View source for Sepsis (peds)

{{PediatricPage|Sepsis}}
==Background==
*Defined as a dysregulated host response to infection that leads to life-threatening organ dysfunction<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
*Tachycardia is typically most predominant, hypotension is a late and ominous sign

==Clinical Features==
[[Pediatric shock|Shock]]: Warm vs Cold Shock

{| class="wikitable"
|-
!  !! Warm Shock !! Cold Shock
|-
| Peripheries || Warm, Flushed || Mottled, Cold, Clammy
|-
| Cap Refill || <2 sec || >2 sec
|-
| Pulse || Bounding || Weak, Thready
|-
| BP || Compensated || Hypotension
|-
| HR || Tachy || Tachy or Brady
|-
| Pulse Pressure || Widen || Narrow
|}

===Neonatal Sepsis===
*Early onset
**First few days of life
**Fulminant, associated with maternal or perinatal risk factors
**[[Septic shock]] and [[neutropenia]] are more common
*Late onset
**Occurs after 1 week of age
**Gradual
**[[Meningitis (Peds)|Meningitis]] more likely
*Consider if feeding disturbance, rash, lethargy, irritability, [[seizure]], apnea, tachypnea, grunting, vomiting, poor PO, gastric distention, [[diarrhea]]

==Differential Diagnosis==
{{Sick neonate DDX}}

{{Pediatric fever DDX}}

==Evaluation==
===Work-Up===
*CBC, CMP
*Coags, [[D-dimer]], fibrinogen
*[[Lactate]], CRP
*Blood glucose
*[[Urinalysis]]/[[urine culture]]
*[[CXR]]
*[[Blood cultures]]
*Consider [[LP]] for [[CSF]]

===Diagnosis===
*Initial screening and decision to send studies is based on provider judgement
*Use the [https://www.mdcalc.com/calc/10509/phoenix-sepsis-score Phoenix Sepsis Score] to calculate sepsis criteria, including septic shock.<ref>Schlapbach LJ, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):665-674. doi: 10.1001/jama.2024.0179.</ref><ref>Sanchez-Pinto LN, et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):675-686. doi: 10.1001/jama.2024.0196.</ref>
**Not indicated for adults, preterm (<37 weeks), or peri-birth hospitalizations

==Management==
===Initial Resuscitation Focus===
#Treat hypoxemia with supplemental [[oxygen]] (goal SpO2 92-98%)<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
#Obtain intravenous/[[intraosseous access]]
#*Rapidly transition to [[IO access]], if difficulties with starting IV
#Collect diagnostic tests (including [[blood culture]], [[lactate]], ionized calcium; see workup above)
#*Treat [[hypoglycemia]], if present
#Early empiric broad-spectrum [[antibiotics]] (see below)
#Administer bolus [[intravenous fluid therapy]] administration (see below), if shock is present
#Start vasoactive agents, if shock persists
#Airway
#*Consider [[CPAP]] (may buy time for fluid resuscitation prior intubation)
#*Consider [[intubation]], especially in fluid refractory [[pediatric shock|shock]]
#**Consider use of [[ketamine]] for sedation (less hypotension)
#**Be prepared for cardiovascular collapse
#Consider corticosteroids<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
#Continue to reassess (see below)

===Empiric Broad-Spectrum Antibiotics===
''If in shock, administer as soon as possible. If not, it is reasonable to perform expedited diagnostics before administration.<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>''

====Neonatal====
*Ill-appearing and/or concern for [[meningitis]]
**[[Ampicillin]] 50mg/kg Q8h + ([[Ceftazidime]] or [[cefotaxime]]) + [[Acyclovir]] 20 mg/kg/DOSE IV Q8<ref>Harbor-UCLA ID Guidelines 2026</ref>
*Well appearing
**[[Ampicillin]] 50mg/kg Q8h + [[gentamicin]] 2.5mg/kg q24, AND<ref>Harbor-UCLA ID Guidelines 2026</ref>
**Consider [[Acyclovir]] 20 mg/kg/DOSE IV Q8, if any one of the following:<ref>Harbor-UCLA ID Guidelines 2026</ref>
***Perinatal [[HSV]] contact
***[[Seizures]]
***Abnormal [[neuro exam]]
***[[Vesicles]]
***[[Thrombocytopenia]]
***Elevated transaminases
***[[CSF]] pleocytosis with (-) gram stain

====Peds====
''Treatment will differ by local protocols''
*Extended-spectrum penicillin (e.g. [[piperacillin-tazobactam]]) ± [[aminoglycoside]] ± [[vancomycin]] 
'''OR'''
*3rd or 4th generation [[cephalosporin]] ± [[aminoglycoside]] ± [[vancomycin]] 
'''OR'''
*[[Carbapenem]] ± [[aminoglycoside]] ± [[vancomycin]]

{{Infant fever well antibiotics}}

===Fluid Resuscitation===
*For shock, 20 mL/kg boluses of isotonic crystalloid fluid titrated to clinical markers of cardiac output<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
**Frequently ≥40 mL/kg in the first hour of resuscitation
*In low-resource settings (e.g., low income countries), fluid bolus therapy should be avoided unless the child exhibits hypotension<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>

===[[Vasopressors]]===
*Indicated for children that have:
**Myocardial dysfunction
**Shock in the setting of fluid overload
**Continue to have abnormal perfusion after 40-60 mL/kg of fluid resuscitation
*1st line: [[epinephrine]] or [[norepinephrine]] (i.e., ''not'' dopamine)<ref>Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.</ref><ref>Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus [[Epinephrine]]as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302. </ref><ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
*2nd and 3rd line: consider [[epinephrine]], [[norepinephrine]], [[dobutamine]], [[milrinone]], [[vasopressin]], angiotensin II<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>

===Corticosteroids===
*Intravenous [[hydrocortisone]] recommended only for children with fluid-refractory, catecholamine-resistant shock.<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
**There are no data on the addition of fludrocortisone to enhance the mineralocorticoid effect in pediatric septic shock.<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>

===Reevaluation===
*Patients should be continuously reassessed for signs of:
**Ongoing or worsening shock
**Iatrogenic fluid overload (e.g., pulmonary rales, hepatomegaly, peripheral edema, and echocardiographic findings that may suggest fluid overload)
*Golden Hour Goals
**Cap refill <2 sec
**Normal BP
**Normal pulses, similar central and peripheral
**Warm extremities
**UOP >1 mL/kg/hr
**Normal mental status

==Disposition==
*Admit

==See Also==
*[[Pediatric Fever]]
*[[Sepsis (Main)]]

==External Links==
*https://www.mdcalc.com/calc/10509/phoenix-sepsis-score

==References==
<references/>

[[Category:Pediatrics]]
[[Category:Critical Care]]
[[Category:ID]]