Know the New Pediatric Sepsis Criteria

The SCCM and ESICM have published “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children” to provide guidance for clinicians caring for children with septic shock and other sepsis-associated organ dysfunction (not sepsis without shock/organ dysfunction). New included guidelines are not intended to update or iterate on prior recommendations for the care of children with sepsis and septic shock (not sepsis without shock/organ dysfunction).

Although application of Sepsis-3 to children has been attempted (19,20), formal revisions to the 2005 pediatric sepsis definitions remain pending (21). Therefore, the majority of studies used to establish evidence for these guidelines referred to the 2005 nomenclature in which severe sepsis was defined as 1) greater than or equal to two age-based systemic inflammatory response syndrome (SIRS) criteria, 2) confirmed or suspected invasive infection, and 3) cardiovascular dysfunction, acute respiratory distress syndrome (ARDS) or greater than or equal to two non-cardiovascular organ system dysfunctions; and septic shock was defined as the subset with cardiovascular dysfunction, which included hypotension, treatment with a vasoactive medication or impaired perfusion.

The article defines septic shock in children as severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication or impaired perfusion) and “sepsis-associated organ dysfunction” in children as severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction. Because several methods to identify acute organ dysfunction in children are currently available (17,19,20,22,23), the authors chose not to require a specific definition or scheme for this purpose.

This report covers five main topic areas:

  • early recognition
  • infection therapies and adjunctive therapies
  • hemodynamics therapies and adjunctive therapies
  • ventilation therapies and adjunctive therapies
  • endocrine therapies adjunctive therapies
  • metabolic therapies and adjunctive therapies

Some notable aspects/differences of this report:

  • The article did not issue a recommendation about using blood lactate values to stratify children with suspected septic shock or other sepsis-associated organ dysfunction into low- versus high-risk of having septic shock or sepsis. However, in practice, if lactate levels can be rapidly obtained, measure blood lactate in children when evaluating for septic shock and other sepsis-associated organ dysfunction may have merit. Unfortunately, the optimal threshold to define “hyperlactatemia” in children remains unclear.
  • The article suggests using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction (weak recommendation, very low quality of evidence).
  • Recommendations do not apply to premies < 37 weeks or infants < 28 days of age.

17. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis: International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2–8

19. Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171:e172352

20. Schlapbach LJ, Straney L, Bellomo R, et al. Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Med 2018; 44:179–188

21. Schlapbach LJ, Kissoon N. Defining pediatric sepsis. JAMA Pediatr 2018; 172:312–314

22. Leteurtre S, Duhamel A, Salleron J, et al.; Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP): PELOD-2: An update of the PEdiatric logistic organ dysfunction score. Crit Care Med 2013; 41:1761–1773

23. Proulx F, Gauthier M, Nadeau D, et al. Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 1994; 22:1025–1031

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