This is presentation on pediatric sepsis seeks to explain all that is important about infection leading to septicemia and then causing sepsis. It gave explanation to predisposing factors of sepsis in children and how best to put an end to causes of sepsis. It is a quick overview of all you need to know in pediatric sepsis. It is a brief presentation of everything you need to know about why your child may be having high or low temperature.

1. Pediatrics Sepsis
Presented by DR ONWOSI I. D
Supervised by DR OKEKE
NATIONAL OBSTETRIC FISTULA CENTER, ABAKALIKI
Department of Pediatrics
1
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

2. OUTLINE
• OBJECTIVE
• INTRODUCTION
• DEFINITION OF TERMS
• SEPSIS THE CURRENT TREND
• ETIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL MANIFESTATIONS
• DIAGNOSIS
• TREATMENT
• COMPLICATIONS
• PREVENTION
• CONCLUSION
• BIBILOGRAPHY
2
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

3. OBJECTIVE
• To improve the accurate diagnosis of sepsis using a constellation of
symptoms, signs, and laboratory findings.
• To improve the management of patients with sepsis
3
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

4. Introduction
• Sepsis is a clinical syndrome that complicates severe infection and is
characterized by Systemic Inflammatory Response Syndrome(SIRS),
immune dysregulation, microcirculatory derangements and end organ
dysfunction. It is SIRS + proven or suspected septicemia.
• SIRS is an inflammatory cascade that is initiated by the host in
response to infection with bacteria, virus , fungi , and protozoa
• It occurs when the host defense system does not adequately
recognize or clear the infection.
4
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

5. • Severe sepsis: Presence of sepsis combined with organ dysfunction.
• Septic Shock: severe sepsis and the persistence of hypotension ,or
hypoperfusion for > 1hr despite adequate fluid resuscitation or
requirement of inotropic agent or vasopressors .
• Sepsis with cardiovascular dysfunction: It occurs when there is two
of the following: prolonged capillary refill time, oliguria, metabolic
acidosis or increased lactate despite administration of more than
40ml/kg of isotonic saline in one hour.
• MODS; Multiple Organ Dysfunction Syndrome
5
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

6. Epidemiology
• Sepsis is a frequent cause of death in the developing world.
• The risk of sepsis is inversely related to age in children
• Neonates are at the highest risk 1-10 per 1000 live births.
• No sex predilection except for Uro-sepsis.
• More common in patients that has HBSS
• Among top 3 causes of admission in NOFIC New Born Unit.
6
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

7. Epidemiology
• Among 4 commonest causes of admissions in the NBSCU of UNTH
recent review
• Causes 18-35% of neonatal deaths in Nigeria and other parts of Africa
• Up to 10% neonates have infections within 1st month of life (US
figures)
• Mortality for pediatrics sepsis ranges from 9% to 35%
• Almost half of neonatal deaths is caused by sepsis
• In Nigeria Case fatality for Pediatrics sepsis ranges from 21.5-40%
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY
7

8. Risk factors
• Sepsis may develop as a complication of localized infection or may
follow colonization and mucosal invasion by virulent pathogens
• Patient at risk of sepsis include: neonates, preterm, infants admitted
in hospital especially ICU infants, children with serious injuries,
chronic antibacterial therapy, malnourished children, steroid therapy,
chronic medical illness, immunocompromised patients, transplant,
malignancy on chemotherapy, congenital immune deficiencies,
splenic dysfunction, congenital heart diseases, burns, indwelling
devices.
8
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

9. Etiologic agents
• Myriad of bacteria , viruses, fungi and parasites
• Among the bacteria causes there are age related causes: neonates-
Streptococcus agalactiae, E. coli, Listeria monocytogenes
• Late neonatal infections are usually due to staphlococcus auerus, ,
coagulase negative staph, E.coli klebsiella spp, Enterobacter,spp
Pseudomonas.
• Infancy: H. influenza type b, Strep. Pnuemoniae, Salmonella spp,
Neisseria meningitidis
9
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

10. • The same organisms that cause sepsis in infancy causes it in
childhood. However the presence of encapsulated organism becomes
less as the child’s immune system matures
• Other pathogens include
• Rickettsia rickettsia, Candida, Aspergillus (fungi) especially in
immunocompromised patients in which the polymicrobial sepsis
occurs.
10
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

11. Pathogenesis of sepsis and organ dysfunction
syndrome.
11
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

12. • If this cascade is uncontrolled, SIRS occurs with subsequent organ
and cellular dysfunction as a result of microcirculatory system
dysfunction.
• Series of events ensues which include ; complement activation,
endothelial injury, changes in the cardiovascular tone, platelet
aggregation and obstruction of the capillary beds.
12
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

13. • In sepsis SIRS is caused by infectious agent or toxins.
• The outcome depends on the intricate interplay of upregulating and
downregulating cytokines and inflammatory cells and the direct
effects of the insult itself.
• The earliest manifestation of SIRS is a triad of: temperature alteration,
tachypnea, and tachycardia.
• If it identified early subsequent cascade can be mitigated lest it will
progress to organ damage
13
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

14. • 2 out of the 4 SIRS MUST be met and 1 out of the two must be either
a or b
• a. Increase temp of 38.5 degrees or decrease <36 degree
• b. Leukocyte count elevated or depressed or >10% immature
neutrophils
• Tachycardia above normal for age in the absence of external stimuli
or drugs or bradycardia (<1yrold) in absence of vagal stimulation ,
drugs or congenital heart disease.
• Tachypnea Respiratory rate above the normal for age or need for
mechanical ventilation
14
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

15. Cellular response
• Decreased oxygen delivery-decreased oxidative phosphorylation
• Anaerobic metabolism
• Glycogen depletion
• Lactate production and fatty acid
• Decreased ATP production
• Prostaglandin production.
15
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

16. Biochemical response
• Production of arachidonic acid metabolites
• Myocardial depressant factors
• Endogenous opiates activation of complement system as well as
production of many other mediators: decrease sympathetic activity
and release of vasoactive mediators that cause increase capillary
permeability , vasodilatation and platelet aggregation.
16
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

17. • Myocardial depressant factors; TNF and some interleukins cause
myocardial depression via direct injury and also by an intra-cardiac
increase in nitric oxide synthase
• Thus the clinical manifestation of sepsis and septic shock are
mediated through the inflammatory cascade due to stimulation of
these pro inflammatory mediators by the TNF and interleukins.
17
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

18. • These inflammatory cascade is initiated by toxins or super-antigens
of gram positive organisms or endotoxin (lipopolysaccharide)
glycoprotein components of cell wall of gram negative bacteria as
well as fungi.
• In sepsis the body has compensatory mechanisms to maintain blood
pressure through increased heart rate and peripheral
vasoconstriction when these compensatory fails, hypotension ensues.
This is a late sign in infants.
18
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

19. • Septic shock is a combination of 3 classic shock: Hypovemic,
Cardiogenic, and Distributive shock.
• The degree of manifestation is variable
• In children cold shock which involves decreased cardiac output and
elevated systemic vascular resistance is more common while warm
shock is more common in adult
19
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

20. Clinical manifestation
• Alteration in temperature
• Tachycardia
• Tachypnea
• Toxic appearance
• Distended abdomen
• Altered mental status(confusion , irritability, agitation, lethargy, coma
• Hypotension(late sign) cold extremities.
• Delayed capillary refill time
• Cutaneous lesion: purpura, petechiae, diffuse erythema, ecchymosis, ecthyma gangrenosum,
symmetric peripheral gangrene
• Jaundice.
• The patient may have signs and symptoms of local infection eg rales in pneumonia, neck
stiffness in meningitis etc.
20
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

21. Sequential Organ Failure Assessment(SOFA)
and qSOFA
• Increased respiratory rate
• Altered mental status
• Decreased systolic blood pressure
• Deranged creatinine and bilirubin
• Platelet abnormalities, Pao2/Fio2
• Glasgow coma score
• Mean arterial blood pressure or requirement of vasopressors
Thus defining sepsis as life threatening organ dysfunction
caused by dysregulated host response to infection
21
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

22. Investigation
• Complete blood count
• SEUCr and liver function tests
• Coagulation profile
• Etiology specific serology
• Acute phase reactants
• Culture of fluids , CSF, pleural fluid, urine abscess
• Chest x-ray
• Ultra sound, echocardiography
22
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

23. Differential diagnosis
• Localized infections such as UTI, Pericarditis, bacterial meningitis, etc.
• In Newborn, the following differentials are possible:
• Transient tachypnoea of the newborn
• Meconium aspiration syndrome
• Intracranial hemorrhage
• Cyanotic congenital heart disease
• Perinatal asphyxia
• Respiratory distress syndrome
• Bronchopulmonary dysplasia
23
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

24. Diagnosis
• Diagnosis depends on clinical presentation with evidence of SIRS and
proven or suspected infection.
• Laboratory abnormalities include thrombocytopenia, prolonged
prothrombin and partial thromboplastin time, elevated fibrin products
• Anemia
• Elevated WBC count with neutrophilia, left shift of WBC, vacuolation of
neutrophils, neutropenia, band cell greater than 10%.
• Electrolyte derangements, hyperglycemia or hypoglycemia, hypocalcaemia
, hypoalbuminemia, hyperlactatemia, low serum bicarbonate, Deranged
liver function test, renal function test,
• Decrease PaO2 and increased PCO2
24
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

25. Treatment
• Treatment of sepsis involves diligent antibiotic stewardship.
• Early recognition and treatment is important in reduction of mortality
and morbidity
• Choice of antimicrobial is dependent on the predisposing risk factors
and clinical situation
• Empiric antimicrobial therapy should be based on pathogens most
frequently encountered in each age group, history of comorbidities,
clinical syndrome, gram stain data, local resistance
25
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

26. • Specific treatment
– Antibiotics
– Empirical tx needed pending bacterial cultures and requires broad spectrum
coverage
– Common combinations include: ampicillin/gentamicin, cloxacillin/gentamicin,
cefuroxime/gentamicin
– In the critically ill, third generation cephalosporins can be added or used in
place of ampicillin/penicillins
– Duration of treatment b/w 10 &14 days; can be longer in some cases.
26
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

27. SUPPORTIVE/ADJUNCT TREATMENT
• Transfusions: blood, EBT, fresh frozen plasma
• Crystalloids for volume expansion
• Pressor agents – dopamine, dobutamine for hypotension or hypoperfusion
(or both)
• Sodium bicarbonate for acidosis
• Anticonvulsants for seizures
• Adjunct immunotherapies:
– Intravenous immunoglobulins (IVIG), Telipressin, Inhaled nitric oxide, Pentoxifylline,
ECMO- extracorporeal membrane oxygenation
– Treatment with granulocyte colony stimulating factor and granulocyte macrophage
stimulating factor
– Recombinant cytokines
27
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

28. Prognosis
• Mortality depends on the site of infection, pathogen , MODS, and
host immune response
• Complications include SHOCK , MODS.
• Neurological deficit,
• Disabilities
• Death ; severe sepsis and septic shock causes about 30-50%
mortalities
28
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

29. Prevention
• General Health promotion
• Specific protection
• Early diagnosis and prompt treatment
• Limitation of disability
• Rehabilitation
29
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

30. Conclusion
• Sepsis is a leading cause of death, morbidity and expenditure ,
contributing to one third to half of the deaths in hospitalized patients
• Management of sepsis is quite challenging requiring early
recognition , management of infection, antibiotic stewardship,
hemodynamic issues and other organ dysfunctions
30
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

31. BIBILOGRAPHY
• Nelson Textbook of Paediatrics 18TH EDS Pg 1094.
• Azubuike Nkanginieme, Paediatrics and child health in tropical region 2nd edition
• Nelson textbook of Paediatrics 20th edition. Shock in the critically ill child.
• Surviving sepsis campaign 2012,.
• Surviving sepsis campaign 2023 update accessed from
https://www.mdpi.com/2077-0383/12/9/3188
• Sepsis Guidelines by WHO: https://www.who.int/news-room/fact-
sheets/detail/sepsis
• Cleveland clinic 2023 Sepsis vs Septicemia accessed from
https://my.clevelandclinic.org/health/diseases/21539-septicemia
• Yale Medicine, Pediatric sepsis: accessed from
https://www.yalemedicine.org/conditions/sepsis-in-kids
31
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY

32. Thanks for your rapt attention
32
Pediatric sepsis presented by DR ONWOSI IKECHUKWU
DESTINY