Page 124 - JSOM Summer 2022

Management of Pediatric Sepsis

Considerations for the Austere Prehospital Setting

Nikhil C. Williams, NRP, FP-C, C-NPT

ABSTRACT
Septic children are among the most challenging and re- Prior to 2005, literature regarding criteria to diagnose and
source-intensive patients that clinicians see around the world manage pediatric sepsis was saturated with variation; this was
daily. These patients often require a broad range of therapies primarily due to the lack of age-specific and comprehensive
and assessment techniques, frequently relying on expertise definitions. In realization of these limitations, a consensus
across multiple specialties such as radiology and laboratory congress was held in 2002. The results from the Pediatric Sep-
services. In developed nations, these resources are readily sis Consensus Congress defined sepsis as meeting the follow-
available or in close proximity, as transport is often logistically ing criteria :
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feasible to coordinate transfer to definitive care. In develop-
ing nations and areas of conflict, this is not the case. Most of 1. Two or more systemic inflammatory response syndrome
the world’s population lives in developing nations, resulting (SIRS) criteria (Figure 1)
in inadequate access to specialized pediatric intensive care re- 2. Suspected OR confirmed invasive infection
sources. As a result, many clinicians globally face the unique
challenge of caring for septic children in resource-deprived FIGURE 1 SIRS definition.
and austere settings. Areas recovering from natural disasters, The presence of at least two of the following four criteria, one of
remote villages, and conflict zones are examples of austere which must be abnormal temperature or leukocyte count:
environments where children have an increased risk of sep- • Core temperature of > 38.5°C or < 36°C.
sis while having the fewest medical resources available. This • Tachycardia (mean HR >2 standard deviations above normal
creates a unique challenge that prehospital clinicians are spe- for age in the absence of external stimulus, chronic drugs, or
cifically tasked with managing, sometimes lasting for multiple painful stimuli; or otherwise, unexplained persistent elevation
days pending the possibility of a transport option. Clinicians over a 0.5- to 4-hr time period OR for children <1 year old:
in these environments must be aggressive in identifying and bradycardia, defined as a mean heart rate <10th percentile for
age in the absence of external vagal stimulus, beta-blocker drugs,
treating critically-ill children in resource limited environments, or congenital heart disease; or otherwise, unexplained persistent
but also nuanced in their care plan due to the limitations of the depression over a 0.5-hr time period.
environment. • Mean respiratory rate 2 SDs above normal for age or mechanical
ventilation for an acute process not related to underlying
Keywords: sepsis; austere; pediatric; prehospital; child; critical neuromuscular disease or the receipt of general anesthesia.
care; resources; limited • Leukocyte count elevated or depressed for age (not secondary
to chemotherapy-induced leukopenia) or 10% immature
neutrophils.
Adapted from: Goldstein B, Giroir B, Randolph A, International
Introduction Consensus Conference on Pediatric S. International Pediatric Sepsis
Consensus Conference: definitions for sepsis and organ dysfunction in
Sepsis is an aggressive condition that is a component of many pediatrics. Pediatr Crit Care Med. 2005;6(1):2–8.
leading causes of death in children. It simultaneously places
an enormous strain on health systems worldwide. Causes of The congress also defined severe sepsis to additionally include
sepsis include acute respiratory infection, diarrheal diseases, one of the following: acute respiratory distress syndrome
malaria, and injury-related infection, which are particularly (ARDS), myocardial dysfunction/compromise, or two or more
prevalent in developing nations with poor public health infra- organ system dysfunctions. To qualify for septic shock, patients
structure and lack of available clean water. Sepsis is also a needed to also have accompanied hemodynamic compromise.
1–3
leading cause of acute kidney injury (AKI) and disseminated
intravascular coagulation (DIC) in children, both of which These criteria have been widely cited and applied; however,
independently pose a significant threat to survival. Even in multiple studies have since been published demonstrating the
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countries with readily available pediatric intensive care re- need to improve definitions and management. In 2015, the
sources, pediatric sepsis is a challenging disease process to Sepsis Prevalence, Outcomes, and Therapies (SPROUT) study
manage, making it even more imperative that clinicians in surmised that only 42% of pediatric sepsis patients met the
austere settings be prepared to manage patients until a higher above criteria. Furthermore, in 2016 the Sepsis-3 study made
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level of care becomes available. progress in standardizing the diagnosis of sepsis, however,
Correspondence to nw3xd@virginia.edu
Nikhil C. Williams is a critical care paramedic affiliated with the University of Virginia Medical Transport Network, Charlottesville, VA.

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