Paediatric ECAT protocol

Sepsis (suspected)

P3.3 Published: December 2023 Printed on 2 May 2024

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Any person, 4 weeks to 15 years, presenting with symptoms that fulfil Paediatric Sepsis Pathway criteria.

Escalate immediately as per local CERS protocol.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

  • Activate the Paediatric Sepsis Pathway.
  • This protocol authorises nurses to request diagnostics and give medication and fluids as indicated below, in line with the Paediatric Sepsis Pathway.
  • For babies up to 28 days (corrected), use the Neonatal Sepsis Pathway. Do not use this protocol.
CEC Paediatric Sepsis Pathway

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Precautions and notes

  • IV antibiotic administration is preferred. IM antibiotics may not be absorbed if there is shock and/or hypotension.

Interventions and diagnostics

Pathology

Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

  • Priority to collect: VBG with lactate, blood cultures, glucose
  • FBC, UEC, LFT, coags, CRP
  • Urinalysis:
    • Patient who can void in the toilet: mid-stream urine
    • Patient who is not toilet trained: clean catch or catheter urine
    • Send for MC&S. Keep sample refrigerated if transport is delayed
  • Consider using for specific fever sources: wound swab, sputum culture, stool culture, respiratory viral screen

Antibiotic management

  • Give antibiotics within 60 minutes if:
    • patient has probable sepsis
    • and a medical or nurse practitioner is unavailable
    • and patient is being treated as an emergency patient or as an inpatient as part of a CERS response and presented less than 24 hours ago (designated facilities only).
  • Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.
  • Document source of infection if known.

Gentamicin

Do not give gentamicin if patient has:

  • pre-existing significant auditory impairment or vestibular condition
  • history of hypersensitivity reaction to aminoglycoside
  • myasthenia gravis
  • history of aminoglycoside-induced vestibular or auditory toxicity, or first degree relative has history of same.

If the patient has any of the above contraindications, continue to give the other antibiotics and seek advice about gentamicin.

Give gentamicin:

  • 1 month–10 years: 7.5 mg/kg IV once only, maximum dose 320 mg
  • 10–15 years: 7 mg/kg IV once only, maximum dose 560 mg

Additional antibiotics

Select one:

No known allergies

Give:

ceftriaxone 50 mg/kg IV/IM once only, maximum dose 2 g

and if known MRSA or risk of colonisation and/or CVAD in situ: also give vancomycin 15 mg/kg IV once only, maximum dose 750 mg

Non-severe, severe or uncertain penicillin allergy

Give:

ciprofloxacin 10 mg/kg IV once only, maximum dose 400 mg

and vancomycin 15 mg/kg IV once only, maximum dose 750 mg

Fluid resuscitation

Give initial sodium chloride 0.9% 20 mL/kg IV/intraosseous bolus.

If no improvement in circulation, repeat once.

Glucose

Measure BGL.

If BGL less than 3.0 mmol/L:

  • Give glucose 10% at 2 mL/kg slow IV injection once only
  • If delay in IV access, give glucagon:
    • Up to 25 kg: 0.5 mg IM, once only
    • 25 kg and over: 1 mg IM, once only

Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

ondansetron:

  • 8–15 kg: 2 mg, orally once only
  • 15–30 kg: 4 mg, orally once only
  • Over 30 kg: 8 mg, orally once only.

Radiology

  • If chest thought to be source or source is difficult to determine: CXR

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

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Drug Dose Route Frequency

Ceftriaxone

50 mg/kg

Maximum dose 2 g

IV/IM

Once only

Ciprofloxacin

10 mg/kg

Maximum dose 400 mg

IV

Once only

Gentamicin

1 month–10 years: 7.5 mg/kg
Maximum dose 320 mg

10–15 years: 7 mg/kg
Maximum dose 560 mg

IV

Once only

Glucagon

Up to 25 kg:
0.5 mg

25 kg and over:
1 mg

IM

Once only

Glucose 10%

2 mL/kg

Slow IV injection

Once only

Ibuprofen H, R

3 months and over:
10 mg/kg

Maximum dose 400 mg

Oral

Pain score 1–10

Once only

Ondansetron

Over 6 months and 8–15 kg:
2 mg

15–30 kg:
4 mg

Over 30 kg:
8 mg

Oral

Once only

Oxygen

0.25–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

15 mg/kg

Maximum dose 1000 mg

Oral

Pain score 1–10

Once only

Sodium chloride 0.9%

20 mL/kg

IV/intraosseous

Bolus

Repeat once if required

Vancomycin

15 mg/kg

Maximum dose 750 mg

IV

Once only

Medications with contraindications or requiring dose adjustment are marked:

  • H for patients with known hepatic impairment
  • R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

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Evidence informed

Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.

Collaboration

This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.

Currency Due for review: Jan 2026. Based on a regular review cycle.
Feedback Email ACI-ECIs@health.nsw.gov.au

ECAT home pageGlossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/sepsis

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