By Rommie L. Duckworth
Children can develop sepsis secondary to infection from an illness or traumatic injury. Here are 10 quick facts about pediatric sepsis to increase your confidence and better prepare you and your co-workers the next time you find yourself facing this challenging syndrome.
1. Sepsis isn’t the infection, it’s the reaction
Sepsis is not the infection itself. Sepsis is an over-reaction that is triggered by infection, not unlike anaphylactic shock. It is appropriate for the body to have a local reaction to a bee sting. With anaphylaxis, the problem is that the body is having a systemic, out of control reaction to that bee sting. The bee sting is the trigger, but the real problem is the reaction.
When a similar system-wide reaction occurs in sepsis it results in physiological changes that include vasodilation causing distributive shock, capillary leakage causing hypovolemic shock and increased clotting causing obstructive shock.
2. The smaller they are, the harder they fall
Infants are, by far, the age group most generally susceptible to infections and sepsis. They are also the age group in which sepsis is most severe [1]. In the United States, each year almost 50,000 cases of sepsis occur in pediatric patients (age 0 – 19 years old) and approximately 4,400 of these children don’t survive [2,3].
3. There is no test for sepsis
There are many things to assess with the patient for whom you suspect sepsis. These can include vital signs as well as blood lactate, ETCO2, and in some services even blood cultures.
Unfortunately, there is no single clinical indicator or test for sepsis. Instead, EMS providers need to put together a variety of sepsis indicators. Consider these indicators to be the sepsis red flags. If you work in a system that uses a sepsis alert, these may already be defined for you. If not, consider the following tips for patient assessment.
4. Assess complaints with SEPSIS mnemonic
For children, specifically, keep an eye out for complaints that classically point to infection such as fever, runny nose, rash, vomiting or diarrhea, concentrated foul-smelling urine, discharge or pus [4].
A mnemonic for sepsis complaints to watch for is patients of any age who complain of or are observed:
Shivering
Extreme discomfort
Pale
Sleepy
“I feel like I might die” complaint
Short of breath
5. Consider the patient’s history
Ask questions about anything that might decrease the patient’s immune system such as immunotherapy, chemotherapy, regular use of steroids or HIV/AIDS, which can reduce the effectiveness of the immune system, as these make it more likely that a patient will acquire an infection and react with sepsis [5].
Look for any co-morbid factors that may lead a patient to either be more susceptible to either an infection, cardiovascular collapse or both. These include diseases such as cancer, cystic fibrosis, sickle cell disease, liver or splenic dysfunction, poor cardiac or respiratory reserves and factors related to surgery including children with organ transplants, indwelling devices, recent surgery or traumatic injury (especially burns) or dependence on mechanical ventilation [5].
6. Perform a sepsis specific assessment
If the patient’s complaints and history have you suspecting sepsis, focus on the following sepsis indicators during your assessment:
- Altered mental state
- Body temperature: <97 F or >101 F (<36 C or >38.5 C)
- Tachycardia for age
- Tachypnea for age
- Hypotension for age
- Serum Glucose > 180 mg/dL
Additional assessment criteria, especially capnography and serum lactate, that may be helpful include the following:
- Pale, ashen, cyanotic or mottled skin
- Skin that has a non-blanching rash
- Prolonged capillary refill
- Respiratory dysfunction including severe respiratory distress, grunting or apnea
- ETCO2 <32 mm Hg
- Serum Lactate > 4 mmol/L
- Urine Output <1 mL/kg/hr (dry diaper)
- Supplemental oxygen required to maintain SpO2 > 92 percent
- Vasopressors required to maintain BP after administration of fluids
7. Wave those red flags
Use those sepsis red flags that you have collected from the patient’s complaints, history and assessment. If your service has a formal sepsis alert protocol, use the specific red flags listed in the protocol. If not, use those listed here and advise the receiving hospital, “I suspect sepsis.”
8. Treat what you find
You can use the ABCD format for prioritized treatment of the septic pediatric patient.
Airway: RSI or med facilitated intubation should be used with caution as induction agents may precipitate cardiac arrest in pediatric patients in septic shock, especially etomidate [6,7].
Breathing: Septic pediatric patients will often be working very hard to breathe and will require ventilation to both increase oxygenation as well as reduce the oxygen demand from the stress and effort it takes to breathe. Again, CO2 monitoring is a great way to monitor for effective ventilation.
Circulation: Initial fluid administration is 20 mL/kg boluses of normal saline (0.9% sodium chloride) over 5 to 10 minutes [7].
Drugs: While dopamine may be appropriate for adults, it should not be used in pediatric patients with septic shock [1,8]. For cold shock — cool extremities, delayed capillary refill — administer epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrating to effect. For warm shock — warm extremities, flash capillary refill — administer norepinephrine 0.1-2 mcg/kg/min IV/IO infusion, titrating to effect.
9. We’re not sure which treatment does the most good
While emergency care for pediatric victims of sepsis can begin in the field, we don’t yet know what care does the most good for patient outcomes [9]. This doesn’t mean that current recommendations for treatment are ineffective, just that more sepsis research, especially for prehospital treatment, is needed.
10. There’s more to come
The Third International Consensus Definitions For Sepsis and Septic Shock were introduced in February, 2016 followed by the United Kingdom National Institute for Health and Care Excellence sepsis recognition, diagnosis and early management guidelines published in July, 2016 [10,11].
Research continues to improve our understanding of the pathophysiology, assessment and best treatments for sepsis patients. As with other diseases and syndromes that we encounter, EMS providers must remain ready to employ new assessment tools and treatment techniques as we gain better understanding of the problems that our patients encounter.
In the meantime, share this list of 10 things paramedics need to know about pediatric sepsis and the SEPSIS assessment mnemonic with co-workers and colleagues to help take a step towards improved EMS recognition, assessment and treatment of pediatric sepsis.
References
1. Ventura, A. M. C. et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Critical Care Medicine Publish Ahead of Print, 1 (2015).
2. Watson, R. S. & Carcillo, J. A. Scope and epidemiology of pediatric sepsis. Pediatric Critical Care Medicine 6, S3–S5 (2005).
3. Balamuth, F. et al. Pediatric Severe Sepsis in US Children’s Hospitals. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 15, 798–805 (2014).
4. Plunkett, A. & Tong, J. Sepsis in children. BMJ 350, h3017–h3017 (2015).
5. Santhanam, S. Pediatric Sepsis Differential Diagnoses. emedicine.medscape.com (2014). Available at: http://emedicine.medscape.com/article/972559-differential. (Accessed: 16 June 2014)
6. Duckworth, R. L. Personal Interview with Dr. Adrian Plunkett. Royal College of Emergency Physicians (2016).
7. de Caen, A. R. et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 132, S526–42 (2015).
8. Brierley, J. & Peters, M. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. PEDIATRICS 122, 752–759 (2008).
9. Smyth, M. A., Brace-McDonnell, S. J. & Perkins, G. D. Impact of Prehospital Care on Outcomes in Sepsis: A Systematic Review. West J Emerg Med 17, 427–437 (2016).
10. Singer, M. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315, 801–810 (2016).
11. National Institute for Health and Care Excellence. NICE consults on guideline to speed up recognition and treatment of sepsis. NICE (2016).