Sepsis (peds)

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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 [1]

Pediatric fever

Diagnosis

Work-Up

  • CBC, CMP, arterial lactate, CRP
  • 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
    • CPAP can buy time for fluid rescuss prior intubation

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

  1. ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.

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

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