Diagnosis and management of sepsis in the paediatric patient

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Sepsis is a major cause of hospital admission, morbidity, and mortality in children ^[1][3][4]. This practice point describes clinical patterns that should lead a clinician to apply guidelines initiated by the Global Sepsis Initiative of the World Federation of Pediatric Intensive and Critical Care Societies ^[5] and updated by the Surviving Sepsis Campaign’s Pediatric Subgroup in 2013 ^[6] and 2020 ^[4] and the American College of Critical Care Medicine (ACCM) ^[7] in 2017. 

Underlying these guidelines is recognition that a timely and systematic approach is essential to optimize stabilization. This approach includes early recognition of sepsis and septic shock, rapid vascular access, provision of serial fluid boluses, and the initiation of antibiotic and vasoactive medications as indicated within one hour of initial patient assessment ^[8]. Because the identification of sepsis states and the evaluation of response to treatment follow clinical parameters, knowledge of age-appropriate normal values is essential (Table 1) ^[9].

Case 1: Recognizing sepsis

A 7-week-old infant presents with a history of decreased feeding and lethargy. On physical exam, he is irritable and his vital signs are: heart rate 185, respiratory rate 55, rectal temperature 35.8°C, blood pressure 100/62 (when crying). He appears mildly dehydrated and has slightly mottled extremities.

What is this patient’s clinical status?

Sepsis is a systemic inflammatory response to the presence of suspected or proven infection. Tachycardia, tachypnea, and hyperthermia are classic features ^[7][10]. The absence of fever in an infant less than 60 days old does not eliminate the possibility of sepsis. This infant should undergo cultures of blood, urine, and cerebrospinal fluid (CSF) in addition to a complete blood count with differential (CBCD). Both bacterial and viral etiologies should be considered because their presentations can be similar in the young infant. If a lumbar puncture (LP) is deferred due to clinical signs of respiratory or hemodynamic instability or other contraindications (e.g., coagulopathy, cutaneous lesions at the proposed puncture site, or signs of impending cerebral herniation ^[11]), empiric antibiotics should be prescribed at appropriate meningitis doses. In this case, empiric antibiotic therapy would include ceftriaxone or cefotaxime, and vancomycin.

Case 2: Assessing the ABCs and identifying the source of infection

A 2-year-old child presents with a history of cough, fever of 39°C, and breathing difficulty. On examination, she appears unwell. Vital signs are: heart rate 160, respiratory rate 35, blood pressure of 100/60 and a capillary refill time (CRT) of 3 seconds, with cool extremities. Oxygen saturation by pulse oximetry in room air is 89%. There is decreased air entry on the right side and chest X-ray reveals a right lower lobe infiltrate and pleural effusion. She is fatigued but responds appropriately during the physical exam.

Is this sepsis or septic shock?

This patient’s fever, tachycardia, tachypnea, and her abnormal chest radiograph consistent with pneumonia and possible empyema, together fulfill the definition of sepsis. New definitions for adults recognize sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection”, with septic shock implying both hypotension requiring vasopressors to maintain mean arterial pressure, and an elevated serum lactate despite adequate volume resuscitation ^[12][13]. In newly-published paediatric guidelines by Weiss et al, septic shock is defined as  “severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication, or impaired perfusion)” and sepsis-associated organ dysfunction in children is described as “severe infection leading to cardiovascular and/or noncardiovascular organ dysfunction” ^[4]. Some clinicians have advocated for more objective criteria based on organ dysfunction scores ^[14]. In this case, the child fulfills clinical criteria for sepsis and shows signs that suggest she is at risk of organ dysfunction.

Many centres have developed sepsis “trigger tools” to aid in the rapid identification of patients with suspected sepsis and expedite access to medical evaluation and treatment. Most such tools incorporate vital signs abnormalities (in heart or respiratory rate, blood pressure, perfusion indicators such as CRT, pulse pressure, skin colour and temperature), as well as mental status, always with consideration of underlying medical conditions which entail higher risk for sepsis, such as age, malignancy, asplenia, immunodeficiency, or immunosuppression. Examples of such tools include the TREKK PedsPacs Sepsis Triage Poster ^[15] and a tool developed by the American Academy of Pediatrics Pediatric Septic Shock Collaborative ^[16].

How should this patient be managed?

She should receive oxygen by face mask, or if her work of breathing is markedly increased, non-invasive ventilation may be considered. Peripheral intravenous (IV) access should be obtained, with consideration of intra-osseous needle insertion if peripheral venous access is not achieved rapidly. Fluid resuscitation should begin with a bolus of 10-20 mL/kg of balanced/buffered crystalloid solution(such as Ringer’s lactate, Plasma-Lyte/Normosol or isotonic saline), given over 5 to 20 minutes. Vital signs and peripheral perfusion should be monitored closely to evaluate the response to treatment, including potential fluid overload. Hepatomegaly or crackles on auscultation may suggest fluid overload. The bolus may be repeated depending on patient response, with frequent re-assessment ^[17]. Clinical deterioration after bolus fluid administration, particularly in the presence of signs of volume overload, suggests the presence of cardiogenic shock ^[17]. Other useful parameters include urine output, blood gases to assess presence of metabolic acidosis, serum lactate, bedside glucose, serum electrolytes, urea, and creatinine.

What is the definitive treatment in this case?

Blood cultures should be obtained before administration of antibiotics, but awaiting results should not delay initiation of antimicrobial therapy, ideally within one hour of diagnosing severe sepsis ^[6]. Intramuscular or intraosseous injections can be used until IV access is obtained. The agents chosen should reflect the patient’s age and clinical presentation. In this case, a cephalosporin such as cefotaxime or ceftriaxone (in addition to vancomycin if methicillin-resistant Staphyloccus aureus (MRSA) is suspected, and depending on local epidemiology) would be appropriate in the presence of pneumonia and empyema ^[18][19]. Drainage of the pleural effusion may be considered for both diagnostic and therapeutic purposes.

Case 3: Septic shock—when volume expansion is not enough

A 15-year-old adolescent female is admitted for fever and weakness. She began her most recent menstrual period 3 days ago, and regularly uses tampons. On physical examination she is confused. Vital signs are: temperature 39.4°C, heart rate 150, respiratory rate 24, blood pressure of 80/24. She has diffuse erythroderma and her distal extremities are warm with bounding pulses and rapid CRT. She remains hypotensive despite 60 mL/kg of fluid boluses and initiation of appropriate antibiotics (cloxacillin and clindamycin).

What hemodynamic support should be given to this patient?

This patient shows signs of vasodilated  septic shock. Despite her warm extremities and bounding pulses, she is hypotensive and likely to have some degree of multi-organ dysfunction, as is observed frequently in staphylococcal toxic shock syndrome ^[19]. Toxin-mediated sepsis can be caused by strains of S. aureus or Streptococcus pyogenes, which produce a superantigen toxin that causes over-activation of cytokines and inflammatory cells and leads to a characteristic pattern of multi-organ involvement.

In the context of large volume fluid resuscitation in septic shock or sepsis-associated organ dysfunction, balanced/buffered crystalloids have been associated with lower mortality ^[20] and may be preferable to large volumes of isotonic saline ^[4].  There is no clear benefit to using colloids such as albumin, and there is potential harm in using starches and gelatins; thus, they are not recommended ^[4]. Since this patient remains in shock unresponsive to fluid resuscitation, vasopressor therapy should be started, ideally through a central venous line, though a peripheral IV line may be used initially. The choice of agent is driven by the patient’s clinical condition, as shown in Table 2. While dopamine has often been used as the initial vasoactive agent for hypotension in paediatric patients, it is no longer the first choice ^[21]. In this case, norepinephrine, with its pure alpha-adrenergic vasoconstrictor effect, would be most efficacious ^[15][22].

Where should this patient be treated?

This patient requires continuous monitoring and close assessment of organ function. Central venous access would allow for measurement of central venous pressure and saturation to guide fluid resuscitation and adjustment of vasoactive medication. Transfer to a tertiary care centre is recommended.

Case 4: The patient with underlying medical issues

An 8-year-old boy with nephrotic syndrome who is currently receiving daily corticosteroids presents with a one-day history of being generally unwell, diffuse abdominal pain, and multiple episodes of vomiting. On initial assessment he appears Cushingoid, and his vital signs are: heart rate 140, respiratory rate 30, temperature 37.5°C, blood pressure 88/32. CRT is less than 2 seconds and peripheral pulses are easily palpated. The patient is confused and somewhat uncooperative. His abdomen is distended and diffusely sensitive to palpation, with mild involuntary guarding. You suspect that this patient may have primary peritonitis, likely due to Streptococcus pneumoniae and a well-described infectious complication of nephrotic syndome ^[23]. Treatment with a third-generation cephalosporin such as ceftriaxone or cefotaxime should be initiated, as well as vancomycin.

What distinguishes this patient from others with sepsis?

Chronic corticosteroid administration in this patient has caused suppression of the hypothalamic-adrenal axis, which can lead to adrenal insufficiency when stressed. Clinical signs of adrenal insufficiency are difficult to distinguish from other causes of vasodilated shock. Serum biochemistry may show relative hyponatremia, hyperkalemia, and hypoglycaemia.

What is the role for corticosteroids in sepsis?

The diagnosis and role of adrenal insufficiency and its treatment in paediatric sepsis remain controversial ^[24]. Patients at risk for adrenal insufficiency in the setting of septic shock include individuals with purpura fulminans or Waterhouse-Friderichsen syndrome, those who have received steroid therapies for chronic illness (as in this case), and patients with pituitary or adrenal abnormalities. Children with these conditions may benefit particularly from stress doses of hydrocortisone (50 mg/m2; then 100 mg/m2 per day divided in 3 or 4 doses) early in the course of an illness and before septic shock develops ^[7]. For other patients, it is suggested that hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability. . However, no gold standard exists for the diagnosis of acute adrenal insufficiency in the context of critical illness, and abstention from hydrocortisone therapy would also be acceptable ^[4], pending results of on-going research on this topic.

Current paediatric sepsis guidelines emphasize three key practice points:

1. The early recognition of clinical presentations compatible with sepsis.
2. Sepsis management should involve obtaining cultures and initiating antimicrobial therapy as well as volume resuscitation and vasoactive therapy tailored to clinical response.
3. Patients who do not respond rapidly or who respond only transiently to volume expanders  should be considered for transfer to a tertiary care facility with capacity to monitor hemodynamic status and organ function invasively when needed.

 

Table 1. Vital signs according to age
Normal heart rate
Age	Awake rate (beats per minute)		Sleeping rate (beats per minute)
Neonate	100 to 205		90 to 160
Infant	100 to 180		90 to 160
Toddler	98 to 140		80 to 120
Pre-schooler	80 to 120		65 to 100
School-aged child	75 to 118		58 to 90
Adolescent	60 to 100		50 to 90
Normal respiratory rate
Age		Breaths per minute
Infant		30 to 53
Toddler		22 to 37
Preschooler		20 to 28
School-age child		18 to 25
Adolescent		12 to 20
Definition of hypotension by systolic blood pressure and age
Age		Systolic blood pressure
Term neonates (0 to 28 days)		< 60 mmHg
Infants (1 to 12 months)		< 70 mmHg
Children (1 to 10 years)		< 70 mmHg + (age in years x 2) mmHg
Children over 10 years of age		< 90 mmHg
Adapted from reference [9]

 

Table 2. Choice of vasoactive medication according to clinical context Evaluation after 60 mL/kg of IV bolus of crystalloid and/or colloid (albumin)
Tachycardia Poor peripheral      → perfusion Low blood pressure	Start epinephrine 0.05 mcg/kg/min Titrate upward by increments of 0.02 mcg/kg/min as required (Acceptable alternative for initial treatment: dopamine 10 mcg/kg/min, followed by epinephrine if efforts to reverse shock fail)
Goal: Treat myocardial dysfunction and low cardiac output
Tachycardia Vasodilatation        → (“flash” capillary refill, bounding pulses, flushing) Low blood pressure	Start norepinephrine 0.05 mcg/kg/min Titrate upward by increments of 0.02 mcg/kg/min,    as required
Goal: Increase systemic vascular resistance
Tachycardia Poor peripheral      → perfusion Normal blood pressure	Consider epinephrine 0.03 to 0.05 mcg/kg/min Consider adding vasodilator in specific cases (e.g., dobutamine or milrinone)
Adapted from references [9][15][22]

Acknowledgements

This practice point has been reviewed by the Adolescent Health, Community Paediatrics, and Infectious Diseases and Immunization Committees of the Canadian Paediatric Society.

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CANADIAN PAEDIATRIC SOCIETY ACUTE CARE COMMITTEE
Members: Carolyn Beck MD, Kevin Chan MD (Chair), Laurel Chavin-Kimoff MD (past Chair), Kimberly Dow MD (Board Representative), Catherine A. Farrell MD (past member), Karen Gripp MD, Kristina Krmpotic MD, Kyle McKenzie MD (past member), Evelyne D. Trottier MD
Liaisons: Laurel Chavin-Kimoff MD, CPS Paediatric Emergency Medicine Section; Sidd Thakore MD, CPS Hospital Paediatrics Section
Principal author: Catherine A. Farrell MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.