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

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

• 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 assessment

• Circulation
  • 1 min to attain IV access
  • If unable to get IV in 1 min, consider IO access
  • 60ml/kg IVF over the first hour
  • Consider vasopressors if not fluid responsive
  • Consider steroids if not fluid responsive
• Airway
  • Consider intubation, especially in fluid refractory shock
  • Consider use of ketamine for sedation (less hypotension)
  • Be prepared for cardiovascular collapse
  • Typical paralytic agents
• Breathing
  • CPAP can buy time for fluid resuscitation 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

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

Peds

Treatment will differ by local protocols

• Extended-spectrum penicillin (e.g. Ppiperacillin-tazobactam]]) ± aminoglycoside ± vancomycin

OR

• 3rd or 4th generation cephalosporin ± aminoglycoside ± vancomycin

OR

• Carbapenem ± aminoglycoside ± vancomycin

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
  • Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well

Disposition

• Admit

See Also

• Pediatric Fever
• Sepsis (Main)

External Links

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