Sepsis in Children

1. See Also
   1. Neonatal Sepsis
   2. Sepsis in Adults
   3. Systemic Inflammatory Response Syndrome (SIRS)
   4. Pediatric Assessment Triangle
   5. Fever Without Focus
   6. Pediatric Fever
2. Signs
   1. Fever or Hypothermia
   2. Tachycardia
      1. See Heart Rate for age-based normal range
   3. Tachypnea
      1. See Respiratory Rate for age-based normal range
   4. Abnormal appearance
      1. Irritability
      2. Increased crying
      3. Lethargy
   5. Increased or decreased sleep
   6. Decreased feeding
   7. Petechiae or Purpura
3. Types
   1. Warm Shock (20% of children, most adults)
      1. High or normal cardiac output (CO)
      2. Low systemic vascular resistance (SVR)
   2. Cold Shock (80% of children)
      1. Low cardiac output (CO)
      2. Systemic vascular resistance (SVR)
         1. Increased SVR (60% of children)
         2. Decreased SVR (20% of children)
4. Diagnosis
   1. Sepsis
      1. Systemic Inflammatory Response Syndrome (SIRS) and
      2. Suspected or proven infection
   2. Severe Sepsis
      1. Sepsis and
      2. Organ dysfunction (one of the following)
         1. Cardiovascular organ dysfunction (see criteria below) or
         2. Acute Respiratory Distress Syndrome (ARDS) or
         3. Two or more organ dysfunctions (see criteria below)
   3. Septic Shock
      1. Sepsis and
      2. Cardiovascular organ dysfunction (see criteria below)
   4. Organ Dysfunction criteria
      1. Cardiovascular dysfunction
         1. Dysfunction despite NS or LR fluid bolus >40 ml/kg in 1 hour
         2. Criteria (requires 1 for diagnosis)
            1. Systolic Blood Pressure <2 SD below normal for age or <5th percentile or
            2. Pressors required to maintain adequate Blood Pressure
               1. Dopamine >5 mcg/kg or
               2. Dobutamine, Epinephrine or Norepinephrine
            3. Two of the following
               1. Metabolic Acidosis (Base Deficit >5.0 mEq/L) without other explanation
               2. Arterial Lactic Acid >2 times the upper normal limit
               3. Oliguria (urine output <0.5 ml/kg/h)
               4. Prolonged Capillary Refill >5 seconds
               5. Difference between core temperature and peripheral temperature >3 C (5.4 F)
      2. Respiratory dysfunction
         1. PaO2 per FIO2 <300 mmHg (not due to cyanotic heart disease or preexisting lung disease) or
         2. PaCO2 >65 or 20 mmHg over baseline PaCO2 or
         3. FIO2 >0.5 required to maintain Oxygen Saturation >92% or
         4. Mechanical Ventilation required non-electively (invasive or noninvasive)
      3. Neurologic dysfunction
         1. Glasgow Coma Scale: 11 or less or
         2. Acute change in mental status with a fall in GCS 3 points or more from an abnormal baseline
      4. Hematologic dysfunction
         1. Platelet Count <80k mm3 or
         2. Platelet Count with 50% decline in Platelet Count from highest recorded value in the last 3 days (chronic hematology, oncology patients) or
         3. INR >2
      5. Renal dysfunction
         1. Serum Creatinine >2 times normal for age or 2 fold increase over baseline Serum Creatinine
      6. Hepatic dysfunction
         1. Total Serum Bilirubin >4 mg/dl (not newborn Bilirubin) or
         2. Serum ALT >2 times normal for age
5. Management
   1. Step 1: Immediate
      1. Provide high flow Supplemental Oxygen
      2. Obtain intravenous or Intraosseous Access
      3. Obtain initial lab studies including Blood Culture
   2. Step 2: Initial Resuscitation
      1. NS or LR 20 cc/kg bolus, repeated up to 60 ml/kg until response or Fluid Overload (rales or Hepatomegaly)
      2. Correct Hypoglycemia
      3. Correct Hypocalcemia
      4. Administer brioad-spectrum empiric antibiotics
   3. Step 3: Fluid resistant shock management
      1. Obtain central Intravenous Access
      2. Start inotrope (Catecholamine) and titrate to minimally adequate Blood Pressure
         1. Cold shock: Dopamine (or Epinephrine if resistant)
         2. Warm shock: Norepinephrine
      3. Consider intubation
   4. Step 4: Inotrope (Catecholamine) resistant shock management
      1. Consider Hydrocortisone IV for Adrenal Insufficiency
      2. Central monitoring directs next step
         1. Central Venous Pressure
         2. Mean arterial pressure
         3. SVO2 (>70% is goal)
   5. Step 5: Central monitoring directed management
      1. See shock type definitions above (warm and cold shock)
      2. Goal SvO2 >70% (Hemoglobin >10g/dl)
      3. Cold shock with normal Blood Pressure
         1. First: Titrate crystalloid and Epinephrine to goal SvO2 >70%
         2. Next: Add Vasodilator if SvO2 <70% (e.g. Milrinone)
      4. Cold shock with low Blood Pressure
         1. First: Titrate crystalloid and Epinephrine to goal SvO2 >70%
         2. Next: If persistent Hypotension, consider adding norepinephine
         3. Next: Add Vasodilator if SvO2 <70% (e.g. Milrinone, Dobutamine)
      5. Warm shock with low Blood Pressure
         1. First: Titrate crystalloid and Epinephrine to goal SvO2 >70%
         2. Next: If persistent Hypotension, consider adding vasopressin, Terlipressin, Angiotensin
         3. Next: Consider low dose Epinephrine
6. References
   1. Fuchs and Yamamoto (2011) APLS, Jones and Bartlett, p. 104-13
   2. Brierly (2009) Crit Care Med 37: 666-88
   3. Goldstein (2005) Pediatr Crit Care Med 6:2-8