Sepsis

Sepsis: Excerpt from The 5-Minute Pediatric Consult

Christine S. Cho, MD, MPH

Sepsis - BASICS

Sepsis - description

The terms SIRS (systemic inflammatory response), infection, sepsis, severe sepsis, and septic shock are defined as:

• SIRS: Nonspecific inflammatory response to bodily injury defined as at least 2 of:
  • Temperature >38.5 or <36°C
  • Tachycardia >2sd above normal
  • Tachypnea >2sd above normal
  • Leukocytosis, leukopenia, or >10% bands
• Infection: A suspected or proven infection or a clinical syndrome associated with a high probability of infection
• Sepsis: SIRS in the presence of infection
• Severe sepsis: Sepsis accompanied by evidence of altered end organ perfusion (cardiovascular OR acute respiratory distress syndrome OR 2 or more other organ dysfunctions)
• Septic shock: Sepsis syndrome with hypotension (systolic BP <5% for age)

Sepsis - general prevention

• Routine vaccination for Haemophilus influenzae type b and Streptococcus pneumoniae, particularly in high-risk patients (e.g., sickle cell anemia, asplenia)
• Rifampin prophylaxis for household or day care exposure to H. influenzae type b or Neisseria meningitidis
• Prompt evaluation for fever in immunosuppressed patients

Sepsis - epidemiology

Sepsis - incidence

Mortality rates from sepsis vary with age from 5.6 deaths per 100,000 in infants younger than 1 year of age to 0.5 per 100,000 age 1–4 years, and 0.1 per 100,000 age 5–14 years.

Sepsis - prevalence

Sepsis is among the most common (10–25%) medical diagnoses on admission to PICUs.

Sepsis - risk factors

• Although sepsis may occur in previously healthy children, it is a particular concern for children with chronic underlying conditions that render them immunosuppressed or vulnerable to invasive infections.
• Hyposplenism, either surgical or functional (e.g., sickle cell anemia), increases susceptibility to sepsis from encapsulated organisms
• Neutropenia (<1,000 neutrophils/mm³ of blood, and in especially <500/ mm³)
• Congenital or acquired syndromes of immunodeficiency (AIDS, severe combined immunodeficiencies [SCID])
• Organ transplant recipients
• Chronic use of high doses of steroids
• Patients with indwelling central venous catheters

Sepsis - etiology

The etiology of sepsis varies with age in otherwise healthy children:

• Most common pathogens in the 1st 4 weeks of life: Group B Streptococcus, Gram-negative enterics (particularly Escherichia coli), Listeria monocytogenes
• When there is a history of hospitalization, instrumentation, or mechanical ventilation: Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa
• In older infants and children: Streptococcus pneumoniae, Neisseria meningitidis, group A streptococci, Salmonella spp.

Sepsis - associated conditions

See “Risk Factors” (for identification of subgroups of children at high risk of sepsis).

Sepsis - DIAGNOSIS

Have a high suspicion for sepsis because presenting signs of fever and tachycardia are nonspecific. Hypotension is not a sensitive sign of septic shock.

Sepsis - signs & symptoms

Sepsis - history

• Identify children with “Risk Factors.”
• Duration of illness before presentation:
  • Abrupt onset of symptoms more typical of invasive bacterial infection
• Change in behavior may be initial sign of systemic infection.

Sepsis - physical exam

All patients with suspected sepsis should have a full set of vital signs (e.g., temperature, pulse, respiratory rate, BP, pulse oximetry):

• Temperature:
  • Fever is the hallmark of an infection; however, infants in particular may demonstrate hypothermia.
• Stertor, stridor:
  • Assess for signs of airway obstruction.
• Auscultation of the chest:
  • Assess adequacy of breathing (tachypnea, rales).
• Tachycardia, hypotension, poor skin perfusion, delayed capillary refill, presence of mottling:
  • Evidence of inadequate circulatory function
• Altered mental status (somnolence, confusion, disorientation, agitation)
  • Evidence of severe systemic disease, possible poor cerebral perfusion
• Presence of petechiae and purpura:
  • Meningococcemia or disseminated intravascular coagulation (DIC)
• Thorough physical examination:
  • Look for focus of infection.

Sepsis - tests

Sepsis - lab

Patients with suspected sepsis should have:

• CBC with differential, platelet count:
  • Elevated WBC count with increased band count suggestive of invasive infection
• Electrolytes, glucose:
  • Metabolic acidosis, hypoglycemia
• Blood culture:
  • Identification of causative organism
• Arterial blood gas:
  • Monitoring acid–base status
• Urinalysis and urine culture:
  • Potential source of infection
• Lumbar puncture (when hemodynamically stable):
  • Required for diagnosis of meningitis
• PT, PTT, fibrinogen, fibrin degradation products:
  • Monitor development of DIC
• Gram stain and culture of petechiae or abscess contents
  • May yield causative organism

Sepsis - differencial diagnosis

The differential diagnosis varies with age:

• Children younger than 2 months:
  • Viral infections (e.g., enterovirus, respiratory syncytial virus)
  • Congenital heart disease (e.g., congestive heart failure owing to hypoplastic left heart syndrome, coarctation of the aorta, ventricular septal defect [VSD], valvular insufficiency)
  • Myocarditis, pericarditis
  • Cardiac dysrhythmia
  • Myocardial infarction secondary to anomalous coronary artery insertion
  • Congenital adrenal hyperplasia
  • Inborn errors of metabolism (e.g., maple syrup urine disease, methylmalonic or propionic acidemia, urea cycle disorders)
  • Hypoglycemia
  • Severe anemia
  • Methemoglobinemia
  • Gastroenteritis with dehydration
  • Pyloric stenosis
  • Volvulus
  • Infant botulism
  • Nonaccidental trauma
• Older infants and children:
  • Viral infections
  • Myocarditis, pericarditis
  • Cardiac dysrhythmia
  • Intussusception
  • Toxic ingestion/poisoning (e.g., iron, salicylates, tricyclic antidepressants, oral hypoglycemic agents, ethanol, calcium channel blockers, beta-blockers, clonidine, opioids)
  • Trauma
  • Infant botulism
  • Diabetic ketoacidosis

Sepsis - TREATMENT

• Timely intravascular or intraosseous access and generous fluid resuscitation (repeated 20 mL/kg isotonic fluid boluses)
• Early inadequate fluid resuscitation is associated with increased mortality.

Sepsis - general measures

• Ensure a patent airway (consider endotracheal intubation).
• Provide supplemental oxygen.
• Assist ventilation (e.g., bag-valve-mask device) as needed.
• Obtain large bore peripheral intravenous access (consider femoral venous line or intraosseous line).
• Volume resuscitation: Bolus 20 mL/kg of normal saline solution, repeat as needed; consider blood after initial 60–80 mL/kg of crystalloid)
• Giving 60 mL/kg in 1st hour improves outcome.
• Inotropic agents: Dopamine (begin at 5 mg/kg/min, titrate up to 20 mg/kg/min as needed), start epinephrine (begin at 1 to 2 mg/kg/min) if persistent hemodynamic instability after 60 mL/kg isotonic crystalloid resuscitation
• Consider stress-dose hydrocortisone for catecholamine-resistant hypotension.
• Correct hypoglycemia (0.5–1 g/kg of dextrose).
• Antibiotics (depends on age, presence of meningitis, central venous catheter, immune function of patient) generally given IV for at least 10 days:
  • Neonates ≤6 weeks: Ampicillin and gentamicin (no meningitis); vancomycin and cefotaxime (meningitis)
  • Infants and children, ≥6 weeks: Cefotaxime or ceftriaxone (no meningitis); vancomycin and cefotaxime or ceftriaxone (meningitis)
  • Patients with immunosuppression and/or central venous catheters: Antistaphylococcal penicillin or vancomycin, plus aminoglycoside, and 3rd-generation cephalosporin
  • Patients with an intra-abdominal focus of infection: Ampicillin/Sulbactam or ampicillin, gentamicin, and clindamycin or metronidazole
• Drainage and/or eradication of focus of infection
• Pitfalls:
  • Recognize the patient with “Risk Factors.”
  • Initial priorities in management are the proper assessment of airway, breathing, and circulation.
  • Provide adequate initial volume resuscitation; improved outcome is associated with giving >60 mL/kg isotonic saline in the 1st hour of resuscitation.
  • Eradicate the focus of infection (abscess) if present.
  • Continuous monitoring and reassessment of the patient is essential.

Sepsis - diet

Patients with sepsis should remain NPO until clinically stable for enteral feeds.

Sepsis - FOLLOW UP

Sepsis - disposition

Sepsis - admission criteria

• Patients with sepsis should be admitted for close monitoring.
• Patients with severe sepsis or septic shock should be admitted to an ICU.

Sepsis - prognosis

• Case fatality rates have improved from nearly 50% to ~10%.
• Mortality higher if shock exists on initial presentation
• Development of adult respiratory distress syndrome (ARDS) or multiple organ dysfunction syndrome (MODS) associated with increased mortality
• Survival improved in patients receiving >60 mL/kg of volume resuscitation in the 1st hour of management
• Presence of coagulopathy (elevated PT and PTT) associated with elevated mortality from meningococcal sepsis

Sepsis - complications

• Sepsis accounts for 7% of pediatric deaths (one of the leading causes).
• The most common complications of sepsis are those resulting primarily from either acute hypoperfusion of vital organs or from organ injury incurred by the uncontrolled systemic inflammatory response:
  • Acute lung injury
  • Acute renal failure
  • Disseminated intravascular coagulation (DIC)
  • Hypoglycemia
  • Adult respiratory distress syndrome (ARDS)
  • Refractory shock
  • Multiple organ dysfunction syndrome (MODS)

Sepsis - patient monitoring

• Admit all patients with suspected sepsis to the hospital; consider intensive care unit admission.
• Continuous BP monitoring for the development of refractory shock
• Serial vital signs and physical examinations to monitor response to therapy
• Monitor for complications of sepsis and the development of MODS.
• Chest radiograph and serial arterial blood gases for evidence of acute lung injury/ARDS
• Urine output, BUN, creatinine for acute renal failure
• Serial coagulation studies (PT/PTT) for development of DIC
• Serial blood glucose levels for hypoglycemia
• Serial liver function tests (glucose, albumin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], gamma-glutamyl transpeptidase [GGT], bilirubin) for evidence of hepatic dysfunction
• Serial neurologic examinations for evidence of CNS dysfunction

Sepsis - bibliography

1. Buttery JP. Blood cultures in newborns and children: Optimising an everyday test. Arch Dis Child Fetal Neonatal Ed. 2002;87(1):F25–F28.
2. Carcillo JA. What’s new in pediatric intensive care. Crit Care Med. 2006;34(9):S183–S190.
3. Fiorito BA, Farrukh M, Doran T, et al. Intraosseous acess in the setting of pediatric cirtical care transport. Pediatr Crit Care Med. 2005;6(1):50–53.
4. Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8.
5. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcomes. Pediatrics. 2003;112:793–799.
6. Pickert CB, Moss MM, Fiser DH. Differentiation of systemic infection and congenital obstructive left heart disease in the very young infant. PEC. 1998;14(4):263–267.
7. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of sepsis and septic shock. New Eng J Med. 2001;345:1368–1377.
8. Watson RS, Carcillo JA. Scope and epidemiology of pediatric sepsis. Pediatr Crit Care Med. 2005;6:S3–S5.

Sepsis - ADDITIONAL READING

• Butt W. Septic shock. Pediatr Clin North Am. 2001;48:601–625, viii.
• Carcillo JA. Pediatric septic shock and multiple organ failure. Critical Care Clin. 2003;19:413–440, viii.
• Carcillo JA, Fields AI. Clinical practice parameters for pediatric and neonatal patients in septic shock. Crit Care Med. 2002;30:1365–1378.

Sepsis - CODES

Sepsis - icd9

995.91 Sepsis (generalized)

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Septicemia

• Back to disease: Septicemia: Introduction
• Next Book Extract About Septicemia: Surveys relating to Septicemia
• More Book Extracts: All Online Books for Septicemia

More Medical Textbooks Online about Septicemia

Review other book chapters online related to Septicemia:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Surveys relating to Septicemia

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Surveys relating to Septicemia
• Ask Question about Septicemia

Tools & Services:

• Bookmark this page
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City