Management of Sepsis

in Pediatrics
Cecilia Maramba, MD MScID

Epidemiology

Data on sepsis ion the Philippines are lacking

Infections (pneumonia, meningitis, sepsis) one
of the top causes of admissions to ICU
Improvement in mortality for children has been
particularly impressive, decreasing from 97% to
9% in developed countries.
Host-related risk factors for sepsis include:
extremes of age, a compromised immune
system, malnourishment, asplenia, and chronic
antibiotic or steroid use, any insult (shock,
trauma, burn) that makes the GIT permeable to
gram (-) bacteria

Epidemiology

Definitions
International pediatric sepsis consensus
conference: Definitions for sepsis and
organ dysfunction in pediatrics*
Brahm Goldstein, MD; Brett Giroir, MD; Adrienne
Randolph, MD; and the Members of the
International Consensus Conference on Pediatric
Sepsis

Pediatr Crit Care Med 2005 Vol. 6, No. 1

Pediatric age group for severe

sepsis
Newborn

0 days to 1 wk

Neonate

1 wk to 1 mo

Infant

1 mo to 1 yr

Toddler and
preschool
School age child

2-5 yrs

6-12 yrs

Adol and young adult 13 to <18 yrs

Systemic Inflammatory Response Syndrome

The presence of at least 2 of the ff 4 criteria, 1 of

which must be abnormal T or leukocyte count:
1. Core temperature of >38.5C or <36C.
2. Tachycardia, mean HR >2 SD above N for age
in the absence of external stimulus, chronic drugs,
or painful stimuli; or otherwise unexplained
persistent elevation over a 0.5- to 4-hr time period
OR for children <1 yr old: bradycardia, mean HR
<10th percentile for age in the absence of
external vagal stimulus, B-blocker drugs, or
CHD; or otherwise unexplained persistent
depression over a 0.5-hr time period.

Systemic Inflammatory Response Syndrome

The presence of at least 2 of the ff 4

criteria, 1 of which must be abnormal T or
leukocyte count:
3. Mean RR >2 SD above normal for age or
mechanical ventilation for an acute process
not related to underlying neuromuscular
disease or the receipt of general
anesthesia.
4. WBC elevated or depressed for age (not
secondary to chemotherapy-induced
leukopenia) or 10% immature neutrophils.

Age-specific vital signs and laboratory variables

(lower values for HR, leukocyte count, and systolic BP are for the 5th and upper
values for HR, RR, or leukocyte count for the 95th percentile)

Infection
A suspected or proven (by positive culture, tissue
stain, or PCR test) infection caused by any
pathogen
OR
a clinical syndrome associated with a high
probability of infection.
Evidence of infection includes (+) findings on
clinical exam, imaging, or laboratory tests
(e.g.,white blood cells in a normally sterile body
fluid, perforated viscus, chest radiograph
consistent with pneumonia, petechial or purpuric
rash, or purpura fulminans)

Sepsis
SIRS

in the presence of or as a
result of suspected or proven
infection.

Severe sepsis
Sepsis

plus one of the following:

cardiovascular organ dysfunction
OR acute respiratory distress
syndrome OR two or more other
organ dysfunctions.

Organ dysfunction criteria

Cardiovascular dysfunction
Despite administration of isotonic intravenous fluid bolus 40 mL/kg in 1
hr
Decrease in BP (hypotension) 5th percentile for age or systolic BP
>2 SD below normal for age
OR
Need for vasoactive drug to maintain BP in normal range
(dopamine> 5 g/kg/min or dobutamine, epinephrine, or
norepinephrine at any dose)
OR
Two of the following
1. Unexplained metabolic acidosis: base deficit >5.0 mEq/L
2. Increased arterial lactate <2 times upper limit of normal
3. Oliguria: urine output <0.5 mL/kg/hr
4. Prolonged capillary refill: 5 secs
5. Core to peripheral temperature gap >3C

Organ dysfunction criteria

Respiratory
PaO2/FIO2 <300 in absence of cyanotic heart
disease or preexisting lung disease
OR
PaCO2 >65 torr or 20 mm Hg over baseline
PaCO2
OR
Proven need or >50% FIO2 to maintain
saturation >92%
OR
Need for nonelective invasive or noninvasive
mechanical ventilation

Organ dysfunction criteria

Neurologic
Glasgow Coma Score <11
OR
Acute change in mental status with a
decrease in Glasgow Coma Score >3
points from abnormal baseline

Organ system dysfunction

Hematologic
Platelet count <80,000/mm3 or a decline
of 50% in platelet count from highest value
recorded over the past 3 days (for chronic
hematology/oncology patients)

Organ dysfunction criteria

Renal
Serum creatinine >2 times upper limit of normal
for age or 2-fold increase in baseline creatinine
Hepatic
Total bilirubin 4 mg/dL (not applicable for
newborn)
OR
ALT 2 times upper limit of normal for age

Septic shock
Sepsis

and cardiovascular
organ dysfunction (as
defined in previously)

Investigations
History: important part of clinical decision
making
determine organ system
involved/source of infection- pathogen
directed treatment
Fever history: What was child's T prior to
presentation, and how was t measured?

Investigations
Fever Without a Focus
Last Updated:
October 1, 2004
Author: Ann G Egland, MD,

Investigations- History

Fever at presentation
If infant has been bundled excessively, and if a
repeat Temp 15-30 minutes after unbundling is
normal, the infant should be considered afebrile.
Always remember that N or low temperature does not
preclude serious, even life-threatening, infectious
disease.

Current level of activity or lethargy

Activity level prior to fever onset (ie, active,
lethargic)

Investigations- History

Current eating and drinking pattern

Eating and drinking pattern prior to fever onset
Appearance: Fever sometimes makes a child
appear rather ill.
Vomiting or diarrhea
Ill contacts
Medical history
Immunization history (especially recent
immunizations)

Investigations
Physical Examination:
pay particular attention to assessing
hydration status
identifying the source of infection- clues on
pathogen involved and will determine
empiric antibiotic therapy
Record vital signs.
Temperature: Rectal temperature is the
criterion standard.
Pulse rate
Respiratory rate
Blood pressure

Investigations: PE

Measure pulse oximetry levels

more sensitive predictor of pulmonary
infection than RR especially in infants
and young children.
mandatory for any child with abnormal
lung examination findings, respiratory
symptoms, or abnormal RR, although
keep in mind that RR increased when
febrile.
Record an accurate weight on every chart.
All treatments are based on the weight in kg

Investigations-PE

Concentrate on identifying any of the ff:

Toxic appearance, (signs of lethargy, poor
perfusion, hypoventilation or hyperventilation, or
cyanosis (ie, shock)
A focus of infection
Minor foci (eg, otitis media, pharyngitis, sinusitis,
skin or soft tissue infection)
Identifiable viral infection (eg, bronchiolitis, croup,
gingivostomatitis, viral gastroenteritis, varicella,
hand-foot-and-mouth disease)
Petechial or purpuric rashes, often thought to be
associated with invasive bacteremia
Purpura, associated more often with
meningococcemia than presence of petechiae
alone

Investigations- PE

3-36 mo, management decisions are

mostly based on the degree of toxicity and
the height of T.
In this age group, the prevalence of
bacteremia correlates with the height of
fever.
39-39.5C (102.2-103F) -an
approximate 2-4% risk of having occult
bacteremia.
>39.5C (103F) have an approximate
5% chance of having occult bacteremia.

Summary of the Yale Observation Scale

Observation Items

1 (Normal)

3 (Moderate
Impairment)

5 (Severe
Impairment)

Quality of cry

Strong with normal tone or

contentment without
crying

Whimpering or sobbing

Weak cry, moaning, or

high-pitched cry

Reaction to parent
stimulation

Brief crying that stops or

contentment without
crying

Intermittent crying

Continual crying or
limited response

Color

Pink

Acrocyanotic or pale
extremities

Pale or cyanotic or
mottled or ashen

State variation

If awake, stays awake;if

asleep, wakes up
quickly upon
stimulation

Eyes closed briefly while

awake or awake
with prolonged
stimulation

Falls asleep or will not

arouse

Hydration

Skin normal, eyes normal,

and mucous
membranes moist

Skin and eyes normal

and mouth slightly
dry

Skin doughy or tented,

dry mucous
membranes, and/or
sunken eyes

Briefly smiling or alert

briefly (<2 mo)

Unsmiling anxious face

or dull,
expressionless, or
not alert (<2 mo)

Response (eg, talk,

smile) to social
overtures

Smiling or alert (<2 mo)

Yale Observation Scale

-reliable

method for determining degree

of illness.
6 variables: quality of cry, reaction to
parent stimulation, state variation, color,
hydration, and response.
<10 or less has a 2.7% risk of serious
bacterial infection
>16 or greater has a 92% risk of serious
bacterial infection.

Laboratory Studies

Perform the following for children who

appear toxic:
Perform a CBC with manual differential.
Send blood cultures.
Consider obtaining a chest radiograph. Chest
x-ray should be performed for patients with a
WBC ct > 20,000.

Laboratory Studies
Perform UA by bladder catheterization and
urine culture based on the following criteria:
All males < 6 mo and all uncircumcised
males < 12 mo
All females <24 mo and older female
children if symptoms suggest a UTI
Obtain CSF and perform studies and culture
if any suspicion of meningitis exists.
Admit these patients for further treatment;
pending culture results, administer IV
antibiotics

Laboratory Studies

Imaging Studies:
Chest radiography is indicated when the patient has
tachypnea, retractions, focal auscultatory findings, or
oxygen saturation level (SO2) on room air of less than
95%.
Although viral etiologies are considered the cause of
most pediatric pneumonias, 51% of pediatric patients
with pneumonia have serologic evidence of bacterial
infection.

Treatment

Treatment with antipyretics is somewhat

controversial because fever is a defensive
response to infection. Base the decision to
treat a fever without an obvious source of
infection upon age, presentation, and
laboratory results.

TREATMENT
MANAGEMENT OF PEDIATRIC SEPTIC SHOCK
IN THE EMERGENCY DEPARTMENT
September 2003
M. Denise Dowd, MD, MPH, FAAP
Associate Professor of Pediatrics
University of Missouri-Kansas City
Division of Emergency Medicine
The Childrens Mercy Hospital
Kansas City, Missouri

Treatment
initial ABCs should be addressed PALS
guidelines
100% O2 should be delivered to all patients
and if necessary a definitive airway should be
secured through endotracheal intubation.
Increased work of breathing, hypoventilation
and altered mental status are indications for
intubation
Venous access must be established as
quickly as possible or an intraosseous access.

Septic Shock

Early fluid resuscitation

Therapeutic endpoints - urine output >1ml/kg/hr,
normal mental status, normal blood pressure
and pulse, and capillary refill < 2 seconds
PALS guidelines- IV bolus of 20ml/kg followed
by reassessment and re-bolus to a total of
60ml/kg in the first hour of resuscitation
additional 100 to 200ml/kg total not unusual in
the 1st few hours

Septic shock
During rapid fluid resuscitation constant
monitoring of the patient for rales,
hepatomegaly and increased work of
breathing is required.
Fluids should be isotonic but may include
dextrose if hypoglycemia is documented.

If shock lasts more than one hour despite

aggressive fluid resuscitation vasopressor
support becomes mandatory

Vasopressor Therapy
Dopamine- first line vasopressor for the treatment of
fluid resistant septic shock-5 to 10 g/kg IV.
insensitivity to dopamine in < 6 mo has been
documented, due to the lack of development of the
full component of sympathetic vesicles, upon which
dopamine acts to release norepinephrine
Shock not responsive to dopamine will respond to
norepinephrine (0.03-1.5 mcg/kg/min) or epinephrine
(0.1-0.5 mcg/kg/min).
Other inotropes to increase cardiac contractility
(dobutamine), other vasopressors (vasopressin,
angiotensin), vasodilators to reduce systemic and
pulmonary vascular resistance (sodium nitroprusside)

Treatment
Correct:
acid-base abnormalities
Electrolyte imbalances
hypoglycemia

ANTIBIOTIC THERAPY
Handbook of Pediatric Infectious
Disease, Bravo et al, 2005
Personal notes

Antibiotic therapy

Initially the selection of antibiotics is empiric and

should be broad spectrum. IV is mandatory
Choice of specific antibiotic is based on )
1) the suspected site of infection
2) the suspected organism
3) whether infection was acquired in the
community or a hospital setting
4) host factors eg: immune status
5) local pathogen/ antibiotic resistance patterns

Sepsis due to community acquired pneumonia

Suspected
Organisms
0-2 mos

Empiric
Therapy

Gram (-) bacili Ampicillin +

Aminoglycoside

Alternative
therapy
3rd Gen
Ceph +
Amino

H. influenzae Pen G
S.pneumoniae
S. aureus
Chloramphe
nicol

2nd or 3rd
Gen Ceph

>5 yrs

S.
pneumoniae

Pen G

2nd or 3rd
Gen Ceph

Hospital
acquired

Gram (-)
bacilli, S.
aureus

Ceftazidime
or Cefipime

Piperacillintazobactam

3 mos-5
yrs
Severe
Very
Severe

Comments

May switch
to oral if
improved

3rd Gen
Ceph

Choice is based
on susceptibility
pattern of
hospital

Sepsis due to Meningitis

0-2 mos

Suspected
Organisms

Empiric
Therapy

Alternative therapy

E. coli,
Salmonella,
Gram (-) bacili
Streptococci

Ampicillin +

Ampicillin + 3rd gen ceph

Aminoglycoside

>2 mos5 yrs

H. influenzae
Ampicillin or 3rd Gen Ceph
S.pneumoniae Chloramphen
N. meningitidis icol

>5 yrs

S.
Pen G
Pneumoniae
N. meningitidis

Chloramphenicol or 3rd
gen Ceph

Others
Suspected
Organisms

Empiric
Therapy

Alternative
therapy

UTI

E. coli,
Ampicillin + 3rd Gen
Klebsiella spp, Aminoglycoside Ceph
Proteus spp,
Gram (-) bacili

0-2 mos
Without
focus

E. coli,
Ampicillin +
Aminoglycoside
Salmonella,
Gram (-) bacili
Streptococci

>2mos
without
focus

H. influenzae Chlorampheni 3rd Gen

Ceph
S.pneumoniae col

3rd gen ceph

+
aminoglycos
ide

Comments
Switch to
oral once
improved

Others
Suspected
Organisms
Hospital
acquired
without
focus

Empiric
Therapy

Gram (-) bacilli, Ceftazidime

S. aureus
or Cefipime

Febrile
P. Aeruginosa
neutropenia Gram (-) bacilli
S. aureus

Alternative
therapy

Comments

Piperacillintazobactam

Choice is based
on susceptibility
pattern of
hospital

Ceftazidime + Piperacillinaminoglycosi tazobactam +

de
aminoglycosi
de

Antimicrobial therapy
Once culture results are obtained- may
shift to the most appropriate agent
may maintain same drug, shift to a higher
generation/broad spectrum agent if not
responding, or a narrower spectrum agent
if with good response

Adjunctive therapy
role of steroids in septic shock remains
controversial and undefined
The Cochrane Database review of
randomized trials comparing IVIG with
placebo or no intervention in patients of all
ages with sepsis found that polyclonal
IVIG significantly reduced morality.

Summary

Thorough History, PE and Lab studies can help

determine source/focus of infection to direct
antimicrobial therapy
Early recognition and treatment of shock is
mandatory
Correction of other abnormalities is required
Close monitoring is required to anticipate
complications and check response to treatment