Sepsis (peds)

Background

• Tachycardia is typically most predominant, hypotension is a late and ominous sign
• Neonatal Sepsis
  • Early onset
    • First few days of life
    • Fulminant, assoc w/ 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, sz, apnea, tachypnea, grunting, vomiting, poor PO, gastric distention, diarrhea

Differential Diagnosis

Sick Neonate

THE MISFITS

• Trauma
• Heart
  • Congenital heart disease
  • Hypovolemia
• Endocrine
  • hypoglycemia
  • Hypothyroidism
  • Congenital adrenal hyperplasia
• Metabolic
  • Sodium
  • Calcium
  • Glucose
• Inborn errors of metabolism
• Seizure
• Formula / feeding problems
  • Hyponatremia
  • Hypocalcemia
  • FPIES / Food protein-induced enterocolitis syndrome
• Intestinal Disasters
  • Duodenal atresia
  • Midgut volvulus
  • Necrotizing enterocolitis
  • Intussusception
• Toxin
• Sepsis

Pediatric fever

• Upper respiratory infection (URI)
• UTI
• Sepsis
• Meningitis
• Febrile seizure
• Juvenile rheumatoid arthritis
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV
• Specific virus
  • COVID-19 (peds)
    • MIS-C

Diagnosis

• SIRS criteria in peds needs > or equal to 2 of 4 requirements, with abnormal temp or WBC required
  • Temperature >100.4 or <96.8
  • Age specific tachycardia or bradycardia <10th % for age <1 year
  • RR >2 SD above the norm
  • WBC elevated or depressed, based on age, or >10% bands

• SEVERE SEPSIS includes
  • 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 includes
  • hypotension <5th % for age, or SBP <2 SD below normal for age
• OR
  • needs 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 temp gap >3 degrees C
• DESPITE IVF resuscitation >40mL/kg in 1 hour

Work-Up

1. CBC, CMP, arterial lactate
2. UA/Ucx
3. CXR
4. CSF
5. Blood Cx

Treatment

• Neonatal
  • Ampicillin 50mg/kg + gentamicin 2.5mg/kg + acyclovir
    • If gram-negative strongly suspected replace gent w/ cefotaxime or ceftaz
      • Have better CNS penetration

• GOLDEN HOUR goals of resuscitation:
  • Cap refill <2 sec
  • Normal BP
  • Normal pulses, similar central and peripheral
  • Warm extremities
  • UOP >1 mL/kg/hr
  • Normal mental status

• If vasopressors needed for septic shock, follow recommendations:
  • Normotensive shock with impaired perfusion: dopamine
  • Warm shock (vasodilated with poor perfusion or low BP): norepinephrine
  • Cold shock (vasoconstricted with poor perfusion or low BP): epinephrine

• Consider steroids if fluid-refractory, catecholamine-resistant shock or suspected or known adrenal insufficiency
  • Consider AI in septic shock with purpura, chronic steroid use, hx of pituitary or adrenal abnormalities

• Transfuse if Scvo2 <70 and Hgb <10
• Transfuse platelets if <10 without bleeding, or <20 with high risk of bleed

Disposition

• Admit all neonates

See Also

Pediatric Fever

Source

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