Sepsis (peds)

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  • 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


Pediatric fever



  • 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


  • 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


  • Need for vasoactive drugs to maintain BP


  • 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


Initial assessment

  • Circulation
    • 1 min to attain IV access
    • After 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
    • Typical paralytic agents
  • Breathing
    • CPAP can buy time for fluid resus 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


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




Treatment will differ by local protocols




  • 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


  • Admit

See Also


  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 Epinephrineas 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.