Michael Barsotti, MD, FAAP
Chief Medical Officer
Sacred Heart Children’s Hospital
Severe sepsis in pediatrics accounts for greater than 75,000 hospitalization per year in the United States at a cost of 4.8 billion dollars. It is generally accepted that early recognition and intervention improves outcomes.
Systemic Inflammatory Response Syndrome (SIRS) is the body’s response to an insult. The earliest manifestation of SIRS is temperature instability, tachypnea and tachycardia. If the insult is secondary to an infectious cause, that is termed sepsis. Septic shock is when sepsis progresses to include cardiovascular dysfunction. Early identification and treatment can often halt progression of the inflammatory response; however, if allowed to progress, the process can progress into shock with eventual end-organ dysfunction and death.
The Surviving Sepsis Campaign of 2012 brought together 68 international experts, representing 30 international organizations, to update sepsis treatment protocols. The pediatric recommendations have been adopted by the Pediatric Advanced Life Support (PALS) program. The critical recommendations include initial rapid evaluation and recognition of decreased mental status and perfusion, early introduction of high flow nasal cannula oxygen, normal saline boluses of 20 ml/kg x 3 (within the first hour), and correcting hypoglycemia and hypocalcaemia. If shock is not reversed within the first 15 minutes, inotropes (dopamine) should be started and central IV access obtained. Blood cultures should be obtained and IV antibiotics given prior to 60 minutes. If shock is not yet reversed, consider hydrocortisone for possible adrenal insufficiency.
It has been well documented that early and aggressive volume repletion improves outcomes in sepsis, specifically decreasing mortality from 38% to 8% in one study. Conversely, for each hour of inadequately treated shock, the odds of mortality double. Delay in antibiotic administration for more than 3 hours after diagnosis is also associated with an increase in mortality. Multiple well done studies demonstrate that adherence to well defined sepsis protocols dramatically improves outcomes, yet adherence remains only 30-40%.
Protocols for Emergency Room and Pediatric ICU management of pediatric sepsis are readily available in the literature. One such protocol, developed by the team at Children’s Hospital of Philadelphia, can be found at http://www.chop.edu/pathways.