Sepsis in children
Sepsis is a medical emergency that requires immediate recognition and treatment. While the core principles of management remain the same, recent updates from UK guidelines (including NICE, APLS, and the UK Sepsis Trust) have refined the approach to paediatric sepsis, with a focus on early identification, a structured response, and updated definitions.
Definitions and Concepts
The term “Systemic Inflammatory Response Syndrome” (SIRS) is now less commonly used in UK paediatrics to define sepsis as it’s recognised that a dysregulated response to infection, not just inflammation, is the core of the problem.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a clinical diagnosis.
Septic Shock is a subset of sepsis in which circulatory and metabolic abnormalities are profound enough to increase mortality. Hypotension is a late and ominous sign in children, as they can maintain blood pressure for longer than adults due to their greater physiological reserve.
High-Risk Groups
The UK Sepsis Trust and NICE guidelines highlight specific high-risk groups who need a high index of suspicion for sepsis:
Infants under 3 months, especially neonates (including those with perinatal risk factors like maternal fever or prolonged rupture of membranes).
Children who are immunocompromised (e.g., from chemotherapy, systemic steroids, or chronic diseases).
Children with complex medical needs or disabilities, where early signs of deterioration may be subtle.
Children with invasive devices such as central lines, VP shunts, or gastrostomy tubes.
Recent trauma, surgery, or invasive procedures.
Clinical Presentation and Red Flags
Sepsis can be challenging to diagnose early as symptoms can be non-specific. The NICE traffic light system is a widely used tool for risk stratification.
Red Flags (Go straight to hospital or call 999):
Altered consciousness (e.g., not waking, not staying awake, confused).
Non-blanching rash (the “glass test” is crucial here).
Signs of respiratory distress (e.g., fast breathing, grunting, tracheal tug).
Poor circulation (e.g., mottled, ashen, or bluish skin; cold extremities; prolonged capillary refill time >3 seconds; weak or absent peripheral pulses).
High or low temperature, especially in infants under 3 months.
A child who “looks very unwell” to a healthcare professional, or about whom a parent or carer has significant concerns.
Assessment and Management (APLS Approach)
The APLS guidelines for managing sepsis are based on a time-critical, staged approach:
Stage 1: Initial Assessment & Resuscitation (First 5 minutes)
This is the immediate ABCDE approach.
A – Airway: Ensure a patent airway. Use positioning or adjuncts if needed.
B – Breathing: Give high-flow oxygen (15 L/min via a non-rebreather mask). Assess for respiratory distress and prepare for intubation if necessary.
C – Circulation: Obtain intravenous (IV) or intraosseous (IO) access immediately. Assess for signs of shock (tachycardia, prolonged capillary refill time).
D – Disability: Check blood glucose immediately. Assess level of consciousness (AVPU/GCS).
E – Exposure/Environment: Check temperature and examine the skin for rashes or mottling.
Stage 2: Resuscitation and Investigation (First 1 Hour)
This is the “Sepsis 6” adapted for paediatrics.
Give Oxygen: To maintain adequate saturation.
Take Bloods: This includes a blood gas with lactate, blood cultures, full blood count, CRP, electrolytes, and clotting screen.
Give Broad-Spectrum Antibiotics: Do not delay antibiotics if sepsis is suspected. Common choices include ceftriaxone.
Fluid Resuscitation: If signs of shock are present (tachycardia, prolonged CRT), give a fluid bolus of 10-20 mL/kg of 0.9% sodium chloride over 5-10 minutes. This may be repeated, but caution is advised to avoid fluid overload, particularly in children with cardiac or renal issues.
Measure Lactate: This is a marker of tissue hypoperfusion.
Measure Urine Output: A catheter may be needed. Oliguria is a key sign of organ dysfunction.
Advanced Management and Complications
Involve Senior Staff Early: If the child is not responding to initial fluid boluses or shows signs of decompensated shock (low blood pressure), seek senior support immediately.
Inotropes: If more than 40-60 mL/kg of fluid boluses are required, or the child remains in shock, the use of inotropes (e.g., adrenaline or noradrenaline) is indicated. This requires transfer to a paediatric intensive care unit (PICU).
Source Control: Efforts to find and control the source of infection are vital. This may involve draining an abscess or removing an infected central line.
Long-Term Outcome: While early treatment has dramatically improved outcomes, sepsis still carries significant morbidity and mortality. Survivors can have long-term neurological, developmental, and psychological issues. Meningococcal septicaemia can lead to severe tissue damage, requiring amputations of limbs or digits.
Nuances of Paediatric Sepsis Management
Paediatric sepsis management in the UK, as guided by the UK Sepsis Trust, NICE, and APLS, has evolved to a more nuanced approach that goes beyond a simple checklist. The focus is on early recognition, rapid intervention, and a deep understanding of the unique physiological responses in children.
Fluid Resuscitation: The ’20 vs. 10′ Debate. While older guidelines often recommended an initial fluid bolus of 20 mL/kg of 0.9% sodium chloride, recent evidence and guidelines (including some APLS and intensive care unit protocols) are shifting towards a more cautious 10 mL/kg bolus of a balanced crystalloid (e.g., Hartmann’s solution) to be given over 5-10 minutes. The child’s response is then reassessed before administering further fluid. This prevents the pitfall of fluid overload, which can lead to pulmonary oedema and cardiac decompensation, especially in children with underlying cardiac issues or “warm shock.”
The “Sepsis Six” for Children is Not a Simple Checklist. While the “Sepsis 6” is a useful mnemonic, it should not be applied rigidly in children. The order and speed of interventions depend on the child’s clinical state. For example, in a child with a non-blanching rash and fever, the immediate priority is antibiotics, even before blood cultures are taken. Conversely, in a child who is stable but at high risk, a more deliberate approach to obtaining cultures before antibiotics is reasonable.
Choosing the Right Vasoactive Agent. When a child remains in shock despite fluid resuscitation (fluid-refractory shock), they need a vasoactive infusion. The choice of agent depends on the type of shock.
“Cold shock” (with signs of poor peripheral perfusion, such as mottled skin and prolonged capillary refill) typically responds best to adrenaline.
“Warm shock” (with bounding pulses and flushed skin) may respond better to noradrenaline.
The latest guidelines favour adrenaline or noradrenaline over dopamine as first-line agents in most cases of septic shock.
Recognising Different Presentations of Shock. Children can present with cold shock or warm shock. Cold shock is more common in younger children and infants. The presence of a rash (especially non-blanching) in a child with fever is a red flag for meningococcal septicaemia and requires immediate action.
Common Pitfalls
Delayed Recognition: The most significant pitfall is a failure to recognise sepsis early. The initial symptoms in children are often non-specific, and a child can deteriorate very rapidly. A high index of suspicion is required, especially in at-risk children.
The “Normal” Vital Signs Trap: Children can maintain a normal blood pressure for a long time, even when in shock, by increasing their heart rate and constricting blood vessels. A normal blood pressure in a sick child can be a false sign of stability. The presence of tachycardia, prolonged capillary refill, and reduced urine output are far more reliable indicators of shock.
Failing to Get Senior Support: Sepsis is a complex, multi-system illness. If there is any concern about a child with a suspected infection, or if they are not responding to initial treatment, a senior clinician should be involved immediately.
Inappropriate Fluid Boluses: Over-resuscitating with fluid, particularly in patients who have “warm shock,” can lead to pulmonary oedema and cardiac failure.
Delaying Antibiotics: Delaying the administration of broad-spectrum antibiotics to perform investigations (e.g., an MRI or lumbar puncture) is a serious pitfall. Antibiotics should be given within the first hour of recognising sepsis.
Complications and Prognosis
Organ Dysfunction: Sepsis can lead to multi-organ failure, affecting the kidneys (acute kidney injury), lungs (ARDS), heart (cardiogenic shock), and brain (seizures, encephalopathy).
Long-Term Morbidity: While mortality rates have improved, many survivors are left with significant long-term morbidities. These can include neurodevelopmental impairment, chronic pain, and psychological issues like post-traumatic stress disorder.
Meningococcemia-specific Complications: In cases of meningococcal septicaemia, widespread disseminated intravascular coagulation (DIC) can lead to limb and digit ischaemia, sometimes necessitating amputation.
Post-Sepsis Syndrome: A significant proportion of survivors experience a constellation of ongoing problems, including fatigue, pain, and cognitive and psychological issues, which is now recognised as Post-Sepsis Syndrome.