1887
2 - Qatar Critical Care Conference Proceedings
  • ISSN: 0253-8253
  •  E-ISSN:  Will be obtained soon 2227-0426

Abstract

Pediatric sepsis comprises a spectrum of disorders that result from infection by bacteria, viruses, fungi, or parasites. Sepsis ranges from bacteremia, with early signs of circulatory compromise to complete collapse with multiple organ dysfunction and death. Early recognition improves outcomes for infants and children. Over the past two decades, sepsis has been defined and redefined with modifications for the pediatric population. The most recent iteration, complementing the NICE guideline (NG51) “Sepsis: Recognition, diagnosis and early management”, was published in 2017.1

Pediatric severe sepsis usually is community-acquired (57%) with the respiratory tract as the primary site of infection. Mortality rates associated with sepsis and septic shock in patients admitted to the pediatric intensive care unit are 5.6% and 17.0%, respectively.2

The SIRS adult criteria have been modified to produce pediatric-specific definitions. Per the 2017 Sepsis-3 guidelines, sepsis in adults is no longer based on the SIRS criteria, rather it is defined as an infection with at least one organ dysfunction. Although it may change in the future, the definition for the pediatric population remains based on the SIRS criteria due to weak evidence.3,4 Although not included in the definition of sepsis, hyperglycemia, altered mental status, and high lactate, are highly suggestive of sepsis and should be considered when evaluating a patient.

Risk factors for pediatric sepsis include less than one month of age, serious injury, chronic medical problems, immunosuppression, indwelling devices, and urinary tract abnormalities. Sepsis should be in the differential diagnosis in children with persistently abnormal vital signs such as tachycardia that is often missed and attributed to other causes. Hypotension is a late finding in children; the diagnosis of shock cannot be based solely on this finding. Unlike adults, previously healthy children can compensate extremely well during hypoperfusion states and do so for relatively long periods resulting in sudden decompensation.2

Timely response to sepsis is vital to survival. Vascular access needs to be obtained, fluids administered (minimum of 60 ml/kg), broad spectrum antibiotic coverage and initiation of inotropic support in fluid refractory shock need to occur within the first hour. Hydrocortisone should be considered with catecholamine-resistant shock and if at risk for absolute adrenal insufficiency. Laboratory diagnostics such as white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) are often nonspecific. More novel tests such as lactate and procacitonin are more specific clinical adjuncts that will support diagnosis, monitor, and trend a child's progress.1,5

Key recommendations of the 2017 guidelines highlighted the importance of bundles: “recognition bundle” with trigger tools for rapid identification; “resuscitation and stabilization bundle” to increase adherence with best practice principles; and a “performance bundle” to identify gaps and barriers in the system.1

Not every child with fever will have a serious infection leading to sepsis. Delays in recognition and management will worsen the prognosis significantly; early recognition is crucial. Any child with a suspected infection, persistently abnormal vital signs, or a concerning exam after antipyretics and intravenous fluids should be investigated and treated for sepsis. Rapidly changing standard of care makes sepsis a critical diagnosis for clinicians.

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/content/journals/10.5339/qmj.2019.qccc.21
2019-11-05
2020-03-29
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References

  1. Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, et al.  American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med. 2017; 45:6:10611093.
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  2. Novosad SA, Sapiano MR, Grigg C, et al.  Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. 2016; 65:33:864869.
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  3. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al.  The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315:8:801810.
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  4. Kaukonen KM, Bailey M, Pilcher D, Cooper J, Bellomo R. Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. N Engl J Med. 2015; 372::16291638.
    [Google Scholar]
  5. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al.  Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017; 43:3:304377.
    [Google Scholar]
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