The Society of Critical Care Medicine (SCCM) is committed to reducing mortality and morbidity from sepsis and septic shock worldwide. The Surviving Sepsis Campaign (SSC) released its first evidence-based guidelines for the pediatric patient population. “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children” was published in the February 2020 issue of Pediatric Critical Care Medicine (Weiss S, et al. Pediatr Crit Care Med. 2020;21(2);e52-e106).
What are the differences between the SSC adult and children’s guidelines?
“Children are not simply small adults, and the signs of sepsis and its treatment differ, so they need to be assessed and managed differently,” said Scott L. Weiss, MD, MSCE, FCCM, an intensivist at Children’s Hospital of Philadelphia, and co-vice-chair of the guidelines committee.
Signs of sepsis and septic shock may be difficult to gauge in children. Most children who have some symptoms of sepsis do not have sepsis, making early and accurate diagnosis a challenge. Sepsis may be overlooked in children because common symptoms such as fast heart rate and accelerated breathing can be mistaken for fear or anxiety.
Low blood pressure may not occur until very late in the illness, so the guidelines recommend that each institution implement screening and protocols to facilitate timely recognition and treatment for children with sepsis and septic shock that are based on the SSC guidelines and that incorporate local resources and workflows. Healthcare professionals should also consider other assessments of abnormal blood flow in children beyond blood pressure, such as pulse strength, capillary refill time, and hand and foot temperatures.
While the adult sepsis guidelines recommend that all patients with sepsis begin antimicrobial therapy within one hour of diagnosis, the new pediatric sepsis guidelines recommend a two-phase process for assessing children with suspected sepsis. Those who have symptoms of septic shock should be started on antimicrobial therapy within one hour of shock diagnosis. Those who do not have symptoms of septic shock should be further evaluated to confirm or exclude a diagnosis of sepsis and, if results are positive, started on therapy within three hours of initial suspicion of sepsis (or sooner if shock develops during the evaluation).
- Children who are being treated in healthcare systems where intensive care is available (on site or through transport) should be provided up to 40-60 mL/kg bolus fluid in the first hour of treatment, based on cardiac output, and discontinued if they exhibit signs of fluid overload. Healthcare systems where intensive care is not available or accessible might not have the resources to manage fluid overload and therefore should not administer a fluid bolus (unless the child has extremely low blood pressure) and should instead provide maintenance fluids.
- Epinephrine or norepinephrine to treat low blood pressure or other signs of abnormal perfusion should be started if the child continues to show signs of shock despite appropriate fluid therapy. The guidelines note that clinical signs suggesting warm shock (with presumed increased cardiac output and decreased systemic vascular resistance) are often unreliable in children and may mask sepsis-induced heart dysfunction that requires epinephrine to improve heart function.
The guidelines will be presented during SCCM’s 49th Critical Care Congress
and are available at survivingsepsis.org
The SSC is a joint collaboration between SCCM and the European Society of Intensive Care Medicine. The guidelines are jointly published in Pediatric Critical Care Medicine
and Intensive Care Medicine.
Listen to SCCM Pod-406 Surviving Sepsis Campaign Children’s Guidelines
, in which Scott L. Weiss, MD, MSCE, FCCM, outlines the key recommendations for resuscitation of children with sepsis and septic shock and the challenges in implementing the pediatric guidelines in resource-limited areas.