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Quality improvement initiatives in pediatric sepsis have focused largely on
process metrics such as time to initial antimicrobial administration and fluid
resuscitation for which clear improvement has occurred after the institution of
sepsis protocols. There are now multiple organizations focused on quality
improvement in sepsis care, including the Children’s Hospital Association,
Surviving Sepsis Campaign, the World Federation of Pediatric Intensive and
Critical Care Societies, and the World Health Organization. Outcome metrics
include mortality, severity and progression of organ dysfunction, and
ICU/hospital length of stay. To date, reductions in both ICU and hospital length
of stay and mortality have been demonstrated with the presence of bundled sepsis
care in pediatric septic shock. Ongoing multi-institutional efforts by the
Improving Pediatric Sepsis Outcomes collaborative through the Children’s
Hospital Association are helping to implement bundled sepsis care at over 50
U.S. pediatric hospitals and track associated improvements in both process and
outcome metrics. Efforts to track longer-term outcomes after septic and other
forms of shock are ongoing in adults, but more data are needed for children.
Several states and the Centers for Medicare and Medicaid Services (CMS)
have recently enacted mandates to report care processes and outcomes for
patients with septic shock. In New York State, there is evidence that compliance
with a bundle of therapies within specified time periods is associated with
improved outcomes for adults and children with septic shock. However, the full
impact of legislated compliance with therapeutic bundles on clinical outcomes,
including potential for overtreatment, remains to be established.

CLINICAL PARAMETERS OF SHOCK REVERSAL
Several clinical and laboratory parameters should be frequently reassessed to
determine response to initial resuscitative efforts for shock ( Tables 10.6 and 10.7
). Clinical signs of successful resuscitation include a decrease in heart rate and
respiratory rate, increase in blood pressure, improved urine output to >0.5
mL/kg/hr, normalization of mental status, decreased capillary refill time, and
warmth of distal extremities. If a central venous catheter has been inserted, an

increase in CVP to >8 to 12 mm Hg in the absence of pulmonary hypertension or
right ventricular heart dysfunction may suggest satisfactory initial fluid therapy.
However, while a low CVP (<5 mm Hg) generally supports that additional
volume loading would be tolerated, CVP is an unreliable surrogate of volume
status and perfusion may well be adequate in the setting of a low CVP for many
patients. Therefore, titration of fluid resuscitation to a prespecified CVP goal is
no longer recommended.