per year ( 12.6 deaths per 100,000 population ). 2 In a review of prospectively collected data from 43 U . S . children ’ s hospitals from 2004 to 2012 , pediatric severe sepsis was identified in over 49,000 cases , with an associated mortality of 14.4 %. Severe sepsis affects slightly more males ( 53 %), with a mean age of 7 years . Infants less than 1 year of age had the highest mortality ( 31.5 %), followed by children 1-4 years of age ( 23.7 %). The most common pediatric co-morbidities associated with mortality included cardiovascular ( 36.9 %), neurologic ( 22.7 %), and malignancy ( 22.3 %). 3
Diagnosis
Septic shock is a clinical diagnosis . Various definitions of sepsis and septic shock have evolved over time . The 2005 International Pediatric Sepsis Consensus Conference established definitions for sepsis , severe sepsis , and septic shock . These guidelines apply to children from full-term to 18 years of age . Sepsis can be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection . Severe sepsis is defined as a ) systemic inflammatory response syndrome ( SIRS ), b ) confirmed or suspected invasive infection , and c ) cardiovascular dysfunction or acute respiratory distress syndrome ( ARDS ), or ≥ 2 non-cardiovascular organ system dysfunctions . Septic shock occurs in a subset of patients with sepsis and manifests as cardiovascular dysfunction leading to a ) hypotension , b ) treatment with vasoactive medication , and / or c ) impaired end-organ perfusion4 ( see Table 1 ).
In the updated 2020 pediatric sepsis guidelines from the Society of Critical Care Medicine , septic shock is defined as severe infection leading to cardiovascular dysfunction ( including hypotension , need for treatment with a vasoactive medication , or impaired perfusion ), and sepsis-associated organ dysfunction as severe infection leading to cardiovascular and / or non-cardiovascular organ dysfunction . 1 These new definitions were established to prevent potentially confusing classifications of sepsis , severe sepsis , and septic shock .
The recent update also added a broader pediatric age range : infants from 37 weeks ’ gestation to 18 years of age . Additionally , serum lactate was proposed as a useful surrogate marker of tissue hypoperfusion . However , it is not required to diagnose shock in children . Pediatric mortality from septic shock remains high , even if lactate levels are not elevated ; lactate levels > 2 mmol / L ( 32.0 % mortality ) versus lactate levels < 2 mmol / L ( 16.1 % mortality ). 5
Figure 2 . Fluid and Vasoactive-Inotrope Management Algorithm for Children . ( Source : Surviving Sepsis Campaign . www . sccm . org / SurvivingSepsisCampaign / Guidelines / Pediatric-Patients )
Management
The Best Practice Statement from the SSC recommends implementing a protocol or “ bundle ” for the management of children with presumed sepsis . 1 A study evaluating 1,179 pediatric patients across 54 hospitals in New York demonstrated that initiation of a sepsis bundle within one hour of recognition resulted in lower risk-adjusted odds of in-hospital mortality ( OR 0.59 [ 95 % CI , 0.38 to 0.93 ], p = 0.02 ; with a predicted risk difference ( RD ) of 4 % [ 95 % CI , 0.9 % to 7.0 %]. Each hospital created its own unique sepsis bundle , with all containing three common elements : 1 ) blood culture collection within one hour , before antibiotics , 2 ) administration of broad-spectrum antibiotics
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