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Next Lesson - Child Safeguarding
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.
- We identify sepsis using criteria relating to the patient's temperature, heart rate, respiratory rate and white cell count.
- 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 occurs when an infection causes a dysregulated host response in terms of inflammation, the neuroendocrine response, coagulation, and metabolic responses. The infection becomes disseminated throughout the body and so the response is not limited to the source, but takes place throughout the body. This massive widespread response directly causes life-threatening organ dysfunction that can very easily result in death.
Therefore, the definition of sepsis is “A life-threatening organ dysfunction caused by a dysregulated host response to infection”.
The Sequential Organ Function Assessment (SOFA) score was devised to identify any organ dysfunction, and is then simplified to the q-SOFA score (quick-SOFA score) for clinical use. This is based off the if the patient’s respiratory rate is over 22 breaths per minute, blood pressure is below 100 mmHg systolic and any drop in consciousness level. The score is associated with a higher risk of mortality in septic patients when any two of the three factors are present.
There has not been a q-SOFA score released for paediatrics, so these guidelines are based on the 2005 international sepsis consensus and categorise SIRS (systemic inflammatory response syndrome) as an indicator of potential sepsis. It requires at least two of the following criteria to be present:
- A temperature, either high or low
- A raised heart rate
- A raised respiratory rate
- A high or low white cell count
Sepsis is defined as SIRS with a suspected or proven infection (i.e. inflammation + infection = sepsis).
Sepsis with organ dysfunction is known as severe sepsis. This can be any organ, but if it involves the cardiovascular system then this is known as septic shock.
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%! The aim is to easily identify those children with organ dysfunction and severe sepsis, as they will need the most medical care[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.
A lactate level should be measured through an arterial blood gas. This can be used to assess the level of cardiovascular impairment, as tissues that are without a good blood supply rely on anaerobic respiration, which increases lactate levels.
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. The national confidential enquiry into patient outcome and death (NCEPOD) found that 62% of these severely acutely unwell children did not receive this care within that first golden hour[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://www.ncepod.org.uk/2015report2/downloads/JustSaySepsis_FullReport.pdf
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell
In this article
Sepsis in children can often be missed as the presentation is very similar to that of a normal viral illness.
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