Scientific Article
BY Christopher W . Edwards , MD ; 1 Lauren R . Edwards , MD ; 2 Brittany M . B . Slagle , DO 1
1
Section of Pediatric Hospital Medicine , Department of Pediatrics , UAMS / Arkansas Children ’ s Hospital
2
Section of Pediatric Critical Care Medicine , Department of Pediatrics , UAMS / Arkansas Children ’ s Hospital
Pediatric Sepsis : Prompt and Effective Management Strategies
Abstract
Sepsis continues to be a leading cause of mortality in children and is challenging to diagnose early , even for the most experienced physicians . It is important to bring a critical eye and an anticipatory attitude to the assessment of a pediatric patient . Bacteria remain the primary culprits in triggering the cascade of events leading to severe sepsis and shock . Once identified , prompt action should be taken to deliver rapid therapy for shock , including 1 ) aggressive fluid resuscitation , 2 ) frequent reassessment targeting restoration of adequate perfusion , and 3 ) broad-spectrum antibiotics .
Introduction
Sepsis is an overwhelming and life-threatening response to an infection ; it can cause dysfunction of multiple organ systems . In pediatrics , diagnosing sepsis is especially challenging , as children can compensate for severe illness for prolonged periods , painting a relatively reassuring picture : subtle fluctuations in vital signs , normotension , and seemingly normal mentation . Because of this compensation , children can look “ well ,” yet be septic . It is not until the child reaches the most severe end of the spectrum that the patient decompensates , sometimes to a degree that is irrecoverable . Due to the differences in children as compared to adults , it is essential to appreciate these characteristics and treat sepsis early in pediatric patients .
Epidemiology
Sepsis is a leading cause of morbidity and mortality . As of 2015 , the global prevalence of pediatric severe sepsis was 8.2 %. 1 Sepsis can occur in all ages but is more common in toddlers with a median age of three years old . 1 The respiratory tract is the primary site of infection that most commonly leads to sepsis , followed by the bloodstream . 1 , 2 In children admitted to the pediatric intensive care unit ( PICU ), the mortality rate for sepsis is 5.6 % and as high as 17-24 % for pediatric septic shock . 1 , 3
Diagnosis
Sepsis is currently defined in pediatric patients by the presence of systemic inflammatory response syndrome ( SIRS ) and a known or possible infection . SIRS has numerous etiologies , but overall , it describes the complex pathophysiological response to an insult . To meet SIRS criteria , you must have abnormalities in two or more of the following : temperature , white blood count , respiratory rate , and heart rate ( one of which must be abnormal temperature or leukocyte count ). 4 Severe sepsis is defined as sepsis with signs and symptoms of organ hypoperfusion or dysfunction . Lastly , septic shock is sepsis with cardiovascular organ dysfunction ( such as poor peripheral pulses , alteration in central-peripheral temperature gradient , altered mental status , abnormal capillary refill , mottled or cool extremities , diminished urine output ). 4 , 5 Hypotension is not needed to meet the criteria of septic shock ( as it is indicative of late , decompensated shock ); however , it can confirm the diagnosis in the setting of a suspected or proven infection . 4
Table 1 . Risk Factors Associated With Pediatric Sepsis Pediatric Sepsis Risk Factors Age < 1 month Asplenia Serious injury ( e . g . major trauma , burns , or wounds ) Chronic debilitating medical condition Sickle cell disease Immunosuppression Transplant recipient Indwelling medical device Urinary tract abnormalities Recent steroid use
Etiology
Sepsis , in all of its forms , necessitates a known or suspected infectious source . That source of sepsis can be bacterial , fungal , or viral . The respiratory tract is most commonly identified as the originating site of sepsis and historically has had the highest mortality rates . 1 The second most common is the bloodstream . Rates of sepsis from Streptococcus pneumoniae and Neisseria meningitidis are decreasing due to vaccinations , while methicillin-resistant Staphylococcus aureus ( MRSA ) sepsis rates are rising . 2 Many known risk factors increase the likelihood of developing sepsis and septic shock ( Table 1 ).
Pathophysiology
Sepsis involves a complex interaction between the host ’ s immune system and the pathogen . When an infection develops within the body , there is a normal physiological response , mediated by the release of chemokines , cytokines , and interleukins from neutrophils and macrophages . This can lead to local vasodilation , increased endothelial permeability , and activation of coagulation pathways . In sepsis , this normally localized response can escalate and become unregulated , resulting in end-organ damage .
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