02 Jul Identifying and Treating Pediatric Sepsis
Nikhil Patankar, MD, MBA
Director for Quality, PICU
Beacon Children’s Hospital
Pediatric sepsis is one of the leading causes of mortality and morbidity worldwide as well as in the United States. It is one of principal reasons for admissions to the pediatric floors and the pediatric intensive care units. Despite improvement in diagnostic techniques and management procedures, mortality due to pediatric sepsis has remained stable in the last few decades.
Sepsis is on the continuum of systemic inflammatory response syndrome (SIRS), severe sepsis, and septic shock. These definitions are adopted from Goldstein criteria published in 2005 from the International Consensus Conference for Pediatric Sepsis.
SIRS is characterized by presence of abnormal temperature, heart rate, white blood cell count and/or respiratory rate. The presence of a confirmed or presumed infection along with SIRS is diagnosed as sepsis.
Severe sepsis happens when the body gets overwhelmed by the presence of an infection leading to organ dysfunction. This may involve, but is not limited to, respiratory failure, cardiovascular dysfunction, liver failure, bone marrow failure, kidney failure, etc. If not treated at this stage, severe sepsis then progresses toward septic shock. This is manifested by presence of cardiovascular dysfunction, characterized by weak or absent central and peripheral pulses, low blood pressure, need for inotropic support, elevated blood lactate levels, worsening metabolic acidosis. This ultimately leads to compromised end organ perfusion, especially to the brain (irritability, lethargy, or coma), heart, skin (delayed capillary refill, mottling), and kidneys (decreased urine output: less than 0.5ml/kg/hr).
Challenges in Recognizing Sepsis in Children
Sepsis in children manifests quite differently than in adults because of various reasons. Children have higher total body water composition than adults. Hence, fluid losses are proportionately greater in children per kilogram body weight. There are also notable differences in myocardial structure and function. For instance, neonatal myocardium is highly dependent on extracellular calcium for ionotropy. Children also have elevated systemic vascular resistance and left ventricular systolic performance is critically dependent on afterload. In a state of shock, children primarily respond by increasing their heart rate than stroke volume to augment cardiac output and blood pressure.
As a result of these important physiologic distinctions, infants and children maintain normal blood pressure for very long time, unlike adults who present with hypotension as the initial sign of septic shock. Hence, relying on blood pressure to discern septic shock can result in delayed recognition and treatment of pediatric sepsis. Children also have notable differences in their renal, immunologic and coagulation function compared to adults. This poses them at higher risk for mortality and morbidity from sepsis.
Joining Forces Against Pediatric Sepsis
Beacon Children’s Hospital is a member of the Children’s Hospital Association at the national level. Since January 2018, we have partnered with them on the Improving Pediatric Sepsis Outcomes (IPSO) initiative, one of 50 participating children’s hospitals nationwide.
IPSO aims at decreasing mortality from severe sepsis and decreasing incidence of hospital onset severe sepsis in acute care settings in all hospitals across the United States. This initiative has been rolled out in our pediatric intensive care unit (PICU) and pediatric floor with a plan to expand to our emergency department in the near future.
All patients from birth through 18 years age admitted to the PICU and pediatric floor will be screened for sepsis and will then be classified into two categories: non-severe sepsis or severe sepsis/septic shock. For patients diagnosed with severe sepsis/septic shock, our plan is to institute and implement treatment and care using the pediatric severe sepsis/septic shock order set. This includes, but is not limited to, administration of antibiotics, fluid resuscitation, and drawing relevant labs (blood culture, lactate) within a specified time period.
We are also currently working on developing a screening tool to differentiate between non-severe sepsis from the severe septic/septic shock patients. Effective communication and multidisciplinary collaboration is the key to improve recognition and treatment of pediatric sepsis and its outcomes.
1. Goldstein et al, International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics, Pediatr Crit Care Med 2005 Vol. 6, No. 1, Pg 2-8.