Sepsis

[Also see Fever in young child]

 

Sepsis is a common paediatric emergency that needs early recognition and management to reduce morbidity & mortality. Incidence is influenced by immunization including vaccines against MenB, Hib, PCV.

 

Systemic Inflammatory Response Syndrome = physiological state with abnormal vital signs (HR, RR, Perfusion, BP) along with increase temperature or White Cell Count (commonly infective or rarely non-infective causes)

 

Sepsis = SIRS due to Bacteremia (presence of bacteria in blood stream, commonly N meningitidis, S aureus, S pneumonia etc)

 

Severe sepsis includes life-threatening features like Shock, ARDS, DIC or multi-organ (>2 organs) failure. Bacterial endotoxins cause systemic toxicity with disseminated intravascular coagulation, capillary leak, and distributive and cardiogenic shock.

 

 

Presentation

Young children (especially infants and toddlers) often display non-specific features of being unwell with a febrile illness. There is no perfect triage system or guideline to diagnose possible sepsis (apart from very unwell children with overt SIRS features).

 

High risk of sepsis in (adapted from UK Sepsis Trust):

 – Children with low immunity (post chemotherapy, systemic steroids, Nephrotic, Synd etc)

 – Those with chronic illness or complex disability who are difficult to assess

 – Children with indwelling catheter, central line, VP shunt or broken skin etc

 – Recent trauma, surgery or invasive procedure

 – Newborn babies (esp if PROM, maternal fever, GBS positive or other perinatal factors)

 – Young children under 3 months (even infants)

 

Children may be sleepy / irritable with poor feeding, reduced urine output or off-colour. Source of infection may give localised symptoms such as ear discharge, breathlessness, abdominal or joint pain etc.

 

Sepsis can be difficult to identify during early presentation with evolving features; and most febrile children do NOT have sepsis but continue to remain a clinical challenge, whether a focus of infection is found or not.

If in doubt seek a senior opinion early.

 

Presence of ‘Amber or Red’ features on the NICE Traffic Light System indicates high-risk of sepsis or seriously unwell child. Also see NORMAL ranges of vital signs in different age groups.

 

Assessment is similar to a Febrile Child, with initial assessment to identify any immediately life threatening features with the standard ABCDE approach, including recording of Temp, HR, RR, CRT and SaO2 (Also BP if high HR or altered consciousness level).

 

Meningococcal Septicaemia has widespread awareness (esp in the UK) with the ‘glass test’ to identify a typical non-blanching purpuric or petechial rash. Presence of Fever & Non-Blanching rash should alert to a high possibility of meningococcal sepsis to initiate management.

 

Features of Meningitis or raised ICP (headache, vomiting, etc) may be present.

 

Management

Do not delay antibiotics if you consider sepsis in a child.

 

Airway: Ensure patency with positioning or adjuncts; give O₂ 15 l/min by face mask

Breathing: ensure adequate effort ; monitor SaO₂

Circulation: Obtain IV access; Give fluid bolus if needed; attach cardiac monitor

  – Low BP is a late sign when shock becomes ‘decompensated’

  – If tachycardia and prolonged central capillary return of >2 seconds, give fluid bolus and reassess

  – If bolus >40ml/kg normal saline needed, involve seniors, anaesthetics and PICU teams to consider inotropes and intubation (due to risk of pulmonary oedema)

Disability: If reduced consciousness level, signs of neck stiffness, abnormal pupils, abnormal posturing or seizures à call for senior support

Exposure: Presence of non-blanching petechiae or purpuric rash, especially if spreading is considered meningococcal sepsis

 

If unwell immediately check blood gas, lactate and glucose. Investigate as for a febrile child (FBC, U&E, LFT, Bone profile, CRP, Coagulation, Blood culture) with consideration to LP, Urine culture, Chest x-ray etc.

 

Antibiotics: give broad-spectrum antibiotics such as Ceftriaxone (see localpolicy) without delay.

Consider Aciclovir if suspecting herpes simplex meningoencephalitis.

 

Correct any abnormal of electrolyte, calcium or glucose.

Monitor vital parameters, SaO2, BP, urine output, electrolytes and infection markers.

 

Majority of children with Sepsis recover completely with early identification and prompt treatment; however sepsis still has significant morbidity and mortality; sometimes with long term impact on neurodevelopmental outcome. Meningococcemia can lead to loss of digits or limbs.