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Sepsis is a major cause of morbidity and mortality in the paediatric population and can be very challenging to diagnose and manage.
For every hour a child remains in septic shock the mortality risk doubles. Care delivered in the first hour after presentation or sepsis identification is crucial in ensuring the optimum outcome for the patient.
Key principles in managing severe sepsis or septic shock
- Early recognition
- Rapid vascular access: Intravenous (IV) or intraosseus (IO) access within 5 minutes
- Empiric antibiotic therapy: as soon as possible after access obtained
- Rapid, judicious, fluid resuscitation: 20ml/kg fluid boluses of isotonic crystalloids (e.g. Normal saline or Plasma-Lyte 148) or albumin 4%
- Early initiation of inotropes via peripheral access if shocked and not fluid responsive. Transfer to PICU as soon as possible
- Source control (if possible): For example, to operating theatre as soon as stabilised if suspected abdominal source
Click on the image below or follow this link to view the flowchart for the management of septic shock/severe sepsis in CED.
Click on this link to a calculator for Paediatric resuscitation drug doses (http://www.paediatricdrugs.net/EnterPtData.aspx)
Defining sepsis and early recognition
Sepsis is a clinical syndrome complicating infection characterised by systemic inflammation, microcirculatory dysfunction, immune dysregulation and end-organ dysfunction. There is a continuum of severity from sepsis to severe sepsis and septic shock.
Sepsis can be particularly challenging to diagnose in the paediatric population. There are a large number of mimics (e.g. viral illnesses) and infants and toddlers in particular can often appear very unwell with significantly abnormal physiology when febrile.
|Systemic Inflammatory Response Syndrome (SIRS) in Paediatrics|
|The presence of at least 2 of the following criteria, one of which must be abnormal temperature or white cell count:|
|1||Temperature (core) >38.5 or <36°C|
|2||Tachycardia (or bradycardia in those <1 year of age) in the absence of painful stimuli, pharmacologic explanation, other external stimulus|
|3||Tachypnoea or the need for ventilator support|
|4||Elevated or depressed white cell count for age|
|SIRS in the setting of suspected or proven infection.|
|Sepsis with cardiovascular organ dysfunction. Hypotension is not required to diagnose septic shock in children and is generally a late sign. However the presence of hypotension is confirmatory of shock.|
|Sepsis with evidence of cardiovascular organ dysfunction or acute respiratory distress syndrome or evidence of dysfunction at least 2 other end organs.|
Some of the information required to meet the above formal definitions may not be available to the clinician at the time of assessment.
Severe Sepsis or Septic shock should be suspected in a patient with suspected or proven infection, fever (or hypothermia in infants)
AND any of the following
- Altered mental status (e.g. reduced level of consciousness, lethargy, irritability, floppiness).
- Reduced peripheral perfusion, cool or mottled skin, prolonged central capillary refill time (CRT) >2sec and narrow pulse pressure (which can signify "cold shock").
- Flushed skin with brisk CRT, bounding pulses and wide pulse pressure (which can signify "warm shock").
- Tachycardia (persistent above limits for age with no other explanation)
- Tachypnoea +/- hypoxia (not resulting from bronchiolitis, viral wheeze or asthma)
- "Unwell" appearance
Acceptable Upper Limits
|Based on Starship PEWS "yellow zone" parameters derived from (Bonafide et al., 2013). These equate to 90-95% upper limit of normal for hospitalised children|
The following children have a higher risk of sepsis and the threshold for investigation/management of sepsis should be lower:
- Infants less than 3 months of age
- Immunosuppression due to chemotherapy, long-term steroids, other immunosuppressants or chronic medical conditions
- Indwelling lines/medical devices
- Children presenting with petechial (non-blanching) rash (Refer Meningococcaemia guideline)
Manage all patients with suspected severe sepsis/septic shock in the Emergency Department in the resuscitation bay with senior support (Fellow or Consultant) and a low threshold for PICU review.
Recommend Code Pink for patients with suspected severe sepsis/septic shock on the ward.
|This is a priority and should be tasked to an experienced
If unable to gain peripheral intravenous access within 5 minutes or after two attempts an intraosseus (IO) line should be inserted.
It may be appropriate to opt for IO access straight away in critically unwell patients or those in whom access is clearly going to be difficult.
Blood tests should be taken at the time vascular access is
obtained, if possible. Antibiotic administration should not be
delayed by repeated attempts to collect bloods.
Correct hypoglycaemia (if present) with 2ml/kg 10% dextrose.
|Administer empiric intravenous antibiotic cover as soon as possible after access is obtained. For most patients the following empiric options will be suitable first-line antibiotic therapy, however take into account local infection and resistance patterns:|
|<6 weeks:||Cefotaxime 100mg/kg load and
then 50mg/kg Q6H
and Amoxycillin 50mg/kg Q6H
|>6 weeks:||Cefotaxime 100mg/kg load and then 50mg/kg Q6H|
Consider adding Acyclovir if possible disseminated Herpes Simplex infection in under 3 months of age (e.g. if skin lesions present).
There will be situations where additional empiric cover may be warranted at the discretion of the senior clinician, e.g. Vancomycin for suspected MRSA or pneumococcal disease
|Antibiotic choice in septic
Paediatric Oncology patients see
Febrile Neutropenia Guideline
Discuss these patients early with a Paediatric Haematologist/Oncologist.
Evidence suggests that rapid fluid resuscitation may have a key
role in preventing end-organ damage and improving survival in a
developed world setting with intensive care support. The following
is consistent with best practice guidelines for such a
Choice of fluid:
Large volumes of 0.9% saline (e.g 40-60ml/kg) can lead to hyperchloraemia and increasing acidosis.
Plasma-Lyte 148 is a suitable alternative for patients who have a significant metabolic acidosis or who have received significant volumes of 0.9% saline already.
|Adrenaline||A good first line option for most patients.
Usually start at 0.1microg/kg/min. Titrate from 0.05-0.3 microg/kg/min
|Noradrenaline||Consider in "warm shock".
Titrate from 0.05-0.3 microg/kg/min
|Link to Emergency Drug Calculator|
|Intubation in severe sepsis/septic shock is a high risk procedure.|
May be required in the setting of:
If intubation is required, rapid sequence induction (RSI) will
|Children on long-term steroid therapy or with known adrenal
insufficiency should receive stress dose steroids - see Stress Steroid Management
Hydrocortisone therapy should also be considered for those with catecholamine resistant shock with suspected absolute adrenal insufficiency.
Bonafide, C. P., Brady, P. W., Keren, R., Conway, P. H., Marsolo, K., & Daymont, C. (2013). Development of heart and respiratory rate percentile curves for hospitalized children. Pediatrics, 131(4), e1150-1157. doi: 10.1542/peds.2012-2443
Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666
Delinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 4:580.
Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2.
Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003; 112:793.
Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011; 364:2483.
Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med 2014; 42:2409.
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- Date last published: 21 August 2015
- Document type: Clinical Guideline
- Services responsible: Children’s Emergency Department
- Author(s): Mike Shepherd, Bernard McCarthy
- Editor: Greg Williams
- Review frequency: 2 years
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