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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

  1. Early recognition
  2. Rapid vascular access: Intravenous (IV) or intraosseus (IO) access within 5 minutes
  3. Empiric antibiotic therapy: as soon as possible after access obtained
  4. Rapid, judicious, fluid resuscitation: 20ml/kg fluid boluses of isotonic crystalloids (e.g. Normal saline or Plasma-Lyte 148) or albumin 4%
  5. Early initiation of inotropes via peripheral access if shocked and not fluid responsive. Transfer to PICU as soon as possible
  6. Source control (if possible): For example, to operating theatre as soon as stabilised if suspected abdominal source

Management algorithm

Click on the image below or follow this link to view the flowchart for the management of septic shock/severe sepsis in CED.

Sepsis flowchart

Click on this link to a calculator for Paediatric resuscitation drug doses (

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 
Tachycardia (or bradycardia in those <1 year of age) in the absence of painful stimuli, pharmacologic explanation, other external stimulus 
Tachypnoea or the need for ventilator support 
Elevated or depressed white cell count for age
SIRS in the setting of suspected or proven infection.
Septic shock
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.
Severe sepsis
Sepsis with evidence of cardiovascular organ dysfunction or acute respiratory distress syndrome or evidence of dysfunction at least 2 other end organs.

Clinical recognition

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

Age RR  HR Systolic BP 
0-11m  55 160   75
1-4y  45  150   75 
5-11y  35  140  80 
>=12y  30   120  85 
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.


Vascular Access
This is a priority and should be tasked to an experienced clinician.
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

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.

The following tests would be appropriate in most instances:
Full blood count; peripheral blood culture; blood glucose; urea, electrolytes and creatinine; liver function tests; venous blood gas (to check lactate); coagulation profile. 

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: 
<7 days:  Amoxycillin  50mg/kg Q12H
   50mg/kg Q12H
7 - 28 days: Amoxycillin  50mg/kg Q8H
50mg/kg Q8H
1-3 months: Amoxycillin  50mg/kg Q6H
 50mg/kg Q6H
>3 months:  Cefotaxime   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.  
Antibiotic choice
Fluid Resuscitation

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 setting: 

  • 20ml/kg fluid boluses given rapidly as a push or via pressure bag
  • Targeting reversal of shock/impaired perfusion and restoration of heart rate to near normal values for age 
  • Repeated assessment of fluid status, perfusion, clinical condition and assessment for signs of fluid overload (new onset wheeze, worsening SOB etc.) 
  • Fluid volumes of up to and over 60ml/kg may be needed in the first 30-60 minutes  
  • Inotropes should be commenced if shock persists after 60ml/kg fluid. 

Choice of fluid:

  • 0.9% saline, should be used as the initial resuscitation fluid for septic patients in most situations.
  • Albumin 4% should also be considered if needing ongoing fluid resuscitation after 40-60ml/kg of volume. 
  • Fresh frozen plasma may be required if significant coagulopathy is present.
  • Red cell transfusion is rarely needed in the first hour of management of sepsis.
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.  
  • Can be given via peripheral access (IV or IO) whilst awaiting transfer to PICU. 
  • Should be considered in patients who are persistently shocked after 40-60ml/kg of fluid resuscitation. 
  • Preparation for an infusion should be being made as the 3rd fluid bolus is being administered.
  • Ensure the peripheral access is flushing well prior to commencement of inotropes. Monitor closely for signs of ischaemia/extravasation.  
  • Decisions regarding commencement of inotropic support should be made after discussion with (and ideally review by) the PICU team.  
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 
Dopamine  5 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:

  • persistent shock or cardiovascular instability following 60ml/kg fluid resuscitation
  • reduced level of consciousness e.g GCS<9 or unresponsive 
  • imminent respiratory failure or airway compromise.

If intubation is required, rapid sequence induction (RSI) will be necessary. 

  • If not made already a Code Blue "777"call should be put out. 
  • Assemble an appropriately skilled team, clearly assign roles and maximise resuscitation efforts prior to commencement of RSI. 
  • Prepare for potential arrest with resuscitation doses of adrenaline and fluid boluses drawn up and ready to administer. 
  • If appropriate commence inotropes prior to RSI. 
  • Ketamine (1-2mg/kg) will be an appropriate induction agent in most instances due to its relative cardiovascular stability. Fentanyl (5 micrograms/kg) may be an appropriate alternative in infants <6 months of age. 
  • Extreme care should be taken if using agents that can cause cardiovascular depression. 
  • Rocuronium or Suxamethonium may be used as paralytic agents, taking into account possible contraindications for either.     
Children on long-term steroid therapy or with known adrenal insufficiency should receive stress dose steroids - see Stress Steroid Management Guideline
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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Document Control

  • Date last published: 27 March 2019
  • 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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