Sepsis (peds): Difference between revisions
 
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{{Adult top}} [[Sepsis]].''
{{Peds top}} [[Sepsis]].''
==Background==
==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
*Tachycardia is typically most predominant, hypotension is a late and ominous sign
*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 1wk 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


==Clinical Features==
==Clinical Features==
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| Pulse Pressure || Widen || Narrow
| 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==
==Differential Diagnosis==
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#**Consider use of [[ketamine]] for sedation (less hypotension)
#**Consider use of [[ketamine]] for sedation (less hypotension)
#**Be prepared for cardiovascular collapse
#**Be prepared for cardiovascular collapse
#Consider corticosteroids and other metabolic resuscitation options<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>
#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)
#Continue to reassess (see below)


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'''OR'''
'''OR'''
*[[Carbapenem]] ± [[aminoglycoside]] ± [[vancomycin]]
*[[Carbapenem]] ± [[aminoglycoside]] ± [[vancomycin]]
{{Infant fever well antibiotics}}


===Fluid Resuscitation===
===Fluid Resuscitation===
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**Myocardial dysfunction
**Myocardial dysfunction
**Shock in the setting of fluid overload
**Shock in the setting of fluid overload
**Continue to have abnormal perfusion after 40 to 60 mL/kg of fluid resuscitation
**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>
*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
*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===
===Reevaluation===

Latest revision as of 22:42, 5 July 2025

This page is for pediatric patients. For adult patients, see: Sepsis.

Background

  • Defined as a dysregulated host response to infection that leads to life-threatening organ dysfunction[1]
  • Tachycardia is typically most predominant, hypotension is a late and ominous sign

Clinical Features

Shock: Warm vs Cold Shock

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 more likely
  • Consider if feeding disturbance, rash, lethargy, irritability, seizure, apnea, tachypnea, grunting, vomiting, poor PO, gastric distention, diarrhea

Differential Diagnosis

Sick Neonate

THE MISFITS [2]

Pediatric fever

Evaluation

Work-Up

Diagnosis

  • Initial screening and decision to send studies is based on provider judgement
  • Use the Phoenix Sepsis Score to calculate sepsis criteria, including septic shock.[3][4]
    • Not indicated for adults, preterm (<37 weeks), or peri-birth hospitalizations

Management

Initial Resuscitation Focus

  1. Treat hypoxemia with supplemental oxygen (goal SpO2 92-98%)[5]
  2. Obtain intravenous/intraosseous access
    • Rapidly transition to IO access, if difficulties with starting IV
  3. Collect diagnostic tests (including blood culture, lactate, ionized calcium; see workup above)
  4. Early empiric broad-spectrum antibiotics (see below)
  5. Administer bolus intravenous fluid therapy administration (see below), if shock is present
  6. Start vasoactive agents, if shock persists
  7. Airway
    • Consider CPAP (may buy time for fluid resuscitation prior intubation)
    • Consider intubation, especially in fluid refractory shock
      • Consider use of ketamine for sedation (less hypotension)
      • Be prepared for cardiovascular collapse
  8. Consider corticosteroids[6]
  9. 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.[7]

Neonatal

Peds

Treatment will differ by local protocols

OR

OR

Neonatal Antibiotics by Source[8]

Suspected Infection Source 8-21 Days Old 22-28 Days Old 29-60 Days Old
UTI
  • Ampicillin IV or IM (150 mg/kg per day divided q8) AND either:
No source identified
  • Ampicillin IV or IM (150 mg/kg per day divided q8) AND either:
Bacterial meningitis
  • Ampicillin IV or IM (300 mg/kg per day divided q6) AND
  • Ceftazidime IV or IM (150 mg/kg per day divided q8)
  • Ampicillin IV or IM (300 mg/kg per day divided q6) AND
  • Ceftazidime IV or IM (150 mg/kg per day divided q8)

Fluid Resuscitation

  • For shock, 20 mL/kg boluses of isotonic crystalloid fluid titrated to clinical markers of cardiac output[9]
    • 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[10]

Vasopressors

Corticosteroids

  • Intravenous hydrocortisone recommended only for children with fluid-refractory, catecholamine-resistant shock.[15]
    • There are no data on the addition of fludrocortisone to enhance the mineralocorticoid effect in pediatric septic shock.[16]

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

External Links

References

  1. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  2. ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  6. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  7. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  8. ↑ Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228
  9. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  10. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  11. ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.
  12. ↑ Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrineas First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302.
  13. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  14. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  15. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  16. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
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