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    Patent Pending

    Pediatric SIRS, Sepsis, and Septic Shock Criteria

    Defines the severity of sepsis and septic shock for pediatric patients.
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    INSTRUCTIONS

    Note: There is still debate about how to define pediatric sepsis given varying ranges of “normal” vital signs for ages. For patients over 18, please use the Adult SIRS, Sepsis, and Septic Shock Criteria.
    When to Use
    Pearls/Pitfalls
    Why 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.
    • 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.

    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.

    SIRS Criteria (≥ 2 meets SIRS definition, 1 of which must be abnormal temperature or leukocyte count)
    List of Age-Dependent Vital Sign Ranges Available in About Section
    Sepsis Criteria (SIRS + Source of Infection)
    Severe Sepsis Criteria (Sepsis + ≥ 1 following Dysfunction Criteria)
    Organ Dysfunction Criteria »
    Septic Shock Criteria (Sepsis + Cardiovascular Dysfunction)
    Organ Dysfunction Criteria »

    Result:

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    Next Steps
    Evidence
    Creator Insights

    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

    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.

    Formula

    Series of Yes/No questions.

    Facts & Figures

    • 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>140NA>22>15.5 or <6<74
    6 - 12 years>130NA>18>13.5 or <4.5<83
    13 - <18 years>110NA>14>11 or <4.5<90
    1. 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.
    2. 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.
    3. Not as a result of chemotherapy-induced leukopenia. Values taken from The Harriet Lane handbook.
    4. Values differ slightly from PALS definition of hypotension as published by the American Heart Association.

    Evidence Appraisal

    • ICCPS derived 6 clinically and physiologically-based age groups each with distinct VS ranges and laboratory ranges: Newborn (0-7days); Neonate (7days-1month); Infant (1month-1year); Toddler/Preschool (2-5years); School-aged Child (6-12years); Adolescent & Young Adult (13- <18years).
    • Higher temperature cut-off than adult SIRS criteria and requirement of either temperature or leukocyte abnormality are to increase specificity of SIRS criteria.
    • Studies are ongoing to determine pediatric-specific sepsis “bundles” and treatment protocols.
    • There are several pediatric-specific data supporting screening with lactate levels, and high lactate has been associated with increased risk of organ dysfunction and critical illness in ICCPS-defined SIRS. (Scott 2012)
    • Temperature-corrected heart and respiratory rates may improve specificity & PPV without lowering sensitivity. (Sepanski 2014)

    Literature

    Other References

    Research PaperR. P. Dellinger, et. al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Medicine. February 2013; 39(2), 165-228.Research PaperBrierley J, Carcillo J, Choong K, et al. Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. 2007 Update from the American College of Critical Care Medicine. Crit Care Med. 2009; 37:666–688.Research PaperScott HF, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. The Utility of Early Lactate Testing in Undifferentiated Pediatric Systemic Inflammatory Response Syndrome. Academic Emergency Medicine. 2012; 19: 1276-80.Research PaperSepanski RJ, Godambe SA, Mangum CD, Bovat CS, Zaritsky AL, Shah SH. Designing a Pediatric Severe Sepsis Screening Tool. Frontiers in Pediatrics. 2014;2:56. doi:10.3389/fped.2014.00056.
    Dr. Brahm Goldstein

    About the Creator

    Brahm Goldstein, MD, is the senior medical director at Baxter Healthcare. He was formerly chief of pediatric critical care and the medical director of the pediatric intensive care unit at the University of Rochester Medical Center, where he also was a professor of medicine. Dr. Goldstein serves on the editorial board of many leading medical and scientific publications and has been on multiple advisory boards for healthcare companies.

    To view Dr. Brahm Goldstein's publications, visit PubMed

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