The Surviving Sepsis Campaign (SCC) in February released its first guidelines for pediatric patients with sepsis, marking a new milestone in the initiative’s mission to improve sepsis care and save lives.
More than 1.2 million children develop sepsis globally every year, including more than 75,000 in the United States. Nearly 7,000 American children die of sepsis annually, making it more deadly than pediatric cancer.
Establishing a two-phase process for identifying and managing sepsis in children that includes starting antibiotic therapy within one hour of evidence of septic shock are among the recommendations in the new guidelines, published in Pediatric Critical Care Medicine. The guidelines are a valuable resource for hospitals looking to implement screening and protocols to facilitate timely recognition and treatment for children with sepsis and septic shock, as the disease can be overlooked in young patients because low blood pressure may not occur until very late in illness. Healthcare providers should consider other assessments of abnormal blood flow beyond blood pressure, including pulse strength, capillary refill, and hand and foot temperature.
“All physicians, nurses and other clinicians who care for children are likely to come across sepsis at some point. It’s important to recognize the early warning signs and become familiar with guideline recommendations, which provide a roadmap for improving outcomes and saving children’s lives,” said Scott Weiss, MD, MSCE, FCCM, an intensivist at Children’s Hospital of Philadelphia, and co-vice chair of the 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.”
The guidelines recommend obtaining blood cultures before beginning antimicrobial therapy as long as this does not substantially delay antimicrobial treatment. They recommend starting broad-spectrum antimicrobial therapy to cover all likely pathogens that may be causing the infection and narrowing the therapy once the specific pathogen has been identified. But the guidelines also emphasize that antibiotics should be used only when needed.
Children being treated for sepsis should be reassessed daily and taken off antimicrobial therapy once they no longer have evidence of a bacterial infection or the antibiotic spectrum narrowed based on cultures,” said Niranjan Kissoon, MBBS, MCCM, FRCP, FAAP, FACPE, vice president of Medical Affairs, British Columbia Children’s Hospital and Sunny Hill Health Centre for Children, and co-chair of the guidelines. “This helps reduce inappropriate antibiotic use, which has become a global health emergency.”
Other recommendations in the pediatric guidelines include:
- 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. However, healthcare systems where intensive care is not available or accessible may not have the resources to manage fluid overload and therefore should not administer a bolus of fluid (unless the child has extremely low blood pressure) and instead provide maintenance fluid.
- Epinephrine or other vasoactive medication to treat low blood pressure should be started if the child continues to show signs of shock despite appropriate fluid therapy. The guidelines note that symptoms suggesting warm shock (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 SSC is a joint initiative of the Society of Critical Care Medicine (SCCM) and the European
Society of Intensive Care Medicine, which are committed to reducing death and disability from sepsis and septic shock worldwide. The guidelines were developed by 49 international experts from a variety of disciplines representing 12 international organizations, three methodologists and three public members.
The Spring issue of Critical Connections featured an article on the new Surviving Sepsis Campaign (SSC) Pediatric Sepsis Guidelines that included potentially misleading information regarding the delivery of bolus fluid in the first hour of treatment. To ensure accuracy and clarity, the statement on page 9 should read as follows:
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. However, healthcare systems where intensive care is not available or accessible may not have the resources to manage fluid overload and therefore should not administer a bolus of fluid (unless the child has extremely low blood pressure) and instead provide maintenance fluid.
In other words, as long as there is ICU capability – where fluid overload can be managed if it occurs – the SSC suggests that children receive bolus fluid in the first hour. The previous version noted that health systems without ICUs should not provide bolus fluid because they may not have the resources to assess and manage fluid overload. This direction is not applicable in settings where community hospitals without ICUs can readily transfer children to larger hospitals that offer that level of care or in settings where advanced hemodynamic and respiratory care can be provided outside of a formal ICU. Simply put, if intensive care is accessible (even if not on site), the SSC suggests the child 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.