**4. Sepsis and septic shock in pediatrics**

#### **4.1 Introduction**

The prevalence of pediatric septic shock, causing death and long term mobility, has increased over the years, and prior to implementation of early recognition programs and treatment, mortality remained unchanged [43, 44]. Even with millions of dollars being spent and years of research being done, many children still suffer from septic shock [45]. Morbidity in children following severe sepsis is now similar to that in critically ill adults [46]. Due to the high rates of morbidity, mortality and costs associated with pediatric sepsis, there is an increased burden on healthcare communities [47]. As reported by Watson et al., pediatric sepsis patients had an average hospital stay of 31 days and about 2 billion dollars are spent a year for their care [48]. The mainstays of pediatric sepsis treatment, according to the international guidelines, is prompt administration of antibiotics, rapid resuscitation and supportive care of organ dysfunction [1].

Adults and children differ in physiology, predisposing diseases, and sites of infection which necessitates differing diagnostic criteria and management strategies [49]. Among children who develop sepsis worldwide, 49% have a comorbid condition that leaves them vulnerable to infection. The most common comorbidities in children who develop sepsis are age specific; infants have chronic lung disease or congenital heart disease, while children ages one through nine have underlying neuromuscular disease and adolescents have pre-existing cancer [50].

#### **4.2 Diagnosis**

The definition of adult sepsis has undergone continuing revision to keep pace with the high volume of published research; however, it is only recently that attention has been given to the pediatric patient and the many caveats that separate the pediatric patient from the adult. Prior to 2005, there was not a standard definition for pediatric sepsis which resulted in a lack of uniformity among sepsis studies [49]. In 2005, the Pediatric Sepsis Consensus Congress (PSCC) met to standardize the definition of sepsis. Defining sepsis in the pediatric patient is made more difficult due to age specific vital signs, and their tremendous physiologic reserve which often masks the seriousness of their condition. The PSCC divided age into six distinct categories in order to take into account age specific vital signs as well as age specific

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**4.3 Management**

**Figure 3.**

*Sepsis and Septic Shock*

*DOI: http://dx.doi.org/10.5772/intechopen.86800*

risk factors for invasive infections which in turn affect antibiotic coverage guidelines [51]. Pediatric severe sepsis is defined as two or more systemic inflammatory response syndrome criteria, confirmed or suspected invasive infection, and cardiovascular dysfunction, acute respiratory distress syndrome, or two or more organ dysfunctions. Determination of altered physiology is specific to age dependent vital signs [49, 52]. At present, there is no single biomarker that has proven specific or sensitive enough to diagnose sepsis or prognosticate outcome in selected cohorts. Similar to studies of sepsis in adults, there is active research examining both clinical

The current guidelines for treatment are summarized in the pediatric section of the surviving sepsis campaign (**Figure 3**) [49]. Early and aggressive source control

and research measurements applicable to a pediatric population [49].

*Survive sepsis campaign pediatric treatment protocol [21].*

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

significant proportion of deaths [9].

sepsis as compared to normal saline [41, 42].

placental blood flow in a pregnant woman [9].

**4. Sepsis and septic shock in pediatrics**

**4.1 Introduction**

**4.2 Diagnosis**

Pregnant women who develop sepsis are usually infected with multiple organisms. The initial choice of antibiotic should have broad spectrum coverage and base it off of guidelines and patterns of resistance [40]. The initial treatment should include coverage against Group A Streptococcus and *Escherichia coli* because they are the most common contributors to sepsis in pregnancy and responsible for a

In a septic pregnant patient, one big challenge is being able to manage fluids. The

SSC guidelines recommend crystalloid at an initial 30 mL/kg bolus. This recommendation can be too aggressive in the obstetric population, but there is evidence that shows balanced crystalloid solutions are associated with a lower mortality in

Vasopressors can be used in sepsis mediated hypotension and septic shock. If hypotension does occur, the surviving sepsis campaign (SCC) recommends norepinephrine as the first line agent. These SCC guidelines are based on evidence from non-pregnant patients and there is little data on the effect that vasopressors have on

The prevalence of pediatric septic shock, causing death and long term mobility, has increased over the years, and prior to implementation of early recognition programs and treatment, mortality remained unchanged [43, 44]. Even with millions of dollars being spent and years of research being done, many children still suffer from septic shock [45]. Morbidity in children following severe sepsis is now similar to that in critically ill adults [46]. Due to the high rates of morbidity, mortality and costs associated with pediatric sepsis, there is an increased burden on healthcare communities [47]. As reported by Watson et al., pediatric sepsis patients had an average hospital stay of 31 days and about 2 billion dollars are spent a year for their care [48]. The mainstays of pediatric sepsis treatment, according to the international guidelines, is prompt administration of antibiotics, rapid resuscitation and supportive care of organ dysfunction [1]. Adults and children differ in physiology, predisposing diseases, and sites of infection which necessitates differing diagnostic criteria and management strategies [49]. Among children who develop sepsis worldwide, 49% have a comorbid condition that leaves them vulnerable to infection. The most common comorbidities in children who develop sepsis are age specific; infants have chronic lung disease or congenital heart disease, while children ages one through nine have underlying

neuromuscular disease and adolescents have pre-existing cancer [50].

The definition of adult sepsis has undergone continuing revision to keep pace with the high volume of published research; however, it is only recently that attention has been given to the pediatric patient and the many caveats that separate the pediatric patient from the adult. Prior to 2005, there was not a standard definition for pediatric sepsis which resulted in a lack of uniformity among sepsis studies [49]. In 2005, the Pediatric Sepsis Consensus Congress (PSCC) met to standardize the definition of sepsis. Defining sepsis in the pediatric patient is made more difficult due to age specific vital signs, and their tremendous physiologic reserve which often masks the seriousness of their condition. The PSCC divided age into six distinct categories in order to take into account age specific vital signs as well as age specific

**72**

**Figure 3.** *Survive sepsis campaign pediatric treatment protocol [21].*

risk factors for invasive infections which in turn affect antibiotic coverage guidelines [51]. Pediatric severe sepsis is defined as two or more systemic inflammatory response syndrome criteria, confirmed or suspected invasive infection, and cardiovascular dysfunction, acute respiratory distress syndrome, or two or more organ dysfunctions. Determination of altered physiology is specific to age dependent vital signs [49, 52]. At present, there is no single biomarker that has proven specific or sensitive enough to diagnose sepsis or prognosticate outcome in selected cohorts. Similar to studies of sepsis in adults, there is active research examining both clinical and research measurements applicable to a pediatric population [49].
