This document provides information on recognizing and diagnosing sepsis and septic shock in children. It defines systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. It outlines age-specific vital signs and lab values. It describes signs of organ dysfunction and stages of shock. The examination section highlights important assessment findings. Recommended lab workup and investigations are provided. Central venous oxygen saturation is discussed as an indicator of adequate tissue oxygen delivery. Early recognition of septic shock in children through use of a screening tool is emphasized.

1. SEPSIS RECOGNITION

2. Scenario
• You are examining a 4 year old boy in the ER . He has fever, cough and breathing difficulty from last
2 days and is now dull and drowsy.
• His HR is 160/min, RR 50/min, BP 70/25 mm Hg, temperature 38.5 C, normal volume pulses and
normal CRT.
• GCS is 10/15, B/L crackles
• Assessment????......

3. 5/8/2020 3
Definitions & Organ Dysfunction
Shock; checklist & Stages
Examination; Clues towards
Diagnosis
Relevant Investigations
Objectives

4. DEFINITIONS

5. Systemic inflammatory
response syndrome (SIRS)
1- Temperature: >38.5°C or <36°C
2- Tachycardia: mean HR > 2SD for age in the
absence of external stimuli, drugs
OR
In children < 1 yr old, persistent bradycardia (HR
< 10th centile for age in the absence of CHD,
vagal stimuli or drugs
3- Tachypnea: mean RR > 2SD for age or need
for mechanical ventilation
4 - Leukocyte count high/low for age or >10%
immature neutrophils
Sepsis
• Sepsis: SIRS + suspected or proven infection

6. Severe Sepsis & Septic Shock
Severe Sepsis: Sepsis + 1 of the following:
1-CVS dysfunction, defined as :
• Hypotension(< 5th centile for age/ SBP < 2SD
OR
• Need for vasoactive drug to maintain BP
OR
• 2 of the following
• base deficit > 5
• lactate > X 2 times the upper limit
• CRT > 5 sec
• ∆T > 3⁰C
• Oliguria
ARDS
Sepsis + ≥ 2 organ dysfunctions
(respiratory, renal, neurologic, hematologic, or
hepatic)

7. Age-specific vital signs and Labs
Age Tachycardia Bradycardia Tachypnea SBP WBC x
103/mm3
1d-1wk >180 <100 >50 <60 >34
1wk-1mo >180 <100 >40 <65 >19.5 or <5
1mo-1yr >180 <90 >34 <70 >17.5 or <5
2-5 yrs >140 - >22 <75 15.5 or 6
6-12 yrs >130 - >18 <80 13.5 or <4.5
13-18
yrs
>110 - >14 <90 >11 or <4.5
International Consensus Conference on Pediatric Sepsis
Pediatr Crit Care Med 2005; 6:2-8

8. Organ Dysfunction Criteria
• Cardiovascular:
Despite IV fluid 40ml/kg in 1h
 Decreased BP <2SD for age
 Need for vasopressors
 Two of the following:
- Capillary refill >5 s,
- ΔTC >3oC
- Lactate x 2,
-BD >5
-Oliguria <0.5 ml/kg/h
• Respiratory:
- PaO2/FiO2 <300 (<200=ARDS)
- PaCO2 >65 or 20 mmHg above
baseline
- FiO2 >50% => SpO2 > 92%
-Need for invasive or non invasive MV
• Neurologic
- GCS ≤11
- Acute change in GCS ≥ 3pts from
baseline
• Hematologic:
- PL <80.000/mm3 or a decline >50%
-INR >2
• Renal
- 2-fold increased serum creatinine from
base line
-Serum creatinine ≥ 2 times upper limit of
normal
• Hepatic:
- Bilirubin >78 µmol/L (4mg/dL)
- AST/ALT x 2 times the upper limit of
normal

9. Pediatric Septic Shock Collaborative Triage Trigger Tool/
ACCM guidelines 2017

10. Pediatric Septic Shock Collaborative Triage Trigger Tool/
ACCM guidelines 2017

12. Septic Shock Checklist
• Temperature abnormality
• Hypotension
◦ Hypotension – BP below 5th percentile
◦ Systolic BP (mm Hg) = 70 + (2 x age in
years)
◦ Mean arterial pressure (mm Hg) = <40 +
(1.5 x age in years)
• Tachycardia
• tachypnea
• Capillary refill abnormality
• Skin abnormality
• Pulse abnormality
• Mental status abnormality

13. Septic Shock Checklist

14. High Risk Patients
• Malignancy
• Asplenia (including SCD)
• Bone marrow transplant • Central or indwelling line/catheter
• Solid organ transplant
• Severe MR/CP
• Immunodeficiency, immunocompromise or immunosuppression

15. Stages of Shock
Compensated
• Vital organ functions remain maintained
• BP: normal/increased
Uncompensated
• Clinical signs of shock is present (Hypotension + hypoperfusion)
Irreversible
• Failing compensatory mechanisms:
• Profound vasoconstriction
• Lactic acidosis
• MODS may occur

17. Examination
• CNS: Agitation/drowsiness/coma
• CVS: Hypotension – BP below 5th percentile
◦ Systolic BP (mm Hg) = 70 + (2 x age in years)
◦ Mean arterial pressure (mm Hg) = 40 + (1.5 x age in years)
• RESP: Acidotic breathing pattern/altered pattern
• ABD: Distention/tenderness/sclerema

18. Signs of Hypoperfusion
• Increasing tachycardia
• Diminished or absent pulses
• Weakening central pulses
• Narrowing pulse pressure
• Cold extremities with prolonged capillary refill
• Decreasing level of consciousness
• Hypotension (late finding)

19. Lab Workup
• CBC with differential count and PF
• Blood cultures
• CRP, procalcitonin
• Blood gas, lactate, Scvo2
• PT, APTT, INR, d-dimers
• Liver function tests
• BUN/creatinine
• Electrolytes
• Blood glucose levels
• Blood group and cross-match
• CXR
• Echocardiography

20. CentralVenous Saturation
• Because low CO is associated with increased oxygen extraction, ScVO2/MvO2 saturation
can be used as an indirect indicator of whether CO is adequate to meet tissue metabolic
demand.
• If tissue oxygen delivery is adequate, then assuming a normal SaO2 of 100%, mixed venous
saturation is greater than 70%.

22. Summary
• Early recognition of septic shock remains the key to reduction of mortality among children.
• Each pediatric institution should develop a multidisciplinary approach to early identification of septic
shock with employment of a septic shock screening tool

23. THANK YOU