine is started and the first doses of
  antibiotics are given. The patient is transferred
  to the PICU where she requires intubation. Her
  status remains critical for the next 24 hours,
  but she eventually fully recovers from what is
  discovered to be Pseudomonal sepsis.

38
Plan Awaiting Studies

• Time 1500
• While awaiting the echocardiogram and cardiology
  consult the patient becomes unresponsive. When
  the code team arrives she is found to be
  hypotensive. Sepsis is suspected and although
  appropriate treatments are initiated in the PICU,
  the patient dies within the next few hours. A
  blood culture obtained prior to death is found to
  be positive for Pseudomonas.
• Restart the case

39
BILBIOLOGRAPHY Bochud PY, Bonten M, Marchetti O,
et al. Antimicrobial therapy for patients with
severe sepsis and septic shock An evidence-based
review. Crit Care Med. 200432(Suppl.)S495S512.
  Booy R, Habibi P, Nadel S, et al. Meningococcal
research group reduction in case fatality from
meningococcal disease associated with improved
healthcare delivery. Arch Dis Child 2001
85386-390. Bone M, Diver M, Selby A, Sharples
A, Addison M, Clayton P. Assessment of adrenal
function in the initial phase of meningococcal
disease. Pediatrics. 2002 Sep110(3)563-9.   Bone
RC. Immunologic dissonance a continuation
evolution in our understanding of the systemic
inflammatory response syndrome (SIRS) and the
multiple organ dysfunction syndrome (MODS). Ann
Int Med 1996 125680-7.   Brierly J, Carcillo
JA, Choong K, et al. Clinical practice parameters
for hemodynamic support of pediatric and neonatal
patients in septic shock 2007 update from the
American College of Critical Care Medicine. Crit
Care Med. 200937(2)666-668.   Briegel J,
Vogeser M, Annane D, et al. Measurement of
cortisol in septic shock Interlaboratory
harmonization. Am Rev Respir Crit Care Med. 2007
175A436   Carcillo JA, Davis AL, Zaritsky A.
Role of early fluid resuscitation in pediatric
septic shock. JAMA. 1991 2601242-1245.   Casarte
lli CH, Garcia PCR, Piva JP, Branco RG.  Adrenal
insufficiency in children with septic shock. J
Pediatr (Rio J) 200379(Suppl 2)S169-S76 Delling
er, RP, Levy, MM, Carlet, JM, et al. Surviving
Sepsis Campaign International guidelines for
management of severe sepsis and septic shock
2008. Crit Care Med. 2008 published correction
appears in Crit Care Med. 2008 361394-1396
36296-327   Han YY, Carcillo JA, Dragotta MA,
et al. Early reversal of pediatric-neonatal
septic shock by community physicians is
associated with improved outcomes. Pediatrics.
112793-799. Herbert PC, Wells G, Blajchman MA,
Marshall J, Martin C, Pagliarello G, Tweeddale M,
Schweitzer I, Yetisir E. A multicenter,
randomized, controlled clinical trial of
transfusion requirements in critical care.
Transfusion Requirements in Critical Care
Investigators, Canadian Critical Care Trials
Group. N Engl J Med. 1999 Feb 11340(6)409-17. K
umar A, Roberts D, Wood KE, et al. Duration of
hypotension prior to initiation of effective
antimicrobial therapy is the critical determinant
of survival in human septic shock. Crit Care Med.
2006 341589-1596   Lemson J, Nusmeier A, Van
Der Hoeven JG. Advanced hemodynamic monitoring in
critically ill children. Pediatrics 2011 1283
560-571 Rivers E, Nguyen B, Havstad S, Ressler
J, Muzzin A, Knoblich B, Peterson E, Tomlanovich
M. Early goal directed therapy in the treatment
of severe sepsis and septic shock. N Engl J Med
2001 3451368-1377 Watson RS, Carcillo JA,
Linde-Zwirble WT et al The epidemiology of
severe sepsis in the United States. Am J Respir
Crit Care Med 2003 167695-701. Wiedemann HP,
Wheeler AP, Bernarnd GR et al. Comparison of two
fluid management strategies in acute lung injury
2006 3542564-2575.