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

Work-Up

• CBC, CMP, arterial lactate
• UA/Ucx
• CXR
• CSF
• Blood Cx

SIRS Criteria in Peds

Requires > 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

• 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 temp gap >3 degrees C
• DESPITE IVF resuscitation >40mL/kg in 1 hour

Management

Initial assessment

• Circulation
  • 1 min to attain IV access
  • Afer 1 min attain IO access
  • 60ml/kg IVF over the first hour
  • Consider vasopressors if not fluid responsive
  • Consider steroids if not fluid responsive
• Airway
  • Consider early intubation, especially in fluid refractory shock
  • Ketamine for sedation is drug of choice
    • Hypotension can still occur in septic patients
  • Typical paralytic agents
• Breathing

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

Antibiotics

Neonatal

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

Peds

Treatment will differ by local protocols

• Extended-spectrum penicillin �± aminoglycoside ±� vancomycin OR
• 3rd or 4th generation cephalosporin ± aminoglycoside ±� vancomycin OR
• Carbapenem �± aminoglycosidea �± vancomycin

Vasopressors

• 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

Disposition

• Admit

See Also

Pediatric Fever

References

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