EARLY IDENTIFICATION AND MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK IN CHILDREN AND YOUNG PEOPLE. Type: Clinical Guidelines

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1 EARLY IDENTIFICATION AND MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK IN CHILDREN AND YOUNG PEOPLE Type: Clinical Guidelines Register No: Status: Public Developed in Response to: Best practice Contributes to CQC 12 Consulted With Post/Committee/Group Date Alison Cuthbertson / Miss Rao Divisional Director for Women s and Childrens January 2017 Children s Urgent & Emergency Group January 2017 Melanie Chambers Lead Nurse Children and Young People January 2017 Mel Hodge Senior Sister Phoenix Children s Unit January 2017 Dr Agrawal Paediatric Consultant January 2017 Dr Cyriac Paediatric Consultant January 2017 Dr Hassan Paediatric Consultant January 2017 Dr Joseph Paediatric Consultant January 2017 Dr Lethaby Paediatric Consultant January 2017 Dr Lim Paediatric Consultant January 2017 Dr Muthumeenal Paediatric Consultant January 2017 Dr Nambiar Paediatric Consultant January 2017 Dr Ottayil Paediatric Consultant January 2017 Victoria Machell Clinical Governance Facilitator January 2017 Claire Fitzgerald Paediatric Pharmacist January 2017 Dr Louise Teare Director of Infection Prevention & Control January 2017 Professionally Approved by: Dr Datta Clinical Director Children s Services January 2017 Version Number: 3.2 Issuing Service: Children and Young People Ratified by: DRAG Ratified on: 23 February 2017 Trust Executive Sign Off Date: March 2017 Implementation Date: 21 st March 2017 Next Review Date: February 2020 Author/Contact for Information Dr Rachel Thomas, Associate Specialist in Paediatrics Policy to be followed by (target staff) All healthcare professionals Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) 09005: Transferring children 0-16 years 04071: Standard Infection Prevention Precautions Policies 11046: Observation policy CYP 10043: Feverish Illness in children: Assessment and initial management in children younger than 5 years 08066: Antibiotic guidelines for neonates and paediatrics 06045: Antibiotic policy 09065: Preparing and administering intravenous infusion of drugs for children and young people Clinical Audit Strategy and Policy Document Review History: Version Number: Author/ Reviewed by: Active From Date: 1.0 Caroline Fox 15th June Andrea Stanley 12th February Chairmans Action Sarah Moon 30 January Victoria Machell/ Mary Stebbens 21 st March Author correction Dr Rachel Thomas, Associate Specialist in Paediatrics Sept

2 Index 1. Purpose 2. Scope 3. Introduction 4. Recognition of septic Shock 5. Signs and symptoms of Septic Shock 6. Recognition of Sepsis 1month to 4 years 7. Recognition of Sepsis 5 years to 11 years of Age 8. Recognition of Sepsis Over 12 years old 9. Features of severe disease 10. Patient/Parental/Family Concern and Advice 11. Management of sepsis 12. Sepsis Antibiotic choice 14. Indications for intubation 15. Management following intubation 16. Further management 17. Staff Training 18. Equality and Diversity 19. Infection Prevention 20. Monitoring Compliance with policy requirements 21. Implementation & Communication 22. References and Further Reading Appendix A Paediatric Sepsis Screening and Action Tool Under 5 years Appendix B Paediatric Sepsis Screening and Action Tool aged 5 11 years Appendix C Paediatric Sepsis Screening and Action Tool over 12 years Appendix D Sepsis the First Hour (CATS Flowchart) 2

3 1.0 Purpose 1.1 To ensure that effective care and timely response is achieved in the management of sepsis in children and young people. 2.0 Scope 2.1 These guidelines set out the principles of early identification and treatment of severe sepsis and septic shock in children and young people (up to their 16 th birthday). 2.2 These guidelines are for the use of all nursing and medical staff within Mid Essex Hospital Services NHS Trust. 3.0 Introduction 3.1 Sepsis is a life-threatening condition that arises when the body s response to an infection injures its own tissues and organs. 3.2 Sepsis can lead to shock, multiple organ failure and death especially if not recognised early and treated promptly. 3.3 Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care. 3.4 Severe sepsis is a clinical emergency. Signs and symptoms of sepsis in children can be subtle and deterioration to shock rapid. Early initiation of simple treatment improves outcomes. 4.0 Recognition of Septic Shock 4.1 Pyrexia, tachycardia and some alteration in perfusion is very common in children with benign infections. 4.2 Those children who have this combination of clinical features but who are also displaying signs of altered mental status (inconsolable, irritable, poor interaction with parents or difficult to rouse) should be assessed as being at risk of having septic shock. 4.3 Sepsis is a systemic inflammatory response syndrome (SIRS) in the presence of or as a result of suspected or proven infection. 4.4 Signs of septic shock include the following: Core temperature < 36 C or > 38.5 C Inappropriate tachycardia (infants may display bradycardia) Altered mental state (including sleepiness / irritability / lethargy / floppiness) Reduced peripheral perfusion / prolonged capillary refill Decreased urine output Tachypnoea Think: could this child have SEPSIS or SEPTIC SHOCK? If in doubt, consult a senior clinician 3

4 5.0 Signs and symptoms of Septic Shock: 5.1 As above with the addition of the following: Tachypnoea Urine output decreased (<1mL/kg/hour) or absent Other end organ dysfunction Signs of either cold or warm shock. Cold Shock: Capillary Refill > 3s Reduced Peripheral Pulses Cool Mottled Extremities Narrow Pulse Pressure Warm Shock: Flash Capillary Refill Bounding Peripheral Pulses Warm to edges Wide Pulse Pressure Hypotension is a late sign of shock in children and is not required for diagnosis; if present it does however confirm diagnosis. 5.2 Normal ranges for age (APLS) Age (years) Heart Rate Respiratory Rate Systolic BP (mmhg) < y > 12yrs Recognition of Sepsis 1month to 5 years 6.1 Recognise that children aged under 5 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis 6.2 Consider starting Sepsis 6 pathway immediately if one of the below red flags is present: Unresponsive to Social cues/different to rouse Healthcare worker very worried Weak, high pitched or continuous cry Grunting respiration or apnoeic episodes Unexplained sp02 <90% or need for oxygen Severe unexplained tachypnoea No wet nappies/ not passed urine in last 18 hours Clinically concerning non-blanching rash Mottled/ Ashen/Cyanotic Persistent temperature <36 C If under 3 months, temperature <38 C Refer to Appendix A and B 4

5 7.0 Recognition of Sepsis 5 years to 11 years of Age 7.1 Recognise that children aged 5 11 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis: 7.2 Consider starting Sepsis 6 pathway immediately if one of the below red flags is present: Objective change in behaviour or mental state Doesn t wake if roused or wont stay awake Looks very ill to health professional Unexplained Sp02 <90%/ need for Oxygen Severe unexplained tachypnoea Severe unexplained tachycardia Bradycardia (<60 per minute) Not passed urine in last 18 hours Mottled, ashen or blue skin, lips or tongue Clinically concerning non blanching rash Refer to Appendix C and D 8.0 Recognition of Sepsis 12 years Old and Over 8.1 Recognise that children aged 5 11 years with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis: 8.2 Consider starting Sepsis 6 pathway immediately if one of the below red flags is present: Responds only to Voice or pain/unresponsive Systolic BP 90mmHg (or drop > 40 from normal) Clinically unexplained tachycardia Clinically unexplained tachypnoea Unexplained sp02 < 90% or need for oxygen Clinically concerning non blanching rash Mottled, ashen/cyanotic Not passed urine in last 18 hours Recent Chemotherapy Refer to Appendix E and F 9.0 Features of Severe Disease Widespread or rapidly evolving rash Hypotension Base deficit 8 or worse / lactate > 4 Low WCC Thrombocytopaenia Coagulopathy 9.1 The immediate care of a child with suspected sepsis must follow the principles of ABCDE (Airway, Breathing, Circulation, Disability, Exposure/Examination, assessment. 5

6 9.2 Baseline and subsequent measurement of vital signs must be recorded on an observation chart and a Children Early Warning Tool score calculated and recorded on each occasion. Frequency of recording of vital signs should be based on clinical assessment of the child and the calculated Children s Early Warning Tool (CEWT) score. (Refer to Children s Observation Policy 11046) 9.3 Any child who is in shock and/or has organ dysfunction should be discussed with Children s Acute Transport Service (CATS) Patient/Parental/Family Concern and Advice 10.1 Pay Particular attention to concerns expressed by the person and their families or carers. The clinician must take into account concerns raised about unusual behaviour for that particular child assess people who might have sepsis with extra care if they cannot give a good history (for example people with English as a second language or people with communication problems) 10.3 People who have sepsis and their families and carers Ensure a care team member is nominated to give information to families and carers, particularly in emergency situations such as in the emergency department. This should include: An explanation that the person has sepsis, and what this means An explanation of any investigations and the management plan Regular and timely updates on treatment care and progress Ensure information is given without using medical jargon. Check regularly that people understand the information and explanations they are given Give people with sepsis and their family members and carers opportunities to ask questions about diagnosis, treatment options, prognosis and complications. Be willing to repeat any information as needed Give people with sepsis and their families and carers information about national charities and support groups that provide information about sepsis and the causes of sepsis Information at discharge for people assessed for suspected sepsis, but not diagnosed with sepsis Give people who have been assessed for sepsis but have been discharged without a diagnosis of sepsis (and their family or carers, if appropriate) verbal and written information about: What sepsis is, and why it was suspected What tests and investigations have been done Instructions about which symptoms to monitor When to get medical attention if their illness continues How to get medical attention if they need to seek help urgently. 6

7 Confirm that people understand the information they have been given, and what actions they should take to get help if they need it Information at discharge for people at increased risk of sepsis Ensure people who are at increased risk of sepsis (for example after surgery) are told before discharge about symptoms that should prompt them to get medical attention and how to get it Information at discharge for people who have had sepsis Ensure people and their families and carers if appropriate have been informed that they have had sepsis Ensure discharge notifications to GPs include the diagnosis of sepsis Give people who have had sepsis (and their families and carers, when appropriate) opportunities to discuss their concerns. These may include: Why they developed sepsis Whether they are likely to develop sepsis again If more investigations are necessary Details of any community care needed, for example, related to peripherally inserted central venous catheters (PICC) lines or other intravenous catheters What they should expect during recovery Arrangements for follow-up, including specific critical care follow up if relevant Possible short-term and long-term problems Give people who have had sepsis and their families and carers information about national charities and support groups that provide information about sepsis and causes of sepsis Advise carers they have a legal right to have a carer's assessment of their needs, and give them information on how they can get this Management of Sepsis 11.1 There is evidence showing that aggressive optimisation of the haemodynamic status within the first few hours of critical illness has a profound effect in reducing subsequent organ failure and improving overall survival Children in septic shock are consistently under resuscitated in the first few hours. It is not unusual to require > 60 ml/kg of fluid in the first hour of treatment. For every hour that a child remains in septic shock the mortality risk doubles Management of severe sepsis and septic shock follows the Surviving Sepsis International Consensus Guidelines Refer to appendix G Paediatric Sepsis In severe sepsis and septic shock the following elements should be completed within the first hour of recognition. Use the age specific Paediatric Sepsis 6 proforma (refer 7

8 to appendix A, C or E) to document completion and reasons for variation. This should be placed in the patients notes Give high flow oxygen: Saturations > 95% - intubate if indicated 12.3 Obtain IV/IO access and take blood tests: Achieve x 2 access quickly Blood cultures Full Blood Count, Urea, Elecrolytes and Creatinine, Liver Function Test, Coagulation, Serum Calcuim and Magnesium, C Reactive Protein, EDTA (Ethylenediaminetetraacetic acid) sample for PCR(Polymerase chain reaction) Blood glucose treat low blood glucose 2ml/kg 10% Dextrose Blood gas including lactate 12.4 Give IV or IO antibiotics High dose broad spectrum cover as per local policy Consider fluid resuscitation: Aim to restore normal circulating volume and physiological parameters Titrate 20 ml/kg Isotonic Fluid over 5 10 min and repeat if necessary Caution with fluid overload > Examine for crepitations & hepatomegaly Involve senior clinicians / specialists early: Contact consultant paediatrician on-call and CATS retrieval service 12.7 Consider Inotropic support early: If normal physiological parameters are not restored after 20 ml/kg fluids Ephinepherine or Dopamine may be given via peripheral IV or Intra Osseous (IO) access If evidence of end organ dysfunction start dopamine. Add adrenaline for cold shock and noradrenaline for warm shock Obtain urgent anaesthetic help for intubation and central line access 12.8 Goals of the First Hour of resuscitation are to restore: Normal perfusion No difference in quality between central and peripheral pulses Warm extremities Capillary refill time < 3 seconds Normal range for age heart rate, blood pressure & respiratory rate (this may not be possible if the underlying cause is pneumonia) Normal mental status Urine output > 1ml/kg/hr Serum lactate < Antibiotic Choice 13.1 Ensure urgent assessment mechanisms are in place to deliver antibiotics when any high risk criteria are met in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting). 8

9 13.2 Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in locations where transfer time is more than 1 hour For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available. For people with suspected sepsis take blood cultures before antibiotics are given For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance For people aged up to 17 years with suspected community acquired sepsis of any cause give ceftriaxone 80 mg/kg once a day with a maximum dose of 4 g daily at any age For people aged up to 17 years with suspected sepsis who are already in hospital, or who are known to have previously been infected with or colonised with ceftriaxoneresistant bacteria, Refer to Antibiotic Guidelines for Neonates and Paediatrics (08066) for choice of antibiotic For children younger than 3 months give an additional antibiotic active against listeria (for example, Ampicillin or Amoxicillin) For children under 3 months presenting in hospital with suspected sepsis in their first 72 hours with intravenous Benzylpenicillin and Gentamicin Treat neonates who are more than 40 weeks corrected gestational age who present with community acquired sepsis with Ceftriaxone 50 mg/kg unless already receiving an intravenous calcium infusion at the time. If 40 weeks corrected gestational age or below or receiving an intravenous Calcium infusion use Cefotaxime 50 mg/kg every 6 to 12 hours, depending on the age of the neonate Indications for Intubation Impending cardiorespiratory collapse Poor airway reflexes Depressed conscious level GCS 8 or AVPU P Worsening tachypnoea or oxygen requirement Fluid refractory shock (> 60 mls/kg fluid resuscitation in the first hour without reversal of shock) 14.1 Induction of anaesthesia presents a significant risk of hypoxia, myocardial depression and afterload reduction. This can be minimised by: Ensuring the most team members perform the intubation anaesthetic / Intensive Care Unit (ICU) consultant Use induction drugs as per CATS team advice Optimal volume replacement prior to induction Having volume running with bolus attached Dopamine infusion running or drawn up Pre-oxygenation with 100% O2 Preferably intubate with a cuffed ETT (endotracheal tubes) 9

10 14.2 Inhalation anaesthetics present significant risk of causing cardiovascular collapse, as do Thiopentone, Propofol and benzodiazepines Modified rapid sequence induction (with croicoid pressure) 15.0 Management Following Intubation End tidal CO2 monitoring is mandatory Secure ETT do not cut length down Check appropriate position with CXR (Tip at T2-T3) Sedate and muscle relax as per CATS induction of anaesthesia guidelines 15.1 These children are at risk of acute respiratory distress syndrome (ARDS). A low tidal volume strategy of 4-7 ml/kg with an initial PEEP of 5 cm/h 2 0) should be used. PEEP can be titrated up depending on blood gases and evidence of pulmonary oedema Further Management Consider Sodium Bicarbonate if ph remains below Exclude other possible causes for refractory shock (pericardial effusion, pneumothorax, ongoing blood losses etc). Elevated clotting times (INR >1.5) should be treated with 10-20mL/kg of Fresh Frozen Plasma (FFP) Low platelet counts in the absence of active bleeding should not be supplemented unless <20 x 103/mm3. FFP or platelets should be infused, not bolused. Assess and review for signs of raised Intra Cranial Pressure; treat appropriately Treat hypomagnesaemia and hypocalcaemia as per CATS advice Staff Training 17.1 All medical and nursing staff to ensure that their knowledge, competencies and skills are up to date and in line with roles and responsibilities outlined above. During the induction process, all junior medical and nursing staff will receive instruction on current sepsis policies and guidelines Medical and nursing staff will be kept up to date with teaching, ongoing case presentations discussing severe sepsis and learning from outcomes On-going discussion as necessary will take place at all relevant operational and directorate meetings Equality and Diversity 18.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 10

11 19.0 Infection Prevention 19.1 All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands before and after each procedure All staff should ensure that they follow Trust guidelines on infection prevention, using Aseptic Non-Touch Technique (ANTT) when carrying out procedures i.e. administering IV antibiotics All staff should ensure that they follow Trust guidelines on infection prevention. All invasive devices must be inserted and cared for using high impact intervention guidelines (refer to Saving Lives policy guideline, DoH, 2007) to reduce the risk of infection and deliver safe care. This care should be recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork (Medical Devices) Monitoring Compliance with Policy Requirements 20.1 Audit of compliance with this guideline will be considered on an annual audit basis in accordance with the Clinical Audit Strategy and Policy (register number 08076), the Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual audit work plan; to encompass national and local audit and clinical governance identifying key harm themes. The Women s and Children s Clinical Audit Group will identify a lead for the audit The findings of the audit will be reported to and approved by the Multi-disciplinary Risk Management Group (MRMG) and an action plan with named leads and timescales will be developed to address any identified deficiencies. Performance against the action plan will be monitored by this group at subsequent meetings The audit report will be reported to the monthly Directorate Governance Meeting (DGM) and significant concerns relating to compliance will be entered on the local Risk Assurance Framework Key findings and learning points from the audit will be submitted to the Clinical Governance Group within the integrated learning report Key findings and learning points will be disseminated to relevant staff Implementation and Communication 21.1 The policy will be uploaded on the Trust Intranet site and will be communicated to staff via staff focus The policy will be circulated to the Clinical Lead for paediatrics and Lead Nurse for Children and Young People for dissemination References and Further Reading Advanced Life Support Group [ALSG] (2011) Advanced Paediatric Life Support: The practical Approach Fifth Edition.Wiley-Blackwell publishing: Chichester Children s Acute Transport Service (CATS) (2016) Clinical Guideline Septic Shock [online] 11

12 accessed 20/01/2017 Inwald DP, Tasker RC, Peters MJ, et al (2009) Emergency management of children with servere sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit. Arch Dis Child 94: National Institute for Health and Care Excellence [NICE] (2014): Feverish Illness in Children: Assessment and initial management in children younger than 5 years [online] accessed 20/01/2017 National Institute for Health and Care Excellence [NICE] (2016): Sepsis: recognition, diagnosis and early management [online] accessed 20/01/2017 Resuscitation Council [UK] (2011) European Paediatric Life Support Manual: Third Edition Resuscitation Council [UK]: London UK Sepsis Group [online] accessed 20/01/ UK Sepsis Trust [online] accessed 20/01/

13 Appendix A 13

14 Risk Stratification Tool for Children Aged Under 5 years with Suspected Sepsis Appendix B Category Age High risk criteria Moderate to high risk criteria Low risk criteria Behaviour Any 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 Any 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 Raised respiratory rate: 60 breaths per minute or more Raised respiratory rate: breaths per minute No high risk or moderate to high risk criteria met 1 2 years Raised respiratory rate: 50 breaths per minute or more Raised respiratory rate: breaths per minute 3 4 years Raised respiratory rate: 40 breaths per minute or more Raised respiratory rate: breaths per minute 14

15 Any Bradycardia: heart rate less than 60 beats per minute 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 minute or more Rapid heart rate: beats per minute No high risk or moderate to high risk criteria met 1 2 years Rapid heart rate: 150 beats per minute or more Rapid heart rate: beats per minute 3 4 years Rapid heart rate: 140 beats per minute or more Rapid heart rate: beats per minute Mottled or ashen appearance Skin Any Cyanosis of skin, lips or tongue Normal colour Non-blanching rash of skin Any Less than 36ºC Temperature Under 3 months 38 C or more 3 6 months 39 C or more Other Any Leg pain Cold hands or feet No high risk or high to moderate risk criteria met This table is adapted from NICE s guideline on fever in under 5s. 15

16 Appendix C 16

17 Appendix D Risk Stratification Tool for Children Aged 5 11 Years with Suspected Sepsis Category Age High risk criteria Moderate to high risk criteria Low risk criteria Behaviour Any 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 Any 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 Raised respiratory rate: 29 breaths per minute or more Raised respiratory rate: breaths per minute No high risk or moderate to high risk criteria met Aged 6 7 years Raised respiratory rate: 27 breaths per minute or more Raised respiratory rate: breaths per minute Aged 8 11 years Raised respiratory rate: 25 breaths per minute or more Raised respiratory rate: breaths per minute Circulation and hydration Any Heart rate less than 60 beats per minute Capillary refill time of 3 seconds or more Reduced urine output For catheterised patients, passed less than 1 ml/kg of urine per hour No high risk or moderate to high risk criteria met Aged 5 years Raised heart rate: 130 beats per Raised heart rate: beats per 17

18 minute or more minute Aged 6 7 years Raised heart rate: 120 beats per minute or more Raised heart rate: beats per minute Aged 8 11 years Raised heart rate: 115 beats per minute or more Raised heart rate: beats per minute Skin Any Mottled or ashen appearance Cyanosis of skin, lips or tongue Non-blanching rash of skin Other Any Leg pain Cold hands or feet No high or moderate to high risk criteria met 18

19 Appendix E 19

20 Appendix F Risk Stratification Tool for Adults, Children and Young People Aged 12 years and Over with Suspected Sepsis Category High risk criteria Moderate to high risk criteria Low risk criteria 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 Raised respiratory rate: 25 breaths per minute or more New need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease) Raised respiratory rate: breaths per minute No high risk or moderate to high risk criteria met Blood pressure Systolic blood pressure 90 mmhg or less or systolic blood pressure more than 40 mmhg below normal Systolic blood pressure mmhg No high risk or moderate to high risk criteria met Circulation and hydration Raised heart rate: more than 130 beats per minute 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 minute (for pregnant women beats per minute) or new onset arrhythmia Not passed urine in the past hours For catheterised patients, passed ml/kg of urine per hour No high risk or moderate to high risk criteria met Temperature Tympanic temperature less than 36 C Skin Mottled or ashen appearance Cyanosis of skin, lips or tongue 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 20

21 Appendix G 21