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

Clinical Features

Warm Shock 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

• 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
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV
• Specific virus
  • COVID-19 (peds)

Diagnosis

Work-Up

• CBC, CMP, arterial lactate, CRP
• Blood glucose
• 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
• Sepsis (Main)

References

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