APPROACH TO FEVER & SEPSIS Flashcards
DDX: Serious Bacterial Infection
Meningitis
Sepsis
Urinary Tract Infection
Bone, Joint, and Skin Infection
Enteritis
Recognition of Sepsis
Fever > 38 C
OR Hypothermia < 36 C
High Risk Patient (immunocompromised, recent surgery, cardiac history, neuromuscular disorder)
Unexplained Tachycardia (after correcting for fever)
Low BP is a late sign
Cap refill > 2 sec, mottling, pallor
Decreased urine output
Lethargy, irritability
MANAGEMENT:
1-7 DAYS
OR
ILL APPEARING AGE 8 - 60 DAYS OLD WITH A FEVER (>/38 C)
CBC and blood cultures
AND
Catheter urinalysis and culture
AND
CRF or PCT
AND
CSF cell count & diff, gram stain and culture , glucose, protein, HSF PCR
+/-CXR
Stool Clx if diarrhea present
NP swabs
Bolus Fluid:
20 ml / kg IV NS if hypovolemic
Maintenance Fluid:
4 cc / hr for 1st 10 kg
2 cc / hr for 10-20 kg
1 cc / hr per kg for every kg > 20 kg
D5NS after 1st week of life
Antibiotics:
ampicillin 300 mg/kg IV div q6h (Listeria)
Cefotaxime 100-200 mg/kg div q6-8h if 0-28 days
Ceftriaxone 100 mg / kg / day q 24 if 29-60 days
+/- Acyclovir 20 mg/kg q8h
IF
Maternal h/o HSV
Seizure
FND
Diffuse pneumonitis
Skin / mucous membrane vesicles
Signs of coagulopathy
Elevated transaminases
Admit to hospital for 36-48 hrs until preliminary cultures are negative
AAP Approach to a WELL APPEARING febrile infant age 29 to 60 days
Catheter U/A & culture
CBC with diff
Blood Cultures
PCT or CRP
NEGATIVE BACTERIAL CHECK LIST:
>37 weeks gestation
No prior hospital stay
No prolonged nursery stay
WBC > 5000 or < 15000
Urine WBC < 5 / HPF
Cath U/A- nitrites of leuk esterase
Bands < 1500
Normal CRP or PCR
No chronic illnesses, prior antibiotics and unexplained bili
HERPES SIMPLEX CHECK LIST:
No maternal history for HSV
No seizures
No vesicles
IF THEY FIT THE NEGATIVE BACTERIAL CHECK LIST THEN ADMIT & OBSERVE WITHOUT ABX OR LP
If placed on antibiotics OR fail the negative bacterial check list OR fail the HSV Check list YOU MUST do an LP
Approach to the febrile infant (29 - 90 days old) WITHOUT a focal source
Partial diagnostic workup:
CBC, diff, CRP, blood culture
Catheter urinalysis and culture
If significant respiratory symptoms, consider CXR
If respiratory symptoms AND discharge planned, consider NP swab
Boston Criteria:
T >/ 38 C
28-89 days old
No immunizations within 48 hrs
No recent antibiotics
Well appearing
Unremarkable examination
WBC < 20,000
UA <10 per HPF
LP <10 per HPF
CXR -ve
If ill appearing:
Ceftriaxone 50 mg / kg IV / IM & admission OR
outpatient with close follow up
Bolus Fluid:
20 ml / kg IV NS if hypovolemic
Maintenance Fluid:
4 cc / hr for 1st 10 kg, 2 cc / hr for 10-20 kg, 1 cc / hr per kg for every kg > 20 kg D5NS after 1st week of life
DISABILITY
Hypoglycemia:
Neonate & Infant
5ml / kg PO/NG/IV/IO D10 Bolus
6 ml / kg / h maintenance
Child - 5 ml / kg PO / NG / IV / IO D25 bolus
6 ml / kg / h D10 for first 10 kg + 3 ml / kg for 11-20 kg + 1.5 ml / kg / h for each kg over 20 kg
Management of a Septic Child for Children older than 28 days
CIRCULATION
20 ml/kg IV/IO NS bolus push over 10 min
x3 in first hour (i.e. 60 ml/kg)
Repeat boluses until vital signs, perfusion, mental status and urine output improve up to 100 ml / kg total volume
Maintenance Fluid:
4 cc / hr for 1st 10 kg, 2 cc / hr for 10-20 kg, 1 cc / hr per kg for every kg > 20 kg D5NS after 1st week of life
IV ceftriaxone 100 mg/kg q24 hrs (max dose 2 g)
Pip-Tazo 100 mg / kg IV
IV vancomycin 15 mg/kg q 6 hrs (max dose 1 g)
Inotropes:
Epinephrine 0.05 - 0.3 mcg/kg/min (cold shock)
Norepinephrine 0.05 - 0.3 mcg/kg/min (warm shock)
Dopamine 10 mcg / kg / min
DISABILITY
Hypoglycemia:
Neonate & Infant
5ml / kg PO/NG/IV/IO D10 Bolus
6 ml / kg / h maintenance
Child - 5 ml / kg PO / NG / IV / IO D25 bolus
6 ml / kg / h D10 for first 10 kg + 3 ml / kg for 11-20 kg + 1.5 ml / kg / h for each kg over 20 kg
Differentials for children 3 - 36 months with a fever
Otitis Media
Cellulitis
Viral illness / exanthem
Urinary Tract Infection
Pneumonia
Workup for fever in a child 3 - 36 months
An immunized, well appearing child typically does not need blood work or cultures
Consider Urinalysis and Urine Culture alone
Fever > 5 d requires further workup
