Overview
Definition:
Sepsis in children is a life-threatening organ dysfunction caused by a dysregulated host response to infection
The 1-hour sepsis bundle is a critical evidence-based intervention aimed at prompt recognition and initiation of life-saving management for suspected sepsis in the Pediatric Intensive Care Unit (PICU)
It emphasizes completing specific diagnostic and therapeutic interventions within 60 minutes of recognition.
Epidemiology:
Pediatric sepsis is a significant cause of morbidity and mortality in children worldwide
Incidence varies based on healthcare setting, patient population, and diagnostic criteria used, but it remains a common critical illness
Early recognition and prompt management are paramount to improving outcomes.
Clinical Significance:
Timely administration of antibiotics, appropriate fluid resuscitation, and timely diagnostic workup are crucial for reducing mortality, morbidity, and length of hospital stay in pediatric sepsis
Adherence to the 1-hour bundle has been shown to improve survival rates significantly and is a key performance indicator in PICUs.
Recognition And Diagnosis
Recognition Criteria:
Suspected sepsis should be considered in any child presenting with signs or symptoms of infection, especially when accompanied by evidence of organ dysfunction
This includes changes in mental status, increased respiratory rate, decreased urine output, hypotension, or hypoperfusion.
Pediatric Sepsis Criteria:
Commonly used criteria include the Sepsis-3 definitions adapted for pediatrics (e.g., PICS criteria or variations), which focus on suspected infection plus a SOFA score increase of >=2 points
Clinical suspicion remains the cornerstone of early recognition.
Diagnostic Approach:
A rapid and systematic approach is essential
This involves a focused history (onset of symptoms, source of infection, recent illnesses, antibiotic exposure), a thorough physical examination (assessing vital signs, perfusion, respiratory status, neurological status), and immediate initiation of investigations.
The 1 Hour Sepsis Bundle
Lactate Measurement:
Obtain a serum lactate level as soon as possible within the first hour
Elevated lactate is a marker of tissue hypoperfusion and a predictor of severe sepsis and mortality
Repeat lactate measurements guide therapy.
Blood Cultures:
Obtain at least two sets of blood cultures (aerobic and anaerobic) from different venipuncture sites prior to antibiotic administration
If peripheral venous access is difficult or delayed, obtain cultures from an existing central venous catheter, but prioritize obtaining peripheral cultures if possible.
Imaging:
Perform appropriate imaging studies to identify the source of infection, if indicated and obtainable within the initial hour
This may include chest X-ray for suspected pneumonia, abdominal ultrasound for suspected intra-abdominal source, or other relevant imaging.
Antibiotic Administration:
Administer broad-spectrum intravenous antibiotics within 1 hour of recognition of suspected sepsis
The choice of antibiotics should be guided by local epidemiology, suspected source of infection, and patient factors
Empiric coverage should include likely bacterial pathogens.
Fluid Resuscitation And Hemodynamic Support
Initial Fluid Bolus:
Administer a rapid intravenous fluid bolus of 20 mL/kg of isotonic crystalloid (e.g., normal saline, Ringer's lactate) within the first hour for patients with signs of hypoperfusion (e.g., capillary refill time >3 seconds, mottling, decreased urine output, altered mental status).
Vasopressor Support:
If hypotension persists despite adequate fluid resuscitation, initiate vasopressor therapy (e.g., norepinephrine) to maintain adequate mean arterial pressure
Target MAP should be appropriate for the child's age.
Monitoring Of Response:
Closely monitor the patient's response to resuscitation, including vital signs, perfusion parameters (capillary refill, skin temperature, urine output), and lactate levels
Further fluid administration or vasopressor support should be guided by ongoing assessment.
Pharmacological Management
Antibiotic Selection:
Empiric antibiotic selection should cover common pediatric pathogens and be based on local resistance patterns and suspected source
Examples include third-generation cephalosporins, vancomycin (if MRSA suspected), or broader-spectrum agents for critically ill patients
Common choices include Ceftriaxone, Cefotaxime, Vancomycin, Piperacillin-Tazobactam.
Dosing Considerations:
Dosing should be weight-based and adjusted for renal or hepatic impairment
Standard pediatric doses for common antibiotics in sepsis include Vancomycin 15 mg/kg IV q8-12h, Ceftriaxone 50-100 mg/kg IV q24h, Cefotaxime 50 mg/kg IV q6-8h
Consult pediatric pharmacology resources for precise dosing.
Reassessment And De Escalation:
After obtaining culture results and clinical response, reassess antibiotic therapy daily
De-escalate to narrower-spectrum agents or discontinue antibiotics based on microbiological data and clinical improvement to minimize resistance and side effects.
Complications And Prognosis
Potential Complications:
Complications of pediatric sepsis include severe sepsis, septic shock, multi-organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), disseminated intravascular coagulation (DIC), and neurological sequelae.
Factors Affecting Prognosis:
Prognosis is influenced by the severity of illness, underlying comorbidities, promptness of diagnosis and treatment, and development of organ dysfunction
Early and effective implementation of the sepsis bundle significantly improves survival.
Long Term Outcomes:
Survivors of pediatric sepsis may experience long-term sequelae, including cognitive deficits, growth impairment, and increased risk of chronic health conditions
Post-PICU follow-up and rehabilitation are important for optimizing recovery.
Key Points
Exam Focus:
The 1-hour sepsis bundle is a critical intervention in pediatric emergencies
Focus on the core components: lactate, cultures, antibiotics, and initial fluid resuscitation
Understand the timing and rationale for each component.
Clinical Pearls:
Always maintain a high index of suspicion for sepsis in any febrile or ill-appearing child, especially those with signs of hypoperfusion or organ dysfunction
Prioritize obtaining cultures *before* antibiotics, but do not delay antibiotics if cultures cannot be obtained promptly.
Common Mistakes:
Delaying antibiotic administration while awaiting culture results
Inadequate fluid resuscitation
Failure to recognize subtle signs of organ dysfunction
Inappropriate empiric antibiotic selection
Not repeating lactate measurements to guide therapy.