Pediatric sepsis = life-threatening organ dysfunction from dysregulated infection response (Phoenix criteria, 2024). Hour-1 bundle: cultures, broad-spectrum antibiotics, lactate, IV fluid resuscitation (10–20 mL/kg crystalloid, reassess after each bolus), and vasoactive support if persistent shock after 40–60 mL/kg.
🚩 Red-flag clues (must not miss)
- •Cold shock (cool extremities, ↑ cap refill, ↓ pulses) — start epinephrine, NOT norepinephrine
- •Warm shock (bounding pulses, flash cap refill) — start norepinephrine
- •Persistent shock after 40–60 mL/kg fluid → start vasopressor + steroid (hydrocortisone)
- •Hypotension is a LATE sign in children — act on tachycardia, cap refill, mental status
Labs
- Lactate, glucose, VBG/ABG
- CBC + diff, BMP, LFTs, coags, fibrinogen
- Blood culture × 2 BEFORE antibiotics (do not delay > 45 min)
- UA + cx, CSF if meningitis suspected, RVP
- Procalcitonin, CRP
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Bacterial sepsis (GBS, E. coli neonate; Strep pneumo, N. meningitidis older) | — | Empiric abx by age; resuscitation bundle |
| Viral (HSV neonate, influenza, RSV, enterovirus) | Vesicles, seizure, season | Add acyclovir if HSV risk; supportive |
| Toxic shock syndrome | Diffuse erythroderma, mucositis, retained tampon/abscess | Source control, clindamycin + vanc, IVIG |
| MIS-C | Persistent fever + GI + rash + recent COVID | Echo, IVIG ± steroids |
| Adrenal crisis (CAH) | Hypoglycemia, hyponatremia, hyperK, ambiguous genitalia | Hydrocortisone 25–100 mg IV |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| 0.9% NaCl bolus | 10–20 mL/kg over 5–10 min, reassess; up to 40–60 mL/kg in first hr | Stop if rales/hepatomegaly (cardiogenic) |
| Ceftriaxone | 50–100 mg/kg IV (max 4 g) | Avoid in neonate < 28 d |
| Cefotaxime + ampicillin (neonate) | Cefo 50 mg/kg IV q6h + Amp 50 mg/kg IV q6h | |
| Vancomycin | 15 mg/kg IV q6h | Add for severe sepsis / suspected MRSA / meningitis |
| Acyclovir (neonate) | 20 mg/kg IV q8h | |
| Epinephrine (cold shock) | 0.05–0.3 mcg/kg/min IV infusion | First-line peds vasopressor |
| Norepinephrine (warm shock) | 0.05–0.5 mcg/kg/min IV infusion | |
| Hydrocortisone (catechol-resistant) | 1–2 mg/kg IV (50 mg/m²/day) | If suspected adrenal insufficiency or refractory shock |
Management / next steps
- Recognize: persistent tachycardia, prolonged cap refill, AMS, lactate ↑
- Hour-1: O₂, monitor, IV/IO ×2, cultures, antibiotics, fluid bolus, lactate
- Reassess after each bolus; stop if fluid overload; add vasoactive if shock persists
- Source control (drain abscess, remove central line, etc.)
- Admit PICU
Source: https://fprmed.com/fprmedcom/Pages/Pedi/Pedi_Sepsis.html
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