Pediatric SIRS, Sepsis, and Septic Shock Criteria

Why Use

Sepsis is a major cause of preventable death in children, with estimated mortality in severe sepsis ranging from 2% in previously well children to 10% in those with significant underlying medical conditions. This is lower than in adult severe sepsis, but still significant.

When to Use

Children <18 years old with ≥2 SIRS criteria should be screened for severe sepsis / septic shock. Fever in patients <2-3 months - a different topic of study - requires an extensive sepsis evaluation using a lower temperature threshold (i.e., ≥38C). There is good agreement to do full neonatal fever workups for neonates ≤28 days. However workup and interventions for ages 1-3 months are continually changing and often institution-dependent.

Formula

Pearls / Pitfalls

These criteria are more debated than the adult criteria. The International Consensus Conference on Pediatric Sepsis (ICCPS) convened in 2005 to create definitions, but vital sign ranges with age make it difficult to come to clear concensus. Lactate is not yet accepted as standard screening tool. Tachycardia and tachypnea are extremely common in mild pediatric illness; these are not as useful in selecting for septic patients. Therefore either a temperature or leukocyte abnormality must be present to meet pediatric SIRS criteria. Others abnormalities are age-specific – Vital Signs (VS), physiologic processes (e.g., urine output), and certain laboratory values. However , there is no consensus on the particular ages – ICCPS experts differ from PALS ranges published by American Heart Association, which differ from many institutional guidelines. ICCPS-defined cut offs differ slightly from adults: Temperature of >38.5C for pediatrics, >38C for adults. Bradycardia included for newborns and neonates.

Management

Much of the current practice in pediatric sepsis screening are applied from the adult literature, and therefore not directly evidence-based. Similar to adults, Those with a suspected/confirmed infection with hemodynamic instability should immediately be treated for Septic Shock without waiting for laboratory confirmation. Similar to adults, early IV fluids and broad-spectrum antibiotics seem to be the most critical actions. IV fluid recommendations include repeated 20cc/kg boluses of isotonic crystalloid or colloid over 5-10 minute intervals. Consider consulting an ICU when severe sepsis / septic shock is identified. Pediatric Advanced Life Support (PALS) 2011 Algorithm for Septic Shock

Critical Actions

Surviving Sepsis Campaign (2012) section on Pediatric Considerations reiterates the most recent PALS guidelines as described by Brierley and colleagues . Historically pediatric sepsis management has been provider-dependent. More recently some hospitals and US states are instituting, studying, and fine-tuning standardized pediatric sepsis protocols.

More Information

SIRS = ≥2 meets SIRS definition 1 of which must be abnormal temperature or leukocyte count. Sepsis = SIRS + Suspected infection Infectious etiology may be bacterial, viral, or fungal. Severe Sepsis = Sepsis +1 of the following: Cardiovascular organ dysfunction Acute respiratory distress syndrome (ARDS) Evidence of ≥2 organ dysfunction (e.g., respiratory, renal, neurologic, hematologic, or hepatic) Septic Shock = Severe Sepsis + Cardiovascular Dysfunction (despite adequate fluid resuscitation) Unlike with adults, hypotension is not required to make the diagnosis of Septic Shock. Age Group Heart Rate (bpm)¹ Respiratory Rate² Leukocyte Count³ Systolic Blood Pressure⁴ Tachycardia Bradycardia 0 days – 1 week >180 <100 >50 >34 <59 1 week – 1 month >180 <100 >40 >19.5 or <5 <69 1 month – 1 year >180 <90 >34 >17.5 or <5 <75 2 - 5 years >140 NA >22 >15.5 or <6 <74 6 - 12 years >130 NA >18 >13.5 or <4.5 <83 13 - <18 years >110 NA >14 >11 or <4.5 <90 Tachycardia is defined as mean HR >2 SD above normal for age not resulting from external stimulus, chronic drugs, or painful stimuli; or unexplained persistent tachycardia over a 0.5- to 4-hr duration. In children <1 yr old, bradycardia is defined as a mean HR <10th percentile for age not resulting from external vagal stimulus, B-blocker drugs, or congenital heart disease; or unexplained persistent bradycardia over a 0.5-hr duration. Tachypnea is defined as mean respiratory rate >2 SD above normal for age or mechanical ventilation resulting from an acute process not caused by underlying neuromuscular disease or due to general anesthesia. Not as a result of chemotherapy-induced leukopenia. Values taken from The Harriet Lane handbook. Values differ slightly from PALS definition of hypotension as published by the American Heart Association.