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, 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

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 [1]

Pediatric fever

Evaluation

Work-Up

  • CBC, CMP, arterial lactate, CRP
  • Blood glucose
  • Urinalysis/urine culture
  • CXR
  • CSF
  • Blood cultures

SIRS Criteria in Peds

Requires > or equal to 2 of 4 requirements, with abnormal temperature 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 temperature 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
  • Glucose
    • Ensure euglycemia

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

Lactate

  • Compared to adults, pediatric more often has normal lactate levels
  • Controversial but surviving sepsis campaign no longer recommends trending lactate in pediatric patients[2]

Antibiotics

Neonatal

  • Ampicillin 50mg/kg + gentamicin 2.5mg/kg + acyclovir
    • If gram-negative strongly suspected replace gentamicin with 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
  • Consider epinephrine and perhaps norepinephrine over dopamine as a 1st line vasopressor[3]
    • Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[4]
    • RTC trial in 2015 from Brazil, without other larger RTCs or multi-center trials to corroborate information

Disposition

  • Admit

See Also

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.
  2. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Med 2013; 39: 165-228.
  3. Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302.
  4. Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.

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