What is the management of pediatric sepsis?

Management of Pediatric Sepsis

Pediatric sepsis requires immediate recognition and aggressive therapy with fluid resuscitation, antimicrobial administration, and hemodynamic support to reduce mortality and morbidity. 1

Initial Assessment and Recognition

• Implement a protocol/guideline for management of children with septic shock or other sepsis-associated organ dysfunction 1
• Assess for signs of sepsis including abnormal vital signs, altered mental status, decreased capillary refill, diminished peripheral pulses, and changes in urine output 1
• Obtain blood cultures before initiating antimicrobial therapy when this does not substantially delay treatment 1

Antimicrobial Therapy

• In children with septic shock, start antimicrobial therapy as soon as possible, within 1 hour of recognition 1
• For children with sepsis-associated organ dysfunction but without shock, start antimicrobial therapy within 3 hours of recognition 1
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 1, 2
• For neonates with suspected bacterial sepsis, combine gentamicin with a penicillin-type drug 2
• For immune-compromised children or those at high risk for multidrug-resistant pathogens, use empiric multi-drug therapy 1
• Perform daily assessment for de-escalation of antimicrobial therapy based on clinical improvement and microbiological results 1
• Narrow or discontinue antimicrobial therapy once pathogen and sensitivities are available 1, 2

Fluid Resuscitation

• In healthcare systems with intensive care availability, administer up to 40-60 mL/kg in bolus fluid (10-20 mL/kg per bolus) over the first hour 1
• Titrate fluid administration to clinical markers of cardiac output (heart rate, blood pressure, capillary refill, level of consciousness, urine output) 1
• Discontinue fluid boluses if signs of fluid overload develop (hepatomegaly, rales/pulmonary edema) 1
• Use crystalloids rather than albumin for initial resuscitation 1
• In non-hypotensive children with severe hemolytic anemia (severe malaria or sickle cell crises), blood transfusion is considered superior to crystalloid or albumin bolusing 1

Hemodynamic Support

• Begin peripheral inotropic support until central venous access can be attained in children who are not responsive to fluid resuscitation 1
• For cold shock (low cardiac output, high systemic vascular resistance):
  • Titrate central dopamine or, if resistant, titrate central epinephrine 1
• For warm shock (high cardiac output, low systemic vascular resistance):
  • Titrate central norepinephrine 1
• For patients with low cardiac output and elevated systemic vascular resistance with normal blood pressure, add vasodilator therapies (phosphodiesterase inhibitors, nitrosovasodilators) to inotropes 1

Corticosteroids

• Administer timely hydrocortisone therapy in children with fluid-refractory, catecholamine-resistant shock and suspected or proven absolute adrenal insufficiency 1
• Consider hydrocortisone within 60 minutes for catecholamine-resistant shock 1

Source Control

• Implement emergent source control intervention as soon as possible after diagnosis of an infection amenable to source control 1
• Remove intravascular access devices confirmed to be the source of sepsis after establishing alternative vascular access 1

Supportive Care

• Target hemoglobin levels of 10 g/dL during resuscitation of low superior vena cava oxygen saturation shock (<70%); after stabilization, a lower target <7.0 g/dL can be considered 1
• Use lung-protective strategies during mechanical ventilation 1
• Monitor drug toxicity labs because drug metabolism is reduced during severe sepsis 1
• Control hyperglycemia with a target <180 mg/dL; accompany insulin therapy with glucose infusion in children 1
• Provide enteral nutrition when possible; use parenteral nutrition when enteral feeding is not possible 1

Advanced Therapies

• Consider ECMO (Extracorporeal Membrane Oxygenation) for refractory pediatric septic shock or respiratory failure 1
• Use diuretics to reverse fluid overload when shock has resolved; if unsuccessful, consider continuous venovenous hemofiltration (CVVH) or intermittent dialysis to prevent >10% total body weight fluid overload 1
• Use plasma therapies to correct sepsis-induced thrombotic purpura disorders 1

Time-Critical Interventions

• Within 5 minutes: Begin initial resuscitation with fluid boluses and correct hypoglycemia and hypocalcemia; start antibiotics 1
• Within 15 minutes: For fluid-refractory shock, begin inotrope therapy; obtain central access and secure airway if needed 1
• Within 60 minutes: For catecholamine-resistant shock, consider hydrocortisone if at risk for adrenal insufficiency 1

Common Pitfalls and Caveats

• Relying solely on blood pressure as an endpoint for resuscitation is unreliable in children; assess multiple clinical markers of perfusion 1
• Continuing fluid administration despite signs of fluid overload can worsen outcomes; switch to inotropic support if hepatomegaly or rales develop 1
• Delaying antimicrobial therapy significantly increases mortality; do not wait for all cultures before starting antibiotics 1, 3
• Underestimating the need for early inotropic support in fluid-refractory shock can lead to increased mortality 1
• Failure to reassess frequently for clinical improvement and potential de-escalation of therapies 1