Sepsis (peds)
This page is for adult patients. For pediatric patients, see: Sepsis.
Background
- 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
- Early onset
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 |
Differential Diagnosis
Sick Neonate
THE MISFITS [1]
- Trauma
- Heart
- Congenital heart disease
- Hypovolemia
- Endocrine
- Metabolic
- Sodium
- Calcium
- Glucose
- Inborn errors of metabolism
- Seizure
- Formula / feeding problems
- Intestinal Disasters
- 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
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 Phoenix Sepsis Score to calculate sepsis criteria, including septic shock.[2][3]
- Not indicated for adults, preterm (<37 weeks), or peri-birth hospitalizations
Management
Initial Resuscitation Focus
- Treat hypoxemia with supplemental oxygen (goal SpO2 92-98%)[4]
- 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 fluid bolus(es) (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 shock
- Consider use of ketamine for sedation (less hypotension)
- Be prepared for cardiovascular collapse
- Consider corticosteroids and other metabolic resuscitation options[5]
- Constinue to reassess (see below)
Antibiotics
Neonatal
- Ampicillin 50mg/kg q8h + gentamicin 2.5mg/kg q24h + acyclovir
- If gram-negative strongly suspected replace gentamicin with cefotaxime or ceftazadine
- Have better CNS penetration
- If gram-negative strongly suspected replace gentamicin with cefotaxime or ceftazadine
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
Vasopressors
- Traditional teaching:
- 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
- Newer evidence argues to consider epinephrine and perhaps norepinephrine over dopamine as a 1st line vasopressor[6]
- Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[7]
Golden Hour Goals of Resuscitation
and reversal of hypoglycemia and ionized hypocalcemia are also important. Patients should be continuously reassessed for signs of ongoing shock, evolving fluid status (including pulmonary rales, hepatomegaly, peripheral edema, and echocardiographic findings that may suggest fluid overload), and response to each intervention while arranging for transfer to an appropriate intensive/critical care unit.
- 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
- ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
- ↑ 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.
- ↑ 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.
- ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
- ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
- ↑ 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.
- ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.