Pediatric Sepsis and Organ Dysfunction

Topic Name Introduction Definitions & Classification Early Recognition Management Monitoring & Assessment Organ Dysfunction Special Considerations

Introduction to Pediatric Sepsis

Pediatric sepsis remains a significant cause of morbidity and mortality worldwide. Early recognition and prompt intervention are crucial for improving outcomes.

Epidemiology

• Global incidence: 48 cases per 100,000 person-years in children
• Mortality rate: 4-50% depending on geographical location and resources
• Higher risk in:
  • Children under 1 year of age
  • Immunocompromised patients
  • Those with chronic medical conditions
  • Low- and middle-income countries

Pathophysiology

• Initial Response:
  • Recognition of pathogen-associated molecular patterns (PAMPs)
  • Activation of innate immune system
  • Release of inflammatory mediators
  • Endothelial dysfunction
• Cascade Effects:
  • Microvascular dysfunction
  • Tissue hypoperfusion
  • Cellular dysfunction
  • Organ system failure

Definitions & Classification

Sepsis-3 Adapted for Pediatrics

• Infection: Suspected or proven infection
• Sepsis: Life-threatening organ dysfunction due to dysregulated host response to infection
• Septic Shock: Sepsis with cardiovascular dysfunction requiring vasoactive support

Age-Specific Vital Signs for Sepsis

Age Group	Tachycardia	Bradycardia	Tachypnea	Systolic BP
0-1 week	>180	<100	>50	<65
1 week-1 month	>180	<100	>40	<75
1 month-1 year	>180	<90	>34	<100
2-5 years	>140	N/A	>22	<94
6-12 years	>130	N/A	>18	<105
13-18 years	>120	N/A	>14	<117

SOFA Score Modifications for Pediatrics

• Respiratory: PaO2/FiO2 ratio, adjusted for age
• Cardiovascular: Age-specific blood pressure values
• Hepatic: Age-adjusted bilirubin levels
• Coagulation: Age-specific platelet counts
• Neurologic: Pediatric Glasgow Coma Scale
• Renal: Age-adjusted creatinine values

Early Recognition

Clinical Signs and Symptoms

• General Appearance:
  • Altered mental status
  • Decreased activity
  • Poor feeding
  • Reduced perfusion
• Vital Sign Changes:
  • Temperature instability
  • Tachycardia or bradycardia
  • Tachypnea
  • Hypotension (late sign)
• Perfusion Signs:
  • Prolonged capillary refill (>2 seconds)
  • Mottled skin
  • Cool extremities
  • Flash capillary refill

Laboratory Markers

• Initial Studies:
  • Complete blood count
  • Blood gas analysis
  • Lactate level
  • Coagulation profile
  • Blood cultures
• Inflammatory Markers:
  • C-reactive protein
  • Procalcitonin
  • IL-6 (where available)
  • Ferritin

Risk Stratification

• High-Risk Features:
  • Age <1 year
  • Immunocompromised state
  • Chronic medical conditions
  • Recent surgery or invasive procedure
  • Indwelling medical devices

Management

First Hour Bundle

• 0-15 minutes:
  • Establish IV/IO access
  • Obtain blood cultures
  • Start broad-spectrum antibiotics
  • Begin fluid resuscitation
• 15-30 minutes:
  • Assess response to initial fluids
  • Consider vasopressors if needed
  • Complete initial investigations
• 30-60 minutes:
  • Reassess perfusion and vital signs
  • Adjust therapy based on response
  • Consider additional interventions

Fluid Resuscitation

• Initial Approach:
  • Bolus: 20mL/kg crystalloid
  • Rapid push technique
  • Reassess after each bolus
  • Maximum 40-60mL/kg in first hour
• Fluid Choice:
  • Balanced crystalloids preferred
  • Consider albumin in specific cases
  • Blood products if hemorrhagic shock

Antimicrobial Therapy

Clinical Scenario	First-Line Options	Alternative Options
Community-acquired	Ceftriaxone + Vancomycin	Cefotaxime + Vancomycin
Healthcare-associated	Piperacillin-tazobactam + Vancomycin	Meropenem + Vancomycin
Immunocompromised	Meropenem + Vancomycin + Antifungal	Cefepime + Vancomycin + Antifungal
Neonatal	Ampicillin + Gentamicin	Ampicillin + Cefotaxime

Monitoring & Assessment

Clinical Monitoring

• Vital Signs:
  • Continuous heart rate monitoring
  • Respiratory rate and effort
  • Blood pressure every 15 minutes
  • Temperature every 4 hours
• Perfusion Assessment:
  • Capillary refill time
  • Skin temperature and color
  • Urine output
  • Mental status

Laboratory Monitoring

• Every 4-6 hours:
  • Blood gas analysis
  • Lactate level
  • Basic metabolic panel
• Every 12-24 hours:
  • Complete blood count
  • Coagulation profile
  • Inflammatory markers

Organ Dysfunction Assessment

Cardiovascular

• Signs of Dysfunction:
  • Hypotension
  • Poor perfusion
  • Elevated lactate
  • Reduced cardiac output
• Management:
  • Fluid resuscitation
  • Vasoactive medications
  • Inotropic support
  • ECMO consideration

Respiratory

• Signs of Dysfunction:
  • Increased work of breathing
  • Hypoxemia
  • Poor ventilation
  • ARDS development
• Management:
  • Oxygen supplementation
  • Non-invasive ventilation
  • Mechanical ventilation
  • Lung-protective strategies

Renal

• Signs of Dysfunction:
  • Oliguria
  • Elevated creatinine
  • Fluid overload
  • Electrolyte disturbances
• Management:
  • Fluid balance monitoring
  • Renal replacement therapy
  • Electrolyte correction
  • Medication adjustment

Special Considerations

Neonatal Sepsis

• Risk Factors:
  • Maternal GBS colonization
  • Prolonged rupture of membranes
  • Maternal fever
  • Prematurity
• Management Differences:
  • Different antibiotic choices
  • More careful fluid management
  • Higher risk of deterioration
  • Need for closer monitoring

Immunocompromised Patients

• Additional Considerations:
  • Broader antimicrobial coverage
  • Increased risk of fungal infections
  • More frequent monitoring
  • Lower threshold for escalation
• Specific Management:
  • Early infectious disease consultation
  • Consideration of antifungal therapy
  • Growth factor support if needed
  • Modified isolation precautions

Chronic Medical Conditions

• Cardiac Disease:
  • Careful fluid management
  • Earlier inotropic support
  • Close cardiac monitoring
  • Risk of endocarditis
• Respiratory Disease:
  • Lower threshold for ventilatory support
  • Consideration of underlying condition
  • Modified oxygen targets
  • Airway clearance techniques

Post-Operative Sepsis

• Risk Assessment:
  • Type of surgery
  • Duration of procedure
  • Presence of implants
  • Wound classification
• Management Modifications:
  • Source control assessment
  • Surgical site evaluation
  • Modified antibiotic choices
  • Consideration for reoperation

Quality Metrics and Outcomes

• Process Measures:
  • Time to antibiotics
  • Appropriate fluid resuscitation
  • Blood culture collection
  • Lactate measurement
• Outcome Measures:
  • Mortality rate
  • Length of stay
  • Ventilator-free days
  • Long-term morbidity
• Follow-up Care:
  • Post-sepsis syndrome monitoring
  • Neurodevelopmental assessment
  • Rehabilitation needs
  • Family support services

Prevention Strategies

• Hospital-Based Prevention:
  • Hand hygiene compliance
  • Care bundle implementation
  • Device-associated infection prevention
  • Antibiotic stewardship
• Community-Based Prevention:
  • Vaccination programs
  • Early recognition education
  • Access to healthcare
  • Public health measures

Research and Future Directions

• Current Areas of Investigation:
  • Biomarker development
  • Immunomodulation therapy
  • Machine learning applications
  • Precision medicine approaches
• Emerging Therapies:
  • Novel antimicrobial agents
  • Targeted immunotherapy
  • Endothelial protection strategies
  • Point-of-care diagnostics