sepsis and child mortality

Question 1

how common is infection in paediatrics

Answer 1

• common in children
• avg pre-school child will have 8-12 resp infections p/a
• likely to spend 3-5mths p/a w/ viral infection
• majority due to viruses
• majority self limiting and last 8-14 days

Question 2

infections and admissions to hospital

Answer 2

39% of all acute paeds admissions

25% of GP OOH - 60% of these are 1-4y/o

Question 3

UK child mortality (<5y/o)

Answer 3

4. 27 per 1000 live births
5. 4% or 1/ 234 children

Question 4

problems with child mortality in UK

Answer 4

• mortality outcomes are considerably worse than comparable HICs
• UK ranks in bottom 3 countries in the EU15+ for mortality from common infectious in both sexes and across all age groups
• mortality from treatable infection in UK - almost 2x that of best performing European neighbours

failure to recognise serious illness at the 1st point of healthcare contact is an important avoidable factor in child death

Question 5

how many deaths does infection account for

Answer 5

16.2% deaths 1-4y/o

8% deaths 5-9y/o

Question 6

causes of child death

Answer 6

infectious disease ~½ of all deaths

• pneumonia, diarrhoea diseases, meningitis, malaria, measles

neonatal disorders

injuries and accidents

non-communicable diseases

Question 7

how common is sepsis

Answer 7

severe sepsis is one of the leading causes of death in all children

>½ of all sepsis cases worldwide occurred in children

Question 8

when is the peak incidence of sepsis

Answer 8

early childhood

• infants <1y: 1 in 200
• children 1-4: 1 in 2000
• children 5-15: 1 in 5000

Question 9

fatality from sepsis

Answer 9

10%

Question 10

how to improve survival in sepsis

Answer 10

early recognition and appropriate treatment

• UK: only 38% compliance w/ recommended treatment guidelines

Question 11

what is sepsis

Answer 11

sepsis = systemic inflammatory response syndrome (SIRS) + suspected/proven infection

Question 12

what is severe sepsis

Answer 12

severe sepsis = sepsis + organ dysfunction

Question 13

what is septic shock

Answer 13

septic shock = sepsis = CVS dysfuntion

Question 14

what is SIRS

Answer 14

≥ 2 of:

• temp >38 or <36
• WCC >15x 10^9/L or <5x 10^9/L
• tachycardia >2SD above normal for age
• tachypnoea >2SD above normal for age

Question 15

paediatric normal values

Answer 15

• faster HR as baby, slows gradually w/ age
• faster RR as baby, slow gradually w/ age

Question 16

traffic light system for fever <5y/o

Answer 16

• helps identify high risk children
• remember to take CRT centrally e.g. sternum

Question 17

changes in HR w/ temp

Answer 17

10bpm increase for every 1C is normal

Question 18

paeds sepsis signs

Answer 18

temp <36 or >38

inappropriate tachycardia

poor peripheral perfusion/CRT >2s/mottles

altered mental state - sleepiness, irritability, lethargy, floppiness

inappropriate tachypnoea

hypotension - very late sign in children

Question 19

when would we have a lower threshold for treating sepsis

Answer 19

• infants <3mths
• immunosuppresed/immunocompromised/chemotherapy/long term steroids
• recent surgery
• indwelling devices/lines
• complex neuro-disability/long term conditions - observations may vary from their baseline
• high index of clinical suspicion - tachypnoea, rash, leg pain, biphasic illness, poor feeding
• significant parental concern

Question 20

sepsis 6 for paeds

Answer 20

1. high flow oxygen
2. IV/IO access and take blood test - blood cultures, blood glucose, blood lactate
3. IV/IO abx: broad spectrum as per local policy

IF SHOCKED:

4. consider fluid resuscitation
5. consider inotropic support early - adrenaline
6. senior/specialist involvement early

Question 21

why do we have a lower treatment threshold for infants <3mths

Answer 21

• increased risk of bacterial infection
• increased risk of sepsis
• increased risk meningitis
• may have minimal signs and symptoms
• presentation often non-specific
• may not mount a febrile response (~50%)
• deteriorate quickly

Question 22

what are the risk factors for infection in infants <3mths

Answer 22

• prematurity (<37/40)
• prolonged rupture of membranes
• maternal pyrexia/chorioamnionitis
• maternal group B strep (this pregnancy)
• previous child w/ group B strep
• maternal STI - chlamydia, gonorrhoea, syphilis, HSV

Question 23

management of sepsis in children

Answer 23

Airway

Breathing

Circulation - fluid bolus (20ml/kg 0.9% NaCl)

DEFG - 2ml/kg 10% dextrose

abx - 3rd gen cephalosporin (e.g. cefotaxime/ceftriaxone), add IV amoxicillin if <1m/o

Question 24

investigations for sepsis in children

Answer 24

bloods - FBC (leucocytosis, thrombocytopaenia), CRP, coagulation screen (DIC), blood gas (metabolic acidosis, raised lactate), glucose, blood culture

cultures - blood, urine, CSF (incl to send to virology), +/- stool (micro + virology)

imaging - CXR (can be helpful to exclude focal pneumonia)

Question 25

causative organisms of sepsis in neonates (<1mth)

Answer 25

group B strep

Escherichia coli

listeria monocytogenes

Question 26

causative organisms of sepsis in older infants and children

Answer 26

streptococcus pnuemonia

Neisseria meningitidis

Group A streptococcus

Staphylococcus aureus

Question 27

pathogenesis of sepsis

Answer 27

• overwhelming response to infection
• bacterial infection triggers cytokine responses from endothelium and chemotaxis
• LPS produced by bacteria also trigger complement activation and coagulation cascade activation
• release of anti-inflammatory cytokines, disruption of coagulation cascade and activation of complement → impaired vascular permeability

Question 28

sss

Answer 28

sss