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SEPSIS – assessment and management

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  • See also

    Antibiotics
    Febrile child
    Febrile neutropenia
    Emergency Drug and Fluid Calculator

    Key Points

    1. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
    2. It is important to diagnose sepsis quickly but also to not over-diagnose: most children with fever (with or without a focus) do not have sepsis
    3. Septic shock is sepsis with evidence of cardiovascular organ dysfunction; hypotension is a late sign
    4. Rapid vascular access, early initiation of empiric antibiotics and carefully titrated fluid resuscitation is vital
    5. Inotropes and vasopressors may be safely administered via peripheral cannula or intraosseous access (IO) in children during initial resuscitation

    Background

    • Sepsis is a major cause of morbidity and mortality in children
    • Care delivered in the first hour following sepsis identification is crucial

    High risk groups include

    • Neonates
    • Immunocompromised children
    • Children with central venous access devices
    • Aboriginal and Torres Strait Islanders

    Major pathogens in infants <2 months of age

    • Escherichia coli
    • Group B Streptococcus
    • Listeria monocytogenes is uncommon
    • HSV infection should be considered in differential diagnosis of sepsis

    Major pathogens in older children

    • Neisseria meningitidis
    • Streptococcus pneumoniae
    • Staphylococcus aureus (MSSA or MRSA)
    • Group A Streptococcus (GAS)

    Assessment

    Sepsis or septic shock should be considered in a patient with a suspected or proven bacterial infection AND any of the following

    • Altered conscious state (lethargy, irritability, floppiness, weak cry)
    • Unwell appearance ± non-blanching rash
    • Features of cardiovascular dysfunction:
      • Reduced peripheral perfusion, pale, cool or mottled skin, prolonged central capillary refill time (CRT >2), tachycardia, decreased urine output ( <1 ml/kg/hr) or narrow pulse pressure
      • Cold shock: narrow pulse pressure, prolonged capillary refill (more common in neonates/infants)
      • Warm shock: wide pulse pressure, bounding pulses, flushed skin with rapid capillary refill (more common in older children/adolescents and often under-recognised)
    • Tachypnoea ± hypoxia ± grunting (not adequately explained by a respiratory illness)
    • Unexplained pain
    • Fever or hypothermia (temperature may be normal in neonates or the immunocompromised)

    Toxin mediated sepsis: caused by superantigens from toxin-producing strains of S. aureus or GAS

    • Clinical features may include fever, vomiting, diarrhoea, myalgia, conjunctival injection, confusion, collapse and a widespread erythematous rash

    Red flag features

    • High level of parental concern
    • Representation within 48h
    • Clinical deterioration despite treatment
    • Recent surgery or burns

    Management

    Key principles in managing severe sepsis or septic shock

    1. Early recognition/seeking senior help
    2. Assess airway and breathing and administer oxygen if required
    3. Rapid vascular access
    4. Empiric antibiotic therapy
    5. Carefully titrated fluid resuscitation
    6. Early initiation of inotropes
    7. Early involvement of critical care services
    8. Source control
    9. Frequent reassessment

    Approach to Management

    Sepsis

    Consider consultation with local paediatric team:

    For any child with suspected sepsis

    Consider transfer to intensive care unit when:

    Child requiring escalation of care beyond local centre

    • Signs of shock persisting despite 40 mL/kg fluid
    • Inotrope requirement
    • Persistent venous serum lactate >3 mmol/L
    • Neutropenia ( <1000/mm3) unrelated to chemotherapy
    • Large pleural effusion (near white out of the hemithorax)
    • Coagulopathy (INR >1.6, APTT >60, Fib <1)

    Secondary resuscitation measures (second line inotrope/vasopressor, steroids, haemofiltration, ECMO) should be discussed with Retrieval Services or PICU

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Parent information sheet

    Health Direct 

    Last Updated March 2020

  • Reference List

    1. Baske K, Saini SS, Dutta S, Epinephrine versus dopamine in neonatal septic shock: a double-blind randomised controlled trial. European Journal of Pediatrics. 2018.
    2. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666
    3. Delinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 4:580.
    4. Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2.
    5. Kawasaki T, et al. Update on paediatric sepsis: a review. Journal of Intensive Care. 2017; 5:47: 1-12.
    6. Kumar A, Roberts D, Wood K, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical CareMedicine. 2006; 34(6):1589-96
    7. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011; 364:2483.
    8. Rizk MY, Lapointe A, Chu SJ, et al. Norepinephrine infusion improves haemodynamics in the preterm infants during septic shock. Acta Paediatrics. 2018; 107 (3): 408-414.
    9. Rowcliff K, de Waal K, Mohamed AL, et al. Noradrenaline in preterm infants with cardiovascular compromise. Eur J Pediatr. 2016; 175 (12): 1967-1973.
    10. Singer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).   2016; 315(8):801-810.
    11. Tourneux P, Rakza T, Abazine A et al. Noradrenaline for management of septic shock refractory to fluid loading and dopamine or dobutamine in full-term newborn infants. Acta Paediatrics. 2008; 97 (2) 177-180.
    12. Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med 2014; 42:2409.