Sepsis (pediatrics): Clinical sciences

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Introduction0:00–0:41

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.

Acute management0:41–1:39

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.

Focused H&P1:39–4:11

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.

Pediatric SIRS Criteria4:11–4:36

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.

SIRS4:36–6:19

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.
As for labs, procalcitonin is typically elevated, and CBC often reveals leukocytosis or leukopenia. If you ordered a urinalysis, you might see positive nitrites or leukocyte esterase, suggesting urinary tract infection or UTI; and CSF analysis may demonstrate elevated white blood cells and a positive gram stain, suggesting bacterial meningitis; while a positive RVP indicates a respiratory viral infection.
Additionally, the blood, urine, or CSF cultures may eventually become positive. Keep in mind that cultures can take hours or days to grow a pathogen, so don’t delay management while waiting for results.
Finally, imaging may reveal a source of infection, like an intraabdominal abscess. Let’s take a look at Sepsis and Severe Sepsis.

Sepsis and Severe Sepsis6:19–8:27

If the data you’ve collected so far confirms or strongly suggests an infectious source, your next step is to assess the patient for organ dysfunction.
Patients might develop pulmonary signs like hypoxemia or pulmonary edema; hypotension; or neurologic findings like altered mental status, or AMS, or hypotonia.
Additionally, you may see renal manifestations such as oliguria or elevated creatinine; or liver involvement, like elevated transaminases.
If your patient has fewer than two findings indicating noncardiovascular organ dysfunction, diagnose sepsis. In other cases, your patient’s findings might show evidence of cardiopulmonary dysfunction, or dysfunction of 2 or more noncardiovascular organ systems.
This indicates severe sepsis. Here’s a clinical pearl!
Some conditions presenting during infancy and childhood manifest with signs and symptoms that mimic sepsis. For example, adrenal crisis or critical left ventricular outflow tract, or LVOT, obstruction present with lethargy and shock in the newborn period; and Kawasaki disease shock syndrome can present during childhood with hemodynamic instability and rapid decompensation.
Alright, sepsis and severe sepsis are managed similarly. So, your next step is to assess the patient’s hemodynamic status and serum lactate level after the initial IV crystalloid bolus is complete.
Signs of improved hemodynamic status include normal capillary refill and improved heart rate and blood pressure, which indicate adequate perfusion; a urine output of 0.5 milliliters per kilogram per hour or more; and decreasing serum lactate.
Patients with these findings do not require additional bolus fluids. Instead, admit them to the hospital and continue IV fluids to maintain hemodynamic stability and urine output.
Finally, tailor antibiotics to the culture results. On the other hand, some patients do not respond adequately to the initial fluid bolus.

Septic shock8:27–11:03

In this case, they may demonstrate persistently delayed capillary refill, tachycardia, or hypotension, indicating poor perfusion; a urine output below 0.5 milliliters per kilogram per hour; or persistently elevated or increasing serum lactate.
In this case, diagnose septic shock. Patients in septic shock require ongoing hemodynamic resuscitation with repeat boluses of 10 to 20 milliliters per kilogram of crystalloids, up to a total of 40 to 60 milliliters per kilogram.
Here’s another clinical pearl! During volume resuscitation, look out for signs of fluid overload, which include worsening respiratory status, tachypnea, and hepatomegaly.
If you find any, discontinue fluid boluses. Next, assess the patient’s response to each fluid bolus.
If you notice improved capillary refill, heart rate, and blood pressure; a urine output of 0.5 milliliters per kilogram per hour or more; and decreasing serum lactate, then your patient does not require additional fluid boluses.
Admit your patient to the hospital and continue IV fluids to maintain hemodynamic stability and urine output. Finally, tailor antibiotics to the culture results.
However, if your patient isn’t responding to fluids, and they demonstrate persistently delayed capillary refill, tachycardia, or hypotension; a urine output below 0.5 milliliters per kilogram per hour; or a persistently elevated or increasing serum lactate level, you should admit your patient to the pediatric intensive care unit.
Then, obtain central venous access, consider advanced hemodynamic monitoring, and begin an infusion of vasoactive medication like epinephrine or norepinephrine.
Finally, tailor antibiotics to the culture results. Here’s one last clinical pearl!
A recently-released scoring system called the PHOENIX Sepsis Score uses different criteria, based on the presence of respiratory, cardiovascular, and neurologic dysfunction, as well as coagulopathy.
A score above 2 is consistent with sepsis, and any evidence of cardiovascular dysfunction, such as elevated lactate, decreased mean arterial pressure for age, or vasoactive medication requirement; indicates septic shock.

Review11:03–11:48

Alright, as a quick recap… When a pediatric patient presents with a concern for sepsis, first perform an ABCDE assessment and begin acute management.
Obtain a focused history and physical exam, and order labs to look for organ dysfunction and infection. Next, initiate fluid resuscitation, begin broad-spectrum IV antibiotics, and control the source of infection.
Then, use the SIRS criteria, suspicion of infection, and evidence of organ dysfunction to differentiate sepsis from severe sepsis and septic shock.
Based on the patient’s response and culture results, continue hemodynamic resuscitation, begin vasoactive medications; and tailor antibiotics.