Abstract:The Society of Critical Care Medicineand the American College of CriticalCare Medicine created the first set ofsepsis guidelines in 1999. Theguidelines were developed in responseto a call upon medical professionalorganizations, by the Institute ofMedicine, to develop clinical practiceguidelines to facilitate best practicesand potentially improve patientoutcomes. These guidelines onlydealt with adult patients, leavingout the pediatric population. In2002, the American College ofCritical Care Medicine publishedthe first set of pediatric guidelines.The main algorithm from the pediatricguidelines has been incorporated intothe Pediatric Advanced Life Supportsepsis guidelines. Both the adult andpediatric guidelines have undergonerevisions. The most recent pediatricguidelines were published in 2009.

Keywords:sepsis; guidelines; society of criticalcare medicine; american college ofcritical care medicine

Department of Pediatrics, Feinberg Schoolof Medicine, Northwestern University,Chicago, IL 60611.Reprint requests and correspondence:Ranna A. Rozenfeld, MD, AssociateProfessor of Pediatrics, Feinberg School ofMedicine, Northwestern University,Attending Physician, Pediatric Critical CareMedicine, Ann & Robert H. Lurie Children'sHospital of Chicago, 225 E. Chicago Ave, Box73, Chicago, IL 60611.RRozenfeld@northwestern.edu

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SepsisGuidelines: TheWork of the

Society of CriticalCare Medicine

F CRITICAL CARE MEDICINE / RO

Ranna A. Rozenfeld, MD

he Society of Critical Care Medicine (SCCM) and theAmerican College of Critical Care Medicine (ACCM)

Tcreated the first set of sepsis guidelines in 1999. Theguidelines were developed in response to a call upon

medical professional organizations, by the Institute of Medicine,to develop clinical practice guidelines to facilitate best practicesand potentially improve patient outcomes. The first guidelineswere titled “Practice Parameters For Hemodynamic Support OfSepsis In Adult Patients In Sepsis.”1 These guidelines reviewedthe literature and made recommendations for hemodynamicsupport for adults with sepsis. These guidelines only dealt withadult patients, leaving out the pediatric population.

In 2002, ACCM published the first set of pediatric guidelines.These guidelines, “Clinical Practice Parameters For Hemodynam-ic Support Of Pediatric And Neonatal Patients In Septic Shock,”2

brought together members of SCCM with a special interest inneonatal and pediatric septic shock. I had the privilege of being atask force member and working on this first set of guidelines from1998 to 2001. These guidelines were created after a thoroughMEDLINE database search, with the identified literature gradedand recommendations created using a modified Delphi method.

These guidelines were developed because neonatal and pediat-ric sepsis differs from adult sepsis. The adult guidelines did notaddress the specific recommendations required for pediatricpatients. Pediatric patients presenting with septic shock tend to

ZENFELD

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have profound hypovolemia. It is important to makethe diagnosis quickly and begin goal-directedtherapy. Pediatric patients respond differently tofluids and medications than adult patients. Thepediatric guidelines address these differences. Theguidelines were well received and were broadlydisseminated. Although originally published inEnglish, they were subsequently published inSpanish and Portuguese. In addition, the mainalgorithm was incorporated into the PediatricAdvanced Life Support (PALS) sepsis guidelines inthe PALS provider manual published by theAmerican Heart Association in 2002.3

The primary differences between the pediatricand adult guidelines were the recommendations forhigher quantities of fluid resuscitation, whichinotropic and vasodilator therapies to use, the useof hydrocortisone, and the possible use of extracor-poreal membrane oxygenation for refractory shock.

In 2004, theACCMadult guidelineswere updated.4

Thiswas the sole update for the adult guidelines as theSurviving Sepsis Campaign (SSC) was initiated in2004, and the first set of SSC guidelines werepublished. The SSC brought together individualsacross multiple specialties, including critical careand infectious disease and represented 11 interna-tional organizations. The first SSC guidelines: “Sur-viving Sepsis Campaign Guidelines For ManagementOf Severe Sepsis And Septic Shock,”5,6 includes asmall section on pediatric considerations and usedthe flow chart from the ACCM pediatric guidelines.The SSC guidelines were published in both CriticalCare Medicine, the journal of the SCCM as well asIntensive Care Medicine, the journal of the EuropeanSociety of Intensive Care Medicine. The SSC guide-lines are more comprehensive than the ACCMguidelines as they deal with more than just hemody-namic support.

I was again a member of the task force writingupdates to the pediatric guidelines. We worked onthese guidelines from 2004 to 2007. More recentliterature was searched and then graded, andrecommendationsweremadeusing amodifiedDelphimethod. There was greater than 90% expert consen-sus before publication. An update to the pediatricguidelines, “Clinical Practice Parameters For Hemo-dynamic Support Of Pediatric And Neonatal SepticShock: 2007 Update From The American College ofCritical Care Medicine,”7 was published in 2009.

The key difference between the 2002 pediatricguidelines and the 2007 update is the recommen-dation for beginning inotropic support earlier intreatment, through either a peripheral line or anintraosseous catheter, until central venous accesscan be obtained. There is often difficulty in

obtaining central venous access in pediatric pa-tients, and the initiation of inotropic support wasbeing delayed while central line placement wasbeing attempted. The updated guidelines recom-mend beginning inotropic support when indicated,even if via a peripheral catheter, and then, switchingthe medication to a central venous catheter whenthe catheter is placed.

In addition, the updated guidelines recommendthat high-flow humidified oxygen should be deliv-ered via nasal cannula until more definitive respi-ratory support can be provided. The guidelines alsoexplicitly state that antibiotics should be adminis-tered within the first hour. This was implied in thefirst set of guidelines but not explicitly stated.

Because most of these patients initially present tothe emergency department (ED), it is important thatthe sepsis algorithm be started by emergency carepractitioners. Because the guidelines were pub-lished in a critical care journal and not anemergency medicine journal, many emergencyphysicians were unaware of the pediatric sepsisguidelines. A summary of the guidelines waspublished in Pediatric Emergency Care in 2010 inan effort to further promote awareness.8 In addition,the 2011 PALS Provider Manual references theupdated pediatric guidelines.9

Since publication of the updated pediatric sepsisguidelines, multiple studies have been done evalu-ating the implementation of sepsis pathways in thepediatric ED setting.10-13 These studies identifiedbarriers to pathway implementation in these EDsthat investigators are working to overcome.

The adult SSC guidelines were updated in 2008and again in 2012.14-17 These guidelines were againcopublished in Critical Care Medicine and IntensiveCare Medicine by the SCCM and the EuropeanSociety of Intensive Care Medicine. Both revisionshave small sections on pediatric considerations insevere sepsis and reference the updated pediatricACCM guidelines.

Unlike the adult ACCM guidelines, which have notbeen updated since 2004 due to the SSC guidelines,the pediatric guidelines are currently under revisionwith an anticipated publication in 2015. Task forcemembers of the SCCM who have special interest inpediatric and neonatal sepsis began work on therevision in 2012. We are currently grading thecurrent literature and will be providing recommen-dations based upon the new literature that has beenpublished since 2007.

Once the current revisions of the ACCM pediatricguidelines are complete, future directions mightinclude the creation of pediatric surviving sepsisguidelines. Just as the adult surviving sepsis

122 VOL. 15, NO. 2 • THE WORK OF THE SOCIETY OF CRITICAL CARE MEDICINE / ROZENFELD

guidelines provide more comprehensive recommen-dations than the ACCM adult sepsis guidelines, apediatric version could also provide a more compre-hensive set of pediatric specific recommendations.

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