What is the appropriate sepsis screening for a 3-year-old with tachycardia, hypotension, and tachypnea?

Sepsis Screening for a 3-Year-Old with Concerning Vital Signs

This child meets criteria for septic shock and requires immediate systematic screening using an institution-specific protocol that includes vital sign assessment, clinical examination for perfusion markers, and rapid laboratory evaluation—all performed within minutes of recognition. 1

Immediate Clinical Assessment

The vital signs presented are critically abnormal for a 3-year-old:

• Heart rate 183 bpm (severe tachycardia; normal range 80-120)
• Blood pressure 70/43 mmHg (hypotensive; normal systolic ~90-105)
• Respiratory rate 46 (tachypneic; normal 20-30)

These findings indicate septic shock requiring immediate action. 1, 2

Required Screening Components

Physical Examination Markers (Assess Immediately)

Perfusion assessment:

• Capillary refill time (abnormal if >2 seconds) 1
• Peripheral pulse quality and differential between central/peripheral pulses 2
• Extremity temperature (warm vs. cold) 1
• Mental status (lethargy, confusion, poor interaction with parents) 2
• Urine output assessment 1
• Hepatomegaly or pulmonary rales (signs of fluid overload) 1

Critical pitfall: Hypotension confirms shock but its presence here indicates decompensated shock—this child is critically ill. Normal capillary refill can occur in early "warm shock," so don't be falsely reassured. 2

Point-of-Care Testing (Within Minutes)

Mandatory immediate tests:

• Blood glucose (hypoglycemia mimics septic shock in toddlers with limited glycogen stores) 2
• Temperature (fever or hypothermia—absence of fever does not exclude sepsis) 2
• Lactate level (though guidelines note uncertainty about using lactate for risk stratification in children, it remains part of systematic assessment) 1

Laboratory Screening (Before Antibiotics, But Don't Delay Treatment)

Blood cultures must be obtained before antimicrobials when possible, but this should not delay antibiotic administration beyond 1 hour of recognition. 1

Additional screening labs:

• Complete blood count with differential 1
• Blood gas for base excess and lactate 3
• Electrolytes, blood urea nitrogen, creatinine 4
• Coagulation studies if bleeding or purpura present 1

Source Identification Screening

Examine for infection sources:

• Respiratory: auscultation for pneumonia 5
• Urinary: urinalysis if obtainable without delay 3
• Skin: petechiae, purpura, cellulitis 5
• Central nervous system: meningeal signs, altered mental status 1
• Abdomen: peritonitis, intra-abdominal source 1

Screen for complications requiring immediate intervention:

• Pneumothorax 1
• Pericardial tamponade 1
• Endocrine emergencies (adrenal insufficiency, hypothyroidism) 1, 2

Institutional Protocol Implementation

The Surviving Sepsis Campaign strongly recommends implementing a standardized institutional protocol/guideline for management of pediatric septic shock. 1 This screening should be part of a "recognition bundle" that triggers immediate resuscitation. 5

The screening protocol must be tailored to your institution's resources but should enable recognition within minutes and treatment initiation within the first hour. 1, 5

Critical Time-Sensitive Actions Concurrent with Screening

While screening is performed, simultaneously initiate:

1. Vascular access (peripheral IV or intraosseous if IV cannot be obtained within minutes) 1, 2

2. Fluid resuscitation (20 mL/kg isotonic crystalloid boluses up to 40-60 mL/kg in first hour, discontinued if hepatomegaly or rales develop) 1

3. Antimicrobial therapy within 1 hour of recognition (broad-spectrum, empiric coverage) 1

4. Continuous monitoring (pulse oximetry, ECG, blood pressure, temperature, urine output) 2

Common Pitfalls to Avoid

Do not wait for laboratory results to initiate treatment. Sepsis screening is a clinical diagnosis supplemented by labs, not dependent on them. 5

Do not assume normal capillary refill excludes shock. This child has hypotension—shock is confirmed. 2

Do not delay antibiotics for lumbar puncture. Blood cultures yes, but LP should not delay antimicrobials beyond 1 hour. 1

Do not use lactate alone for risk stratification in children. The Surviving Sepsis Campaign was unable to recommend this practice in pediatrics, though lactate measurement remains useful for monitoring. 1