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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 (