Sepsis (peds): Difference between revisions

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


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


{| class="wikitable"
{| class="wikitable"
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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==
Line 39: Line 42:
==Evaluation==
==Evaluation==
===Work-Up===
===Work-Up===
*CBC, CMP, arterial lactate, CRP
*CBC, CMP
*Coags, [[D-dimer]], fibrinogen
*[[Lactate]], CRP
*Blood glucose
*Blood glucose
*UA/urine culture
*[[Urinalysis]]/[[urine culture]]
*[[CXR]]
*[[CXR]]
*CSF
*[[Blood cultures]]
*Blood cultures
*Consider [[LP]] for [[CSF]]


===SIRS Criteria in Peds===
===Diagnosis===
Requires > or equal to 2 of 4 requirements, with abnormal temperature or WBC required
*Initial screening and decision to send studies is based on provider judgement
*Temperature >100.4 or <96.8
*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>
*Age specific tachycardia or bradycardia <10th % for age <1 year
**Not indicated for adults, preterm (<37 weeks), or peri-birth hospitalizations
*RR >2 SD above the norm
*WBC elevated or depressed, based on age, or >10% bands
 
===Severe Sepsis===
*Cardiovascular organ dysfunction
*Respiratory distress
OR
*CNS dysfunction - GCS <11 or >3 loss from baseline
*Platelets <80 or >50% decrease from baseline
*Creatinine >2x upper limit of normal/baseline
*Total bilirubin >4 or ALT >2x normal
 
===Septic Shock===
*Hypotension <5th % for age, or SBP <2 SD below normal for age
OR
*Need for vasoactive drugs to maintain BP
OR
*Metabolic acidosis base deficit >5
*Arterial lactate >2x normal
*UOP <0.5 mL/kg/hr
*Capillary refill >5 sec
*Core to peripheral temperature gap >3 degrees C
*DESPITE IVF resuscitation >40mL/kg in 1 hour


==Management==
==Management==
===Initial assessment===
===Initial Resuscitation Focus===
*Circulation
#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>
**1 min to attain IV access
#Obtain intravenous/[[intraosseous access]]
**Afer 1 min attain [[IO access]]
#*Rapidly transition to [[IO access]], if difficulties with starting IV
**60ml/kg IVF over the first hour
#Collect diagnostic tests (including [[blood culture]], [[lactate]], ionized calcium; see workup above)
**Consider vasopressors if not fluid responsive
#*Treat [[hypoglycemia]], if present
**Consider steroids if not fluid responsive
#Early empiric broad-spectrum [[antibiotics]] (see below)
*Airway
#Administer bolus [[intravenous fluid therapy]] administration (see below), if shock is present
**Consider early intubation, especially in fluid refractory shock
#Start vasoactive agents, if shock persists
**[[Ketamine]] for sedation is drug of choice
#Airway
***Hypotension can still occur in septic patients
#*Consider [[CPAP]] (may buy time for fluid resuscitation prior intubation)
**Typical paralytic agents
#*Consider [[intubation]], especially in fluid refractory [[pediatric shock|shock]]
*Breathing
#**Consider use of [[ketamine]] for sedation (less hypotension)
**CPAP can buy time for fluid rescuss prior intubation
#**Be prepared for cardiovascular collapse
*Glucose
#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>
**Ensure euglycemia
#Continue to reassess (see below)


===Golden Hour Goals of Resuscitation===
===Empiric Broad-Spectrum Antibiotics===
*Cap refill <2 sec
''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>''
*Normal BP
*Normal pulses, similar central and peripheral
*Warm extremities
*UOP >1 mL/kg/hr
*Normal mental status


===Lactate===
*Compared to adults, peds more often has normal lactate levels
*Controversial but surviving sepsis campaign no longer recommends trending lactate in pediatric patients<ref>Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Med 2013; 39: 165-228.</ref>
===Antibiotics===
====Neonatal====
====Neonatal====
*Ampicillin 50mg/kg + [[gentamicin]] 2.5mg/kg + acyclovir
*[[Ampicillin]] 50mg/kg q8h + [[gentamicin]] 2.5mg/kg q24h + [[acyclovir]]
**If gram-negative strongly suspected replace [[gentamicin]] with cefotaxime or ceftaz
**If gram-negative strongly suspected replace [[gentamicin]] with [[cefotaxime]] or [[ceftazadine]]
***Have better CNS penetration
***Have better CNS penetration
====Peds====
====Peds====
''Treatment will differ by local protocols''
''Treatment will differ by local protocols''
*Extended-spectrum penicillin ± aminoglycoside ± vancomycin  
*Extended-spectrum penicillin (e.g. [[piperacillin-tazobactam]]) ± [[aminoglycoside]] ± [[vancomycin]]
OR
'''OR'''
*3rd or 4th generation cephalosporin ± aminoglycoside ± vancomycin  
*3rd or 4th generation [[cephalosporin]] ± [[aminoglycoside]] ± [[vancomycin]]
OR
'''OR'''
*Carbapenem ± aminoglycosidea ± vancomycin
*[[Carbapenem]] ± [[aminoglycoside]] ± [[vancomycin]]
 
{{Infant fever well antibiotics}}


===Vasopressors===
===Fluid Resuscitation===
*If vasopressors needed for septic shock, follow recommendations:
*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>
**Normotensive shock with impaired perfusion: dopamine
**Frequently ≥40 mL/kg in the first hour of resuscitation
**Warm shock (vasodilated with poor perfusion or low BP): norepinephrine
*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>
**Cold shock (vasoconstricted with poor perfusion or low BP): epinephrine
 
===[[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==
==Disposition==
Line 129: Line 127:
*[[Pediatric Fever]]
*[[Pediatric Fever]]
*[[Sepsis (Main)]]
*[[Sepsis (Main)]]
==External Links==
*https://www.mdcalc.com/calc/10509/phoenix-sepsis-score


==References==
==References==
<references/>
<references/>
Tintinalli
"Pediatric Sepsis" published in EM Resident 2013 40(4) , adapted from Goldstein, et al. Pediatr Crit Care Med 2005; 6:2-8.


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

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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