Overview
Definition:
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection
In pediatrics, it is defined by a score of 2 or more on the pediatric sepsis-3 criteria (SOFA-P) based on a suspected infection
Severe sepsis was historically defined as sepsis with organ dysfunction, but this term is largely superseded by the current definition emphasizing organ dysfunction.
Epidemiology:
Pediatric sepsis remains a significant cause of morbidity and mortality worldwide, with incidence rates varying by region and healthcare setting
Neonatal sepsis has a higher incidence in low-resource countries
Early identification and prompt management are critical to improving outcomes.
Clinical Significance:
Sepsis is a medical emergency in children
Rapid progression to septic shock and multi-organ failure can occur
Standardized order sets are crucial for ensuring timely and evidence-based interventions, reducing variability in care, and improving survival rates for critically ill children
Their use is paramount for exam success in DNB and NEET SS.
Timing Of Intervention
Golden Hour Concept:
The "golden hour" in pediatric sepsis management emphasizes the critical importance of initiating interventions within the first hour of recognition
Delaying antibiotics, fluid resuscitation, or source control significantly increases mortality.
Recognition And Activation:
Prompt recognition of SIRS criteria (Systemic Inflammatory Response Syndrome) or qSOFA (quick SOFA) suggestive of sepsis is the trigger for activating the sepsis order set and multidisciplinary team
This includes nurses, physicians, pharmacists, and respiratory therapists.
Escalation Of Care:
Order sets should include clear pathways for escalating care, such as transfer to a higher level of care (e.g., PICU) if initial interventions are insufficient or if the child deteriorates rapidly
Continuous monitoring is essential to detect subtle signs of worsening.
Essential Order Set Components
Initial Assessment And Stabilization:
Within the first hour: Blood cultures (before antibiotics if possible, but do not delay antibiotics for this)
Lactate measurement
Broad-spectrum antibiotics tailored to local resistance patterns and suspected source
IV fluid boluses (20 mL/kg crystalloids over 1-3 hours).
Hemodynamic Support:
For septic shock: Vasopressors (e.g., norepinephrine) if hypotension persists after adequate fluid resuscitation
Inotropes (e.g., dobutamine) if myocardial dysfunction is suspected
Monitoring of central venous pressure and arterial line if available.
Source Control:
Identification and management of the source of infection
This may include surgical drainage of abscesses, removal of infected lines or devices, or debridement of necrotic tissue
The order set should prompt timely consultation with relevant surgical specialties.
Organ Support:
Mechanical ventilation for respiratory failure, renal replacement therapy for acute kidney injury, blood product transfusions for coagulopathy or severe anemia, and nutritional support
Glucose monitoring and control are also critical.
Monitoring And Reassessment:
Frequent vital sign monitoring, urine output, mental status, and lactate levels
Serial reassessment of fluid status and response to therapy
Criteria for de-escalation of antibiotics and vasopressors.
Age Specific Considerations
Neonatal Sepsis:
Unique pathogens (e.g., GBS, E
coli), different clinical presentations (lethargy, poor feeding, temperature instability), and specific antibiotic choices (e.g., ampicillin and gentamicin)
Sepsis workup for neonates requires careful consideration of gestational age and risk factors.
Infants And Young Children:
Vague symptoms, rapid deterioration
High index of suspicion required
Common sources include UTIs, pneumonia, meningitis, and occult bacteremia
Dosing of medications and fluids must be carefully calculated based on weight.
Older Children And Adolescents:
Presentations may be more similar to adult sepsis but with continued pediatric-specific considerations
Pneumonia, intra-abdominal infections, and post-operative sepsis are common
Familiarity with adolescent physiology is key.
Laboratory Investigations
Microbiology:
Blood cultures (aerobic and anaerobic), urine culture, cerebrospinal fluid analysis (if meningitis suspected), wound cultures, and respiratory secretions
Consider viral studies based on presentation (e.g., influenza, RSV).
Biochemistry:
Complete Blood Count (CBC) with differential (leukocytosis/leukopenia, bandemia)
C-reactive protein (CRP) and procalcitonin (PCT) as inflammatory markers
Electrolytes, renal function tests (BUN, creatinine), liver function tests (LFTs)
Lactate is a critical marker for tissue hypoperfusion.
Coagulation Profile:
Prothrombin Time (PT), Activated Partial Thromboplastin Time (aPTT), and Fibrinogen
D-dimer if disseminated intravascular coagulation (DIC) is suspected
Platelet count.
Imaging:
Chest X-ray for suspected pneumonia
Ultrasound for abscesses or pleural effusions
CT scans or MRI may be indicated for specific source identification (e.g., intra-abdominal, CNS).
Pharmacological Management Details
Antibiotic Selection:
Empiric broad-spectrum antibiotics should be initiated within 1 hour
Examples: Vancomycin + Ceftriaxone/Cefotaxime for suspected meningitis/gram-positive coverage
Piperacillin-tazobactam or Meropenem for suspected intra-abdominal or nosocomial infections
Adjust based on local antibiogram and clinical response.
Fluid Resuscitation:
Initial boluses of isotonic crystalloids (20 mL/kg) up to three times
Monitor for fluid overload
Choice of fluid (e.g., Normal Saline vs
balanced crystalloids like Lactated Ringer's) may have implications on acid-base balance and electrolyte levels.
Vasopressors And Inotropes:
Norepinephrine is the first-line vasopressor for septic shock
Dopamine may be used as an alternative or in specific situations
Dobutamine is indicated for myocardial dysfunction
Dosing should be titrated to achieve target mean arterial pressure (MAP).
Other Medications:
Corticosteroids may be considered in refractory septic shock, though their routine use is debated
Sedatives and analgesics for comfort and ventilation management
Antipyretics for fever.
Key Points
Exam Focus:
The recognition of sepsis in children, the critical timing of interventions (the "golden hour"), and the core components of pediatric sepsis order sets are high-yield for DNB/NEET SS
Understand age-specific differences and common pathogens.
Clinical Pearls:
Always consider sepsis in a child with a fever or hypothermia, altered mental status, or signs of organ dysfunction
Do not delay antibiotics for obtaining cultures if it will cause significant delay
Reassess fluid status frequently to avoid overload.
Common Mistakes:
Failure to recognize early signs of sepsis, delaying antibiotics, inadequate fluid resuscitation, inappropriate antibiotic choice, and not identifying/controlling the source of infection are common pitfalls
Over-reliance on SIRS criteria alone without considering clinical context.