Definitions and Epidemiology (1-3)
Approximately 100,000 pediatric patients are diagnosed with severe sepsis per year in the United States. That number drops to 75,000 for septic shock.
The definitions of pediatrics, like everything else, are age based. While the values pertinent to each age are noted, remembering 140 (HR) and 40 (RR) gets you pretty close. Aside from that, the definitions of septic shock is important, because it does not just include hypotension. Rather, other signs of hypo perfusion can be used to make the diagnosis, and reliance on BP to drop can result in delayed recognition or management. The big pearl here is you do not need hypotension to be in shock.
SIRS - Dependent on Age, >/= 2 or more of the following
- Temperature < 36 C (96.8 F) or > 38.5 C (101.3 F)
1 - 5 years; HR > 140 bpm
5 - 12 years; HR > 130 bpm
12 - 18 years; HR > 110 bpm
> 18 years; HR > 90 bpm
1 week - 1 month; RR > 40
1 month - 1 year; RR > 34
1 - 5 years; RR 22
5 - 12 years; RR 18
12 - 18 years; RR 14
- WBC < 4,000 cells/mL3; > 12,000 cells/mL3; or > 10% bands
SIRS and suspect or present source of infection
Sepsis with organ dysfunction, hypotension, and tissue hypoperfusion (altered mental status, acute renal failure, acute liver failure, decreased urine output, etc)
Sepsis plus cardiovascular dysfunction despite 40 mL/kg fluid administration in one hour (not just defined by blood pressure)
1 - 12 months, < 70
1 - 10 years, < 70 + (age in years x 2)
> 10 years, < 90
- Need for vasoactive medication to maintain blood pressure in normal range
Unexplained metabolic acidosis: base deficit > 5.0 mEq/L
Increased arterial lactate > 2 times upper limit of normal
Oliguria: urine output < 0.5 mL/kg/hr
Prolonged capillary refill > 5 sec
Core to peripheral temperature gap > 3C
Although the diagnosis of sepsis can eventually be straight forward, the initial assessment can be challenging. Histories can be limited in non-verbal children or if caregivers are not available. The most important clinical characteristics are tachycardia, fever, and mental status change, as well as respiratory rate and peripheral capillary refill. While all of these clinical findings are not unique to sepsis, they are nevertheless the most commonly used by most pediatric emergency physicians. Like an case of sepsis, your history, physical and workup can most often point toward a source.
Management (3, 5, 6)
The general approach of securing the airway, if needed, and administering early fluids and antibiotics applies to both adults and pediatric sepsis. Here are some specific differences though when if comes to kids.
- Give supplemental oxygen to all patients in septic shock
- Intubation and mechanical ventilation indicated if cannot reach oxygen saturation of 92% despite supplementation, or if pO2 < 65 mmHg
- No atropine pretreatment (dropped in new 2015 ACLS guidelines)
- Avoid etomidate (controversial)
- Ketamine or versed/fentanyl for RSI
- 20 mL/kg and reassess
- Repeat 2-3 times if no evidence of rales, respiratory distress or hepatomegaly develop
- Crystalloid or colloid can be used (NS most common)
- Administer through 3-way stop cock or "push-pull" method (using a 60 mL syringe, draw fluid out of the bag and then either turn the stop cock or inject directly into the line as many times as needed to give desired quantity of fluid)
Each bolus is to be given in 5-10 minutes to allow for reassessment
- Hypoglycemia may also occur and should be corrected (remember rule of 50's; dose of fluid and concentration of dextrose equal 50)
Children: 2-4 mL/kg D25W
- Dopamine 1st line
- "Warm Shock" (shock with vasodilation or flash cap refill)
- "Cold Shock" (shock with vasoconstriction)
Remember 15 for vancomycin, 50 for everything else, and look up acyclovir
- Neonates: ampicillin 50 mg/kg, cefotaxime 50 mg/kg, +/- acyclovir
- > 4 weeks: vancomycin 15 mg/kg and ceftriaxone 50 mg/kg
I know it is a quick and brief review, but hope it helps the next time you approach one of these patients. Until next time.
- Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric S. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan;6(1):2-8.
- Singhal S, Allen MW, McAnnally JR, Smith KS, Donnelly JP, Wang HE. National estimates of emergency department visits for pediatric severe sepsis in the United States. PeerJ. 2013;1:e79.
- Silverman AM. Septic shock; recognizing and managing this life-threatening condition in pediatric patients. Pediatr Emerg Med Pract. 2015 Apr;12(4):1-25;quiz6-7.
- Thompson GC, Macias CG.Recognition and management of sepsis in children: practice patterns in the Emergency department. J Emerg Med. 2015 Oct;49(4):391-9.
- Association AH. Pediatric Advanced Life Support. 2015 [cited 2015 November 18]; available from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-12-pediatric-advanced-life-support/
- Associate AH. Pediatric Advanced Life Support. United States of America: First American Heart Association Printing; 2010.
Submitted by Dr. Michael Craddick, PGY-2