Sepsis (pediatrics): Clinical sciences

Sepsis is a dysregulated immune response to infection, involving not only the initial location of the infection but other areas of the body not even near it. Sepsis is frequently associated with organ dysfunction, shock, and death. The infection can be bacterial, viral, or fungal, and may originate from any tissue, initiating a complex interplay between infectious virulence factors and host defense mechanisms. The main goals of management are to identify and treat the infection while maintaining hemodynamic stability to prevent or minimize organ damage.

When evaluating a pediatric patient with a chief concern suggesting sepsis, your first step is to perform an ABCDE assessment. These patients are generally unstable, so you’ll need to stabilize the patient’s airway, breathing, and circulation; and consider intubating your patient. Next, IV access should be established as soon as possible. Even though most patients require a central line, management should not be delayed for it. Alternatively, you might need to establish intraosseous or IO access. Also, begin continuous vital sign monitoring, and provide supplemental oxygen, if needed. Finally, monitor your patient’s urine output.

Next, obtain a focused history and physical exam, and order labs, including CBC, CMP, procalcitonin, or PCT, and a serum lactate level, as well as blood cultures. Keep in mind that obtaining labs should not delay care.

Now, pediatric patients with sepsis often have vague symptoms, like irritability and poor feeding. On physical exam, they may have altered mental status or AMS and appear toxic or lethargic. They are often febrile or hypothermic. Patients commonly exhibit tachycardia, bradycardia, or hypotension; and occasionally, tachypnea and respiratory distress. With these findings, suspect sepsis, which is a clinical emergency.

Urgently obtain additional labs and imaging to look for evidence of infection. The labs you choose will depend on clues from history and exam findings and could include a urinalysis and urine culture; cerebrospinal fluid, or CSF, analysis and culture; or a respiratory virus panel, or RVP.

Consider ordering imaging if exam findings suggest a locus of infection. For example, order a chest X-ray if you suspect pneumonia; or a head CT if you suspect an intracranial abscess.

At the same time, if there are no signs of fluid overload, such as rales, a gallop rhythm, and hepatomegaly in younger children, initiate fluid resuscitation with a 10 to 20 milliliter per kilogram bolus of intravenous crystalloids, and start broad-spectrum intravenous antibiotics, to cover all suspected pathogens. Keep in mind that you should never delay antibiotic treatment longer than an hour, even if you haven’t obtained cultures yet.

Also, it’s crucial to control the source of infection urgently. So, be sure to drain any septic joint, empyema, or other localized abscess, and if you suspect that a central venous catheter is infected, remove it as soon as possible.

Here’s a clinical pearl! Before selecting antibiotics, you’ll need to consider several factors, including your patient’s age, immune status, and other underlying conditions, as well as local antibiotic resistance patterns.

For most children, sepsis is caused by bacteria, but immunocompromised patients and preterm infants are also at risk of invasive fungal infections. Additionally, neonates often develop sepsis from specific pathogens, like Group B streptococcus, Listeria monocytogenes, and herpes simplex virus. Finally, children requiring frequent hospitalization are at risk of sepsis from methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.

Once you suspect sepsis, assess the pediatric SIRS criteria, which stands for systemic inflammatory response syndrome. These include temperature instability, meaning fever or hypothermia; tachycardia or bradycardia; tachypnea; and either leukocytosis or leukopenia. If less than 2 of these criteria are met, consider an alternative diagnosis.

On the other hand, if your patient meets 2 or more criteria, diagnose SIRS. SIRS typically occurs in response to various insults, such as infection, trauma, ischemia, burns, and autoimmune conditions. When SIRS is caused by infection, it’s called sepsis. To diagnose sepsis, you’ll need to assess the information you’ve gathered and look for evidence of infection.

Occasionally, signs and symptoms from the history and physical exam suggest an active infection. For instance, the presence of meningismus implies meningitis, while costovertebral angle tenderness suggests pyelonephritis. Other examples include crackles or a unilateral decrease in breath sounds, which suggest pneumonia; or a well-demarcated area of redness, warmth, and tenderness of the skin; indicating skin or soft tissue infection.