Overview
Definition:
Pediatric sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection
It is a medical emergency requiring prompt recognition and intervention
Key features include systemic inflammatory response syndrome (SIRS) criteria plus evidence of organ dysfunction
Septic shock is a subset of sepsis characterized by circulatory, cellular, and metabolic abnormalities associated with a higher mortality risk, defined by persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) >= 65 mmHg or a decreased level of consciousness and lactate > 2 mmol/L despite adequate fluid resuscitation.
Epidemiology:
Sepsis is a significant cause of morbidity and mortality in children worldwide, with incidence rates varying from 3% to over 10% in critically ill children
Neonatal sepsis has a higher incidence and mortality
Factors influencing incidence include socioeconomic status, access to healthcare, and vaccination rates
The incidence of multidrug-resistant organisms is a growing concern.
Clinical Significance:
Prompt and appropriate management of pediatric sepsis significantly improves patient outcomes and reduces mortality
Delays in diagnosis or treatment are associated with increased risk of organ failure, prolonged hospital stays, and long-term sequelae
Understanding fluid resuscitation, appropriate antibiotic selection, and the judicious use of vasoactive agents are critical skills for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Fever or hypothermia
Lethargy or irritability
Poor feeding or vomiting
Tachypnea or difficulty breathing
Decreased urine output
Rash, especially petechial or purpuric
Cyanosis
Seizures.
Signs:
Hypotension (MAP < 65 mmHg or age-adjusted threshold)
Tachycardia or bradycardia
Altered mental status (lethargy, irritability, confusion)
Tachypnea or irregular breathing
Cool extremities, delayed capillary refill (>2 seconds)
Mottled skin
Decreased urine output
Worsening metabolic acidosis (high lactate)
Signs of specific source infection (e.g., cough, dysuria, abdominal pain).
Diagnostic Criteria:
The Sepsis-3 consensus criteria are widely adopted for adults and being adapted for pediatrics
Key features include: 1
Suspected or confirmed infection
2
A rapid increase in the Sequential Organ Failure Assessment (SOFA) score of 2 or more points
For children without chronic illness, a SOFA score of 0 is baseline, so an increase of 2 points suggests organ dysfunction
In the absence of SOFA scoring, clinical suspicion combined with evidence of organ dysfunction (e.g., altered mental status, hypotension, oliguria, elevated lactate) is crucial
Pediatric-specific sepsis criteria (e.g., consensus criteria from the Pediatric International Consensus Conference on Neonatal and Pediatric Sepsis) are also relevant for DNB/NEET SS preparation.
Diagnostic Approach
History Taking:
Focus on duration and onset of symptoms
Recent illnesses or infections
Immunization status
History of prematurity or congenital anomalies
Exposure to sick individuals
Medications (especially antibiotics or immunosuppressants)
Recent hospitalizations or procedures
Presence of comorbidities.
Physical Examination:
A rapid, systematic assessment is vital
Assess airway, breathing, and circulation (ABC)
Measure vital signs including temperature, heart rate, respiratory rate, blood pressure (consider age-adjusted hypotension thresholds), and oxygen saturation
Perform a thorough head-to-toe examination, paying attention to skin perfusion (capillary refill, mottling), mental status, urine output, and evidence of localizing infection.
Investigations:
Blood cultures (at least two sets from different sites before antibiotics)
Complete blood count (CBC) with differential
Blood gas analysis with lactate level (crucial for assessing perfusion and severity)
Serum electrolytes, urea, and creatinine
Liver function tests (LFTs)
C-reactive protein (CRP) or procalcitonin (PCT) can aid in diagnosis and response monitoring but are not definitive
Urine culture and urinalysis
Chest X-ray if pneumonia is suspected
Lumbar puncture if meningitis is suspected
Imaging of suspected source (e.g., abdominal ultrasound, CT scan).
Differential Diagnosis:
Non-infectious causes of SIRS: pancreatitis, burns, trauma, anaphylaxis, vasculitis
Other causes of shock: hypovolemic (dehydration, hemorrhage), cardiogenic (myocarditis, congenital heart disease), obstructive (tension pneumothorax, cardiac tamponade)
Fever of unknown origin
Meningitis/encephalitis
Pneumonia
Urinary tract infection
Intra-abdominal infection
Necrotizing enterocolitis (neonates).
Management
Initial Management:
The "Surviving Sepsis Campaign" guidelines are critical for exam preparation
The Hour-1 Bundle: 1
Measure lactate level
2
Obtain blood cultures before antibiotics
3
Administer broad-spectrum antibiotics
4
Begin rapid fluid resuscitation with 20 mL/kg of crystalloids over 1-3 hours
5
Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP >= 65 mmHg
Continuous cardiorespiratory monitoring is essential.
Medical Management:
Fluid Resuscitation: Initial bolus of 10-20 mL/kg of isotonic crystalloids (e.g., Normal Saline, Lactated Ringer's) over 1-3 hours
Repeat boluses may be necessary based on clinical response, perfusion, and hemodynamics
Avoid excessive fluid administration
Vasoactive Agents: If hypotension persists despite adequate fluid resuscitation, initiate vasoactive therapy
Norepinephrine is the first-line agent for septic shock in children
Dopamine can be used as an alternative or in combination
Epinephrine can be used for profound shock or if norepinephrine is unavailable
Vasopressin may be considered as an adjunct
Antibiotics: Administer broad-spectrum antibiotics promptly (within 1 hour of recognition)
Empiric choices depend on the suspected source, local resistance patterns, and patient age
Common regimens include a third-generation cephalosporin plus vancomycin (if MRSA is suspected), or an extended-spectrum beta-lactam/beta-lactamase inhibitor
Narrow antibiotics based on culture results
Neonates (0-28 days) often require ampicillin and gentamicin/cefotaxime.
Surgical Management:
Surgical consultation is indicated for identified surgical sources of infection, such as intra-abdominal abscesses, necrotizing enterocolitis, appendicitis, or osteomyelitis requiring debridement
Source control is a critical component of sepsis management.
Supportive Care:
Respiratory support: supplemental oxygen, non-invasive ventilation, or mechanical ventilation as needed
Nutritional support: initiation of enteral feeding as soon as hemodynamically stable
Glucose control: maintain normoglycemia
Renal replacement therapy if indicated
Management of coagulopathy
Sedation and analgesia.
Complications
Early Complications:
Multi-organ dysfunction syndrome (MODS): acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), hepatic dysfunction, neurological impairment
Disseminated intravascular coagulation (DIC)
Hypoglycemia
Hypothermia or hyperthermia
Gastrointestinal bleeding
Pulmonary edema.
Late Complications:
Post-sepsis syndrome (e.g., fatigue, weakness, cognitive dysfunction)
Prolonged neurological deficits
Limb loss due to peripheral ischemia
Chronic organ damage
Increased susceptibility to future infections
Psychological sequelae for the child and family.
Prevention Strategies:
Early recognition and prompt initiation of resuscitation and antibiotics
Judicious fluid management to avoid overload
Appropriate antibiotic selection and de-escalation based on cultures
Aggressive management of comorbidities
Strict infection control measures in healthcare settings
Vaccination against common pathogens (e.g., pneumococcus, meningococcus, influenza).
Prognosis
Factors Affecting Prognosis:
Severity of illness at presentation
Age of the child (neonates and young infants have worse outcomes)
Presence of comorbidities
Time to effective treatment (fluid resuscitation, antibiotics, source control)
Development of MODS
Identification of causative organism and its susceptibility
Access to critical care resources.
Outcomes:
Mortality rates in pediatric sepsis vary widely, from around 5% in developed countries to over 30% in resource-limited settings
Survivors can experience significant short-term and long-term morbidity
Early and effective management dramatically improves survival and reduces the burden of long-term sequelae.
Follow Up:
Children who have recovered from sepsis require close follow-up to monitor for long-term complications, including neurodevelopmental deficits, growth disturbances, and psychological impact
Rehabilitation services may be beneficial
Regular review of organ function and overall well-being is crucial.
Key Points
Exam Focus:
The Hour-1 Bundle is paramount for DNB/NEET SS
Know the age-adjusted hypotension thresholds for BP
Understand the indications and first-line agents for vasoactive support (norepinephrine)
Be familiar with common broad-spectrum antibiotic choices for empiric therapy in different age groups and suspected sources
Recognize SIRS and sepsis criteria in children.
Clinical Pearls:
Always suspect sepsis in a febrile or hypothermic child with any sign of organ dysfunction, especially altered mental status or poor perfusion
Don't delay antibiotics for blood cultures if it causes significant delay
Lactate is your friend – use it to guide resuscitation and assess response
Reassess the patient frequently after fluid boluses and vasoactive initiation.
Common Mistakes:
Underestimating the severity of illness in children
Delaying fluid resuscitation or antibiotics
Inadequate fluid volume or overly cautious fluid administration
Misinterpreting hypotension – always consider sepsis
Using inappropriate antibiotics or not tailoring them to local resistance patterns and culture results
Failure to consider non-infectious causes of shock.