Sepsis Flashcards
Define
Systemic inflammatory response syndrome / SIRS = generalised inflammatory response, defined by the presence of ≥2 criteria (abnormal temperature or WCC must be one of the criteria):
* Abnormal core temperature (<36 or >38.5°C)
* Abnormal HR (>2 S.D. above normal for age, or less than 10th centile for age if child aged < 1 years)
* Raised RR (>2 S.D. above normal for age, or mechanical ventilation for acute lung disease)
* Abnormal WCC in circulating blood (above or below normal range for age, or >10% immature cells)
Red-flag Sepsis = clinically based criteria to diagnose a high-risk sepsis -> immediate sepsis 6 pathway
- Hypotension
- Blood lactate >2mmol/L
- Prolonged capillary refill >5 seconds
- Pale/mottled or non-blanching (purpuric) rash
- Oxygen needed to maintain saturations >92 %
- RR >60 min-1 or >5 below normal, or grunting
- AVPU = V, P or U
* Abnormal behaviour
* Excessively dry nappies, lack of response to social cues, significantly decreased activity, weak, high-pitched or continuous cry
Sepsis = SIRS in the presence of infection
Severe sepsis = sepsis in presence of CV dysfunction, respiratory distress syndrome, or dysfunction of ≥2 organs
Septic shock = sepsis with CV dysfunction persisting after at least 40 mL/kg of fluid resuscitation in one hour
The neonatal period is the time of highest risk in childhood for acquiring a serious invasive bacterial infection.
Categorised into: early-onset or late-onset sepsis
Causes
Common causative organisms:
GBS and Escherichia coli, L. monocytogenes -> early onset neonatal sepsis
Coagulase-negative Staphylococcus (CoNS) -> late onset neonatal sepsis
* I.E. Staphylococcus epidermidis
Other causative organisms:
- Staphylococcus aureus (Coagulase +ve)
- Non-pyogenic streptococci
- Streptococcus pneumoniae
- Neisseria meningitidis
Early-onset Infection <72h after birth
Bacteria will have either:
* Ascended from the birth canal
* Invaded the amniotic fluid: direct contact with amnoeotic fluid causing pneumonia
Risk factors for early onset sepsis
- Risk factors for Early Onset Neonatal Sepsis
- Mothers previously had baby with invasive GBS
- Current GBS colonisation, bacteriuria or infection in current pregnancy
- Prelabour rupture of membranes
- Intrapartum temperature ≥ 38oC or suspected chorioamnionitis
- Rupture of membranes ≥ 18 hours
- Premature (< 37 weeks)
- Parenteral antibiotic treatment given for confirmed or suspected invasive bacterial infection during labour or in 24 hour period before/ after birth (NOT prophylaxis)- RED FLAG
- Suspected or confirmed infection in another baby in case of multiple pregnancy- RED FLAG
Symptoms and Signs
- Altered behaviour or responsiveness
- Altered muscle tone (e.g. floppiness)
- Feeding difficulties
- Feed intolerance- including vomiting, excessive gastric aspirates
- Abdominal distension
- Abnormal heart rate- bradycardia or tachycardia
- Respiratory distress à grunting, nasal flaring, use of accessory muscles, tachypnoea
Respiratory distress for > 4 hours- RED FLAG
Seizures- RED FLAG
Signs of shock- RED FLAG
Investigations
SEPSIS SIX Protocol
- Chest X-ray and septic screen
1.Blood cultures (x 2 if possible)
2.Urine output
3.Lactate
Bloods:
* Clotting (as DIC can feature in sepsis)
* VBG (including glucose and lactate) – quick
* metabolic acidosis is concerning (especially if base deficit ≥ 10mmol/)
* FBC - check for neutropaenia/ philia
* CRP (N.B. takes 12-24hrs to rise) - NOT useful for diagnosis, but sequential assessment to help guide management and progress (usually raised)
* U&Es and creatinine
- LP- if concerns of meningitis as source of sepsis, <1m old; 1-3m who appear unwell; 1-3m with WCC <5 or >15 x109/L
If the blood culture is positive or there are any neurological signs, CSF must be examined and cultured
* Urine MC&S- not usually done for early onset but may be done for late onset
Management
- ABC (don’t ever forget glucose)
- GET SENIORS
* Review by ST4 or above (<30 minutes) and then a consultant (<1 hour) - Paediatric sepsis 6 within 1 hour and transfer to acute setting (+ continuous monitoring, review hourly)
- IV access (if failed after 2 attempts, gain IO access)
- IV fluid resuscitation + 20mL/kg 0.9% NaCl bolus over 5-10 minutes
Antibiotics (within 1hr) -> follow local guidelines:
IV Benzylpenicillin + Gentamicin (usually 7 days)
If Gram-negative sepsis, add another antibiotic, e.g. Cefotaxime
If meningococcal sepsis:
* IM benzylpenicillin (in the community)
* IV cefotaxime (in hospital)
Switch to appropriate antibiotics once Gram stain/ culture results come back
* Gram negative: IV Cefotaxime alone
* Gram positive: IV Amoxicillin + Cefotaxime
* GBS: Continue with IV Benzylpenicillin + Gentamicin
Late onset infection >72 hours
(most likely staph coagulase negative)
* IV Ampicillin + gentamicin/ ceftriaxone
* Flucloxacillin + gentamicin
After 36 hours, consider STOPPING antibiotics if:
Blood culture is negative
* Tends and levels of CRP are reassuring
* Clinical condition reassuring with no indicators of possible infection
Other management factors:
* Maintain adequate oxygenation
* Maintain normal fluid and electrolyte status
* Prevent or manage hypoglycaemia
* Prevent or manage metabolic acidosis