Sepsis (peds)

This page is for pediatric patients. For adult patients, see: Sepsis

Background

• Defined as a dysregulated host response to infection that leads to life-threatening organ dysfunction
• Tachycardia is typically most predominant, hypotension is a late and ominous sign

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

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 1 week of age
  • Gradual
  • Meningitis more likely
• Consider if feeding disturbance, rash, lethargy, irritability, seizure, 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

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.
  • Not indicated for adults, preterm (<37 weeks), or peri-birth hospitalizations

Management

Initial Resuscitation Focus

1. Treat hypoxemia with supplemental oxygen (goal SpO2 92-98%)
2. Obtain intravenous/intraosseous access
   • Rapidly transition to IO access, if difficulties with starting IV
3. Collect diagnostic tests (including blood culture, lactate, ionized calcium; see workup above)
   • Treat hypoglycemia, if present
4. Early empiric broad-spectrum antibiotics (see below)
5. Administer bolus intravenous fluid therapy administration (see below), if shock is present
6. Start vasoactive agents, if shock persists
7. 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
8. Consider corticosteroids
9. Continue to reassess (see below)

Empiric Broad-Spectrum Antibiotics

If in shock, administer as soon as possible. If not, it is reasonable to perform expedited diagnostics before administration.

Neonatal

• Ill-appearing and/or concern for meningitis
  • Ampicillin 50mg/kg Q8h + (Ceftazidime or cefotaxime) + Acyclovir 20 mg/kg/DOSE IV Q8
• Well appearing
  • Ampicillin 50mg/kg Q8h + gentamicin 2.5mg/kg q24, AND
  • Consider Acyclovir 20 mg/kg/DOSE IV Q8, if any one of the following:
    • Perinatal HSV contact
    • Seizures
    • Abnormal neuro exam
    • Vesicles
    • Thrombocytopenia
    • Elevated transaminases
    • CSF pleocytosis with (-) gram stain

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

• Carbapenem ± aminoglycoside ± vancomycin

Neonatal Antibiotics by Source

Suspected Infection Source	8-21 Days Old	22-28 Days Old	29-60 Days Old
UTI	Ampicillin IV or IM (150 mg/kg per day divided q8) AND either: Ceftazidime IV or IM (150 mg/kg per day divided q8) or Gentamicin IV or IM (4 mg/kg per dose q24)	Ceftriaxone IV or IM (50 mg/kg per dose q24)	Ceftriaxone IV or IM (50 mg/kg per dose q24) Oral options: Cephalexin 50-100 mg/kg per day QID or Cefixime 8 mg/kg QD
No source identified	Ampicillin IV or IM (150 mg/kg per day divided q8) AND either: Ceftazidime IV or IM (150 mg/kg per day divided q8) or Gentamicin IV or IM (4 mg/kg per dose q24)	Ceftriaxone IV or IM (50 mg/kg per dose q24)	Ceftriaxone IV or IM (50 mg/kg per dose q24)
Bacterial meningitis	Ampicillin IV or IM (300 mg/kg per day divided q6) AND Ceftazidime IV or IM (150 mg/kg per day divided q8)	Ampicillin IV or IM (300 mg/kg per day divided q6) AND Ceftazidime IV or IM (150 mg/kg per day divided q8)	Cephalosporin Ceftriaxone IV (100 mg/kg QD) or Ceftazidime IV (150 mg/kg QD) AND Vancomycin IV (60 mg/kg QD)

Fluid Resuscitation

• For shock, 20 mL/kg boluses of isotonic crystalloid fluid titrated to clinical markers of cardiac output
  • Frequently ≥40 mL/kg in the first hour of resuscitation
• In low-resource settings (e.g., low income countries), fluid bolus therapy should be avoided unless the child exhibits hypotension

Vasopressors

• Indicated for children that have:
  • Myocardial dysfunction
  • Shock in the setting of fluid overload
  • Continue to have abnormal perfusion after 40-60 mL/kg of fluid resuscitation
• 1st line: epinephrine or norepinephrine (i.e., not dopamine)
• 2nd and 3rd line: consider epinephrine, norepinephrine, dobutamine, milrinone, vasopressin, angiotensin II

Corticosteroids

• Intravenous hydrocortisone recommended only for children with fluid-refractory, catecholamine-resistant shock.
  • There are no data on the addition of fludrocortisone to enhance the mineralocorticoid effect in pediatric septic shock.

Reevaluation

• Patients should be continuously reassessed for signs of:
  • Ongoing or worsening shock
  • Iatrogenic fluid overload (e.g., pulmonary rales, hepatomegaly, peripheral edema, and echocardiographic findings that may suggest fluid overload)
• Golden Hour Goals
  • 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

• Pediatric Fever
• Sepsis (Main)

External Links

• https://www.mdcalc.com/calc/10509/phoenix-sepsis-score