Pediatric sepsis is one of the leading global causes of mortality and is characterized by systemic
inflammatory response (SIRS) caused due to infection. The definition of sepsis now extends to include
sepsis that is complicated by one or more organ dysfunctions. This definition, however, was developed
to describe sepsis in adults, and a concrete definition for children is needed based on organ dysfunction
scoring in accordance with the definition for adult sepsis.
A life-threatening condition, it accounts for nearly 7.5 million deaths annually. It includes the deaths
resulting from the four most common causes of childhood mortality, viz, severe pneumonia, severe
diarrhea, severe malaria and severe measles.
Sepsis
Pediatric sepsis includes a spectrum of disorders that result from bacterial, viral, fungal, parasitic
infections or from the toxic products of these organisms. Although also seen in adults, sepsis in
children is different in terms of physiology, predisposing diseases and the sites of infection. This
results in differences in the diagnostic criteria and management strategies. Many children who
suffer from sepsis have a comorbid condition, most common of which are chronic lung disease or
congenital heart disease in infants, neuromuscular disease in children ages 1 to 9 years, and cancer
in adolescents. A consensus of what sepsis is exactly is yet to be reached, although most agree that
sepsis is defined as a systemic inflammatory response to the presence of a documented infection.
Earlier, a diagnosis of sepsis required a positive blood culture or confirmation of a documented
infection with the presence of shock or hypotension. The symptoms of sepsis were added to refine
the definition of sepsis, which include fever, mental status changes, tachypnea, tachycardia,
hypotension, leukocytosis, thrombocytopenia and abnormalities in coagulation.
Infection
A suspected or proved infection caused by a pathogen or a clinical syndrome that can be an indication
of infection. Evidences that are used for indicating infection are clinical examination, imaging or lab tests.
Systemic inflammatory response syndrome (SIRS)
SIRS is characterized by the presence of atleast two of the following clinical presentations including
either abnormal body temperature or leukocyte count
- Core temperature-greater than 38.5??C
- Tachycardia or bradycardia- without external stimulus such as due to drugs
- Elevated or depressed leukocyte count
- Suspected or proved infection by a pathogen, or a clinical syndrome indicative of an infection
Severe sepsis
As per the pediatric sepsis consensus congress (PSCC), pediatric severe sepsis is defined as
- Two or more systemic infections inflammatory response syndrome criteria
- Confirmed or suspected invasive infection
- Cardiovascular dysfunction and acute respiratory distress syndrome
- Two or more organ dysfunction
If sepsis is seen in conjunction with organ damage, reduced mental state, disseminated intravascular
coagulopathy, acute respiratory distress syndrome or acute Kidney failure, it is termed as severe sepsis.
It is commonly treated in pediatric intensive care units. It is an increasingly common condition which
reflects an expansion in the population susceptible, i.e., those who suffer from the comorbidities.
Pathophysiology
When a pathogen gains entry to the intravascular compartment, host defense mechanisms are activated.
Depending upon the age and immune status of the child, the virulence, number of pathogens in blood and
the timing and nature of therapeutic intervention, an inflammation response is developed which continues
even after the pathogen has been eradicated. Imbalances between anti-inflammatory and proinflammatory
mediators are aggravated by the microbial toxins. In case of pediatric sepsis, coordinated activation of the
innate response is triggered by pathogens. The effect of this response is secretion of cytokines, activation
and mobilization of leukocytes, activation of coagulation, inhibition of fibrinolysis, and increased apoptosis.
These exaggerated inflammatory responses lead to the clinical manifestations of sepsis, which include
cardiac dysfunction, vasodilation, capillary injury, micro- and macrovascular thrombosis. This can eventually
lead to organ dysfunction, long term neurological damage and even death.
Clinical manifestations of sepsis include
- Abnormal temperature regulation
- Widened pulse pressure
- Flushed warm skin
- Tachycardia
- Metabolic acidosis
- Renal and/or hepatic failure
- Leukocytosis and thrombocytosis
Identifying early sepsis The most important factor for the management of sepsis is timely recognition and
initiation of the therapy immediately. This can be challenging because unlike sepsis in adults, pediatric
sepsis can result in a protracted state of compensated sepsis which is not very apparent but is still
detrimental. Some of the features of sepsis manifest as abnormal vital signs that can be used to alert
the physician into suspecting sepsis.
The earliest sign of clinical infection is change in body temperature, accompanied by hypothermia
and fever in immune compromised children. Once fever has been controlled by antipyretic drug,
persistent change of behavior signified by loss of playfulness can indicate severe infection.
Tachycardia/tachypnea also helps to identify sepsis in children and infants.
Septic shock is one of the major causes of mortality in children worldwide. It is recommended that
this complication of sepsis can be identified within the first hour, as a delay of each hour for therapy
is associated with escalating risk of mortality. These children have to be admitted to emergency care
immediately and triage tools as well as septic shock protocols have shown to reduce the time of
recognition of septic shock and initiation of antibiotics and fluids. Some reco mmendations have
been developed to provide a standardized process for the identification and evaluation of children
with sepsis. In some patients with abnormal screens indicative of sepsis did not demonstrate organ
damage as seen in severe shock. Implementation of fluids and antibiotics early is suggested to
prevent progression to severe sepsis and septic shock. In fact, delayed antimicrobial therapy is reported
to be an independent risk factor for organ dysfunction and mortality in patients with severe sepsis and
septic shock.
Management of SIRS
When two or more SIRS criteria are observed in an individual who still has his blood pressure at the
baseline, clinical assessment is made to determine the possibility of a source infection. Sepsis is
diagnosed when infection is suspected or confirmed, and the degree of hypoperfusion and inflammation
is determined. If severe sepsis is suspected, aggressive management maneuvers are made with
the help of broad spectrum antibiotics, intravenous fluid and vasopressive drugs. Those patients
with infection as well as hemodynamic instability are immediately treated for septic shock. Aggressive
treatments should not be delayed for lab test results.
Management of pediatric sepsis
Much of what is followed for managing pediatric sepsis is similar to the protocols followed for sepsis
in adults. Early and aggressive source control is the top priority, which includes drainage, debridement
as well as surgical intervention. Antibiotic therapy is initiated within one hour of suspecting sepsis and
should not be delayed for blood culture. Positive cultures are not a diagnostic criteria for pediatric sepsis,
however they help in narrowing of antibiotic usage in case of positive cultures. Narrowing the antibiotic
coverage helps the patients, and also addresses the globally rising risk of antibiotic resistance.
Fluid resuscitation is aggressive and is done either intravenously or intraosseously. If done early
and aggressively, fluid resuscitation is shown to decrease mortality, Many children with septic shock
suffer from adrenal insufficiency and are given corticosteroid treatment, especially in cases where
purpura, prior steroid therapy and adrenal abnormalities are suspected. Cardiovascular treatment
endpoints are the normalization of vital signs and improved mental status.
After treatment, supportive care should be initiated, which includes, ensuring adequate circulation,
airway patency and gas exchange. It is also important to determine when, which and how much
pharmacological support is required. This is decided by many factors like patient's clinical state,
vitals and the knowledge of effects of the basic drugs in the setting of a septic shock.
Sepsis is an emergency condition that often requires immediate medical attention. The fact that it
is difficult to identify makes it even more dangerous. It is therefore recommended that if a child suffers
from prolonged infection that is not resolving, but is rather worsening, they should be taken to a doctor
for an expert's examination.
