Hello my name is Jeremy Tong and I am a consultant paediatric intensivist working in University
Hospitals of Leicester. Today I am going to talk to you about pediatric sepsis.
Let’s start with having a look at the scope of the problem.
So here is a thousand children, out of a thousand children every year about one will develop
sepsis. So that’s an instance of 0.9 per thousand per year.
In the large paediatric department assessing 55,000 children a year, we expect to see about one a week.
And half of those cases will be new-born. The mortality rate for paediatric sepsis is
in the region of 6-12%. So that means every day somewhere in the UK, one child will die
from sepsis.
I work in the paediatric intensive care unit where we commonly see sepsis. In the UK approximately
a thousand admissions a year in the P.I.C.U is for sepsis. That’s over a quarter of
our work load.
The hospital length of stay for paediatric sepsis is just over a month but most children will have
to stay two weeks or more.
So looking at our child with sepsis, how do we pick out that one child potentially with
sepsis from the many children we assess with many similar problems.
I think the problem with spotting sepsis in children early is unlike a conditional like
meningococcal sepsis, which is a widely known condition, it has obvious signs that people
can pick up on. Other forms of sepsis can have very subtle signs that
are similar to more self-limiting illnesses. When you have a trigger such as trauma or an allergic
reaction or infection it can lead to a series of events in the body which causes systematic
inflammatory response or SIRS. For SIRS in children you need to have at least
two of the following; a temperature that is too high or too low, a heart rate that is
too high, a breathing rate that is too high or white cell count that is too high or too
low. And for it to count you need to have at least one of the temperature or white cell
count criteria.
Sepsis is systematic inflammatory response with a proven or suspected infection.
Severe sepsis is when you have sepsis and organ dysfunction, either cardiovascular or
respiratory or two or more organ dysfunctions such as acute and renal impairment, or seizures
or altered mental state. When we have severe sepsis in association with cardiovascular dysfunction
we call that shock. This includes a reduced blood pressure, unexplained acidosis, a raised
lactate, reduced urine output or reduced profusion in children.
There are tools out there available that will aid in the recognition and management of sepsis
in children. Here is an example its called the Paediatric Sepsis 6 and it was created in
conjunction with The UK Sepsis Trust. So the Paediatric Sepsis 6 recognition is very similar
to the Goldstein criteria for SIRS. If you have a suspected or proven infection and at least
two of the following.
Either a core temperature that is below 36 degrees or above 38.5 degrees or you have
an unexplained high heart rate that is out of keeping the child’s fever or pain or
fear, an altered mental state, and then with a baby that includes sleepiness, irritability,
lethargy and floppiness. Or you have reduced peripheral profusion or prolonged capillary
refill time.
Then you need to think could this child have spesis? They might not but if you have
any doubt consult a senior clinician or somebody with more experience. When you decide a child
has sepsis there are six elements of care that can be delivered within an hour that
will improve their outcome. First of all you give high flow of oxygen.
You want to get intravenous or interosseous access as soon as possible and take some base
lined bloods. We would recommend the blood culture, flow blood count, a blood gas including
a lactate. After you have done that it is imperative that you give IV or IO antibiotics.
I can’t stress that enough and we will come back to that. Once you have done that consider
giving a fluid bolus, you’ll need to reassess as you go along but start with 10 or 20 mls
per kilo of fluid bolus. At this point if the child is not getting better quickly, you’d
want to involve a senior clinician or somebody more experienced as soon as possible. We would
also consider starting inotropic support at an early stage and I want to come back to the point
I made earlier. That to give IV or interosseous antibiotics.
It is very important to give antibiotics early because bacterial growth is exponential. That
means for every twenty or thirty minutes bacterial count in the blood stream will double. So
that means if you start with 500 bacteria after just six hours you will have 500 million
bacteria.
Therefore never delay giving antibiotics. In adults, for every hour you delay giving
antibiotics, the mortality rate goes up by 7.6%. It is very important that we give antibiotics
early in children also. We recognise that using clinical tool kits to treat children
may lead to few more children being treated for suspected spesis when it wasn’t necessary.
For those who do have sepsis it is very important for the outcome that they get the antibiotics
early. Antibiotics save lives, if there is any doubt consult a senior clinician or somebody
with experience.
As a wise man and a brother of someone whose died from sepsis said: spot it, treat it and beat it.
And we can all become sepsis heroes. For further information please email me at
jtong@nhs.net or contact me via twitter @jez_tong. Further resources can be found at The UK Sepsis
Trust and spottingthesickchild.com. Thank you very much.