Sepsis recognition and initial management

Essentials

1
Paediatric sepsis is the final common pathway for many decompensated infections.
2
Clinical judgement is the best-performing tool for early recognition; senior clinician review should be sought if there is diagnostic uncertainty.
3
Initial resuscitation includes intravenous access, sampling for blood culture and venous blood gas and early administration of empiric intravenous antibiotics.
4
Haemodynamic support using fluid resuscitation should be titrated carefully to avoid the harms associated with inadequate and excessive administration.
5
Inotropes/vasopressors may be safely administered via peripheral intravenous cannula in children.

Background

Sepsis is a major public health concern. It accounts for over 5% of all paediatric hospital admissions, over 10% of paediatric intensive care unit admissions and over $4.8 billion of total United States hospital costs. Mortality from paediatric sepsis is 5–17% in industrialised countries and 20–30% in low- and middle-income countries. In Australia and New Zealand, >50 paediatric intensive care unit deaths per year are attributed to sepsis. Worldwide, sepsis causes >4.5 million childhood deaths per year. Paediatric sepsis has a bimodal age distribution, being most common in infancy, and a decreasing incidence until late adolescence. Early deaths due to refractory shock tend to occur in previously healthy children with community-acquired sepsis, whereas late deaths due to multiorgan failure tend to occur in hospitalised children with multiple preexisting comorbidities. High-risk patient groups include neonates, children with primary or secondary immunodeficiency and children with indwelling vascular catheters.

Definition

Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection.

Aetiology

The most common pathogens causing paediatric sepsis in Australia are Staphylococcus and Streptococcus species. For infants <3 months of age, the most common pathogens are Escherichia coli and group B Streptococcus . Listeria is very uncommon. In older children, Streptococcus pneumoniae , Staphylococcus aureus , Group A Streptococcus , and Neisseria meningitidis are the most common pathogens. Geographic location, immunisation status, immunodeficiency and presence of indwelling vascular catheters all influence the microbiological causes of paediatric sepsis.

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