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Next Lesson - Child Safeguarding
Contents
Abstract
- Sepsis in children can often be missed as the presentation is very similar to that of a normal viral illness.
- Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.
- Suspected infection with life-threatening organ dysfunction defines paediatric sepsis. Clinical warning signs guide early recognition; do not wait for a diagnostic score before assessing and treating an unwell child.
- We assess children with sepsis using an A to E approach and manage them using the paediatric SEPSIS 6 guidelines.
Core
Missing paediatric sepsis is gross negligence, as failure to spot paediatric sepsis can lead to the deaths of children.
The issue with sepsis is that it does not always present clearly and there is no immediate test or clinical sign that medical professionals can latch onto in their thought processes. All of the signs of sepsis are very similar to that of a normal viral illness until the child becomes critically ill.
The definition of sepsis is important so that the common features of severe infections can be identified as early as possible. The presentations and associated symptoms with a severe infection were originally thought to be as a result of inflammation in the body. Therefore, the first early warning system for identifying sepsis was a list of all the different ways that widespread inflammation could present, with the more present, the higher the risk of severe infection. This list has since been refined over multiple iterations based upon studies and vast amounts of data collected from those patients that present with severe infections.
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. The harmful response can affect organs beyond the site of infection. The infection itself does not have to spread throughout the body, and a positive blood culture is not required for sepsis.
Therefore, the definition of sepsis is “A life-threatening organ dysfunction caused by a dysregulated host response to infection”.
Adult SOFA and qSOFA scores should not be substituted for paediatric assessment. In children, use age-appropriate clinical assessment and local sepsis pathways to recognise deterioration and begin treatment promptly.
The 2005 paediatric consensus used systemic inflammatory response syndrome (SIRS) criteria with infection. The following features are historical inflammatory indicators, not the current definition of paediatric sepsis:
- A temperature, either high or low
- A raised heart rate
- A raised respiratory rate
- A high or low white cell count
The 2024 Phoenix consensus identifies paediatric sepsis as suspected infection with a Phoenix Sepsis Score of at least 2, reflecting potentially life-threatening respiratory, cardiovascular, coagulation and/or neurological dysfunction. SIRS with infection alone does not define sepsis. Phoenix is not an early screening tool: clinical concern should prompt assessment and treatment before organ dysfunction is overt. The criteria do not apply to birth hospitalisations or neonates below 37 weeks postconceptional age.
The term severe sepsis is redundant in the current definition because sepsis already requires life-threatening organ dysfunction. Septic shock is sepsis with cardiovascular dysfunction; Phoenix identifies this by at least one cardiovascular score point.
In studies identifying children with blood culture positive bacterial infections, 1/3rd were neonates, 1/3rd were previously well and 1/3rd were children with current comorbidities. Collectively these children had a 7% mortality rate, but in both chances of infection and mortality, there was a large over-representation of the number of neonates and children with co-morbidities compared with the population split.
Importantly this study found that if a child had SIRS and bacteria in the bloodstream, then there was only an overall mortality of 1%, whereas those with organ dysfunction and an infection have an overall mortality of 17%! These historical study categories should not be confused with the current Phoenix definition; infection-associated organ dysfunction remains the central concern[1].
The bodies of children are very effective at compensating for infection. This means that a run-of-the-mill viral infection and sepsis can initially present similar, until the septic child collapses.
Children should be assessed in a specific A to E order. Note this is different to the adult emergency A to E assessment but uses the same principles[2].
The appearance of a child is a good indicator as to how well they are. If the patient looks mottled or ashen, cyanotic or has a non-blanching rash then they should be immediately assessed by a senior and appropriate management started.
The child’s breathing is often a very sensitive indicator as to how well they are doing, the respiratory rate is the first thing to increase in any acute illness. Assess the child’s need for any additional oxygen based on appearance and oxygen saturations. Assessment of additional sounds of breathing (i.e. wheeze or stridor) should also be undertaken.
The circulatory system behaves differently in children than it does in adults. Children have the ability to maintain their blood pressure for a lot longer before it drops suddenly when they are seriously ill, whereas adults often have a more progressive decline. Therefore, a low blood pressure in a young child is a very serious, late sign and requires immediate management. Lactate and heart rate are used to give an indication of the patient’s circulatory system function. Capillary refill time can be used as part of the overall assessment of perfusion, but it is non-specific and can be prolonged by factors such as cold exposure. A normal temperature is not reassuring, as children with serious infection may be normothermic or hypothermic.
The patient’s demeanour can give insight into the severity of illness. A child who is active, talking and crying is less concerning than one who is lying quietly and unresponsive.
The last stage of the assessment is to expose the patient fully, looking for any rashes, wounds or surgical scars, any foreign material or devices.
The risk of a child developing severe sepsis is based upon the patient’s risk factors and physiology.
Pre-existing risk factors include:
- Younger age
- Impaired immune system (e.g. steroid or chemotherapy treatment)
- Co-existing illness (e.g. cystic fibrosis)
The more risk factors present, the lower the threshold of treating the child for the infection.
Managing Severe Sepsis in Children
Managing sepsis in paediatric patients is done through the Paediatric Sepsis 6 Pathway.
The first step in all management pathway for the child with severe sepsis begins with recognising that the patient is severely ill enough to require this pathway. Help should be sought from the most senior doctor available as soon as possible.
The patient should be given high flow oxygen as soon as possible, considering the use of an adjunct to help maintain a clear airway if needed. This should be given alongside starting continuous observations, such as pulse oximetry and cardiac monitoring.
Access should be acquired through an intravenous route, or if proving too difficult, an intraosseous route. At this point, bloods such as full blood count, urea and electrolytes, C-reactive protein and liver function tests should be taken, and the antibiotics should be given depending on local guidelines.
Patients should be given an initial bolus of isotonic saline according to their weight, which can be repeated with a review after each bolus.
Initial blood testing in a child with high-risk suspected sepsis should include a venous blood gas with glucose and lactate. Lactate contributes to the assessment of illness severity and perfusion and must be interpreted alongside the clinical findings. Arterial blood sampling may be useful for other clinical indications, but is not required solely to obtain the initial lactate measurement.
Any abnormalities on the blood tests should be addressed at this stage, such as hypoglycaemia, hyperkalaemia, or hypocalcaemia.
Inotropes are drugs that can be given to support the cardiovascular system if fluid boluses are not successful at raising the blood pressure. These should be prescribed by a senior physician.
In summary, the steps involved in the paediatric sepsis 6:
- Give high flow oxygen
- Obtain access (either IV or IO) and take bloods
- Give IV or IO antibiotics
- Consider fluid resuscitation based on the patient's lactate and fluid status
- Involve senior clinicians/specialists early
- Consider inotropic support early
All of the above should be completed within the first hour of the presentation[3]. If this is achieved, the better the outcome for the child, with the length of stay in paediatric intensive care, general hospital and mortality rate is almost halved. Children’s sepsis boxes can be found on all children’s wards containing everything that is needed to treat the unwell child. A UK audit by the Paediatric Intensive Care Society found that the recommended emergency fluid and inotrope management was not followed in 62% of children in septic shock[4].
[1] https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(17)30010-X/fulltext
[2] https://www.nice.org.uk/guidance/ng51/chapter/recommendations
[4] https://doi.org/10.1136/adc.2008.153064
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell
Quiz
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