Implement protocols for early identification and management. 

Takeaways:

• • Sepsis has received much attention recently, but the pediatric population is missing from many of these discussions.
  • Increased nursing knowledge about sepsis recognition, management, and emergency care can improve outcomes for these patients.
  • The pediatric assessment triangle can aid early identification of sepsis signs and symptoms.

Liz Borough* calls emergency medical ser­vices when her son, Owen, a 28-day-old infant, becomes unresponsive. He requires resuscitation and is taken to the emergency department (ED) at the local hospital. The ED nurse notes Owen’s pale skin and that he has no other vital sign abnormalities. The ED physician admits Owen to the pediatric care unit for observation.

Overnight, Owen develops a fever of 101.2°F (38.4°C). The nurse, Robert Conner, completes a thorough assessment, noting capillary refill >3 seconds. Robert asks Ms. Borough if she’s noticed any changed behavior in Owen. She says that her son has been fussier than usual and not easy to console. Using the pediatric assessment triangle, Robert recognizes these as signs and symptoms of sepsis and calls the pediatric hospitalist. (See Pediatric assessment triangle.)

The hospitalist uses an algorithm (such as the Cincinnati Children’s Fever of Unknown Source) to conclude that Owen is at high risk for a serious bacterial illness. She outlines the plan of care, which includes a complete septic workup with catheterized urine collection, lumbar puncture, blood work, I.V. fluids, and broad-spectrum antibiotics. The hospitalist thanks Robert for his good catch and attention to detail. (See Fever of unknown source algorithm.)

Identifying sepsis

Typically, when a patient between 0 and 60 days old presents with a fever, the source is viral. However, nurses must follow current guidelines for appropriate management, and healthcare leaders should implement protocols and order sets to ensure implementation of evidence-based assessments and treatment.

Assessment 

Infants, such as Owen, at presumed high risk for sepsis should receive a complete sepsis assessment, including blood work (pro-calcitonin [PCT], complete blood count, basic metabolic panel, and blood cultures), lumbar puncture to analyze cerebral spinal fluid (CSF), and catheterization for urine analysis, culture, and sensitivity. Tests appropriate for the initial assessment include protein, glucose, culture and gram stain, cell count, and differential. One tube of blood should be labeled and held in the lab in the event additional studies, such as for herpes simplex virus (HSV), are required.

In the past 20 years, the incidence of HSV in the United States has increased to 1 in 2,000 live births. HSV is most frequently transmitted during delivery, but postnatal transmission also occurs from family and caregivers. The incubation period ranges from 2 days to 2 weeks. HSV should be a consideration for neonates (between birth and approximately 6 weeks of age) who present with fever, a vesicular rash, or abnormal CSF findings.

Make sure to follow your specific lab’s reference range for abnormal values as they may differ. In pediatric patients, a PCT >0.5 ng/mL is considered indicative of a serious bacterial infection. The higher the PCT, the greater the sepsis severity. However, PCT can yield false positives and should be combined with clinical assessment. Patients suspected to have sepsis require prompt antibiotic therapy, but blood cultures should be drawn before administering antibiotics. Obtain cultures immediately to avoid treatment delays. If you encounter difficulty obtaining blood cultures, contact the provider immediately. Urine analysis in patients between 0 and 60 days old with a white blood cell count >10 is considered a positive result that requires treatment.

Group B Streptococcus (GBS), a leading cause of sepsis in infants, has no effective preventive strategy. Early-onset GBS sepsis typically occurs between birth and 6 days; late-onset GBS sepsis occurs in infants up to 90 days of age. All newborn infants should be assessed for their risk of developing GBS sepsis using the Neonatal Early-Onset Sepsis Calculator. Knowing maternal GBS status is important for infants presenting with clinical signs of sepsis, but late-onset GBS occurs in infants regardless of maternal status during pregnancy.

Treatment 

Owen’s initial treatment includes broad-spectrum antibiotics. Patients showing signs of septic shock should receive antibiotics within 1 hour. Patients who have sepsis without shock should receive antibiotics within 3 hours. Owen received his assessment and antibiotics within 1 hour of identification. In addition, the provider ordered an empiric therapy regimen of ampicillin, a third-generation cepha­losporin (alternatively the provider could have prescribed gentamicin), and maintenance I.V. fluids with lactated ringers. Pediatric patients with hypotension should receive between 10 to 20 mL/kg of I.V. fluids within the first hour, with or without pediatric intensive care availability. Because Owen didn’t have hypotension, the provider didn’t order a fluid bolus. Fluid boluses aren’t routinely recommended in hospitals without a PICU because they may not have the resources to manage treatment complications.

Owen receives a final diagnosis of urinary tract infection after his urine analysis shows 10 plus white blood cells and his culture and sensitivity indicate the presence of Escherichia coli. To cover the identified bacteria, the provider modifies Owen’s antibiotic regimen to include ceftriaxone.

Nursing implications

Sepsis has received a great deal of attention recently, but the pediatric population is missing from many of these discussions. Increased nursing knowledge about sepsis recognition, management, and emergency care can improve outcomes for these patients. Many early warning signs of pediatric sepsis go unrecognized, especially outside of pediatric tertiary care centers. According to the Emergency Medical Services for Children Innovation and Improvement Center, approximately 70% of EDs in the United States see fewer than 15 pediatric patients per day. This low volume creates challenges to establishing pediatric quality metrics and performance standards.

Early and accurate diagnosis of pediatric sepsis, a leading cause of morbidity, mortality, and healthcare utilization for children worldwide, remains challenging. To ensure prompt sepsis recognition and treatment, ED nurses must have the knowledge, tools, and equipment necessary to care for pediatric patients of all ages. Standardized screening and early-warning systems aid in early treatment and reduce morbidity and mortality.

In addition, relationship-based nursing practice allows parents and guardians to act as integral members of the care team. Intentional listening and addressing caregiver concerns has the potential to speed sepsis recognition and response. (See What nurses can do.)

Start the change

Nurses should be empowered to speak up for patients through patient safety platforms. Hospital leadership can support inpatient and outpatient sepsis management across the continuum by implementing a comprehensive sepsis recognition and screening program for patients of all ages. Changes in pediatric sepsis management start with you.

Alysia Adams is nursing faculty at the University of Florida and the lead advanced practice provider at Ascension St. Vincent’s Riverside Hospital in Jacksonville, Florida. Ashley Lynch Denton is a nurse manager in the neonatal intensive care unit at Owensboro Health in Owensboro, Kentucky.

References

Bobillo-Perez S, Rodríguez-Fanjul J, Garcia IJ. Is procalcitonin useful in pediatric critical care patients? Biomark Insights. 2019;13:1177271918792244. doi:10.1177%2F1177271918792244

Cincinnati Children’s. Evidence-based care guideline for management of infants 0 to 60 days with fever of unknown source. May 7, 2019.

Downes KJ, Fitzgerald JC, Weiss SL. Utility of procalcitonin as a biomarker for sepsis in children. J Clin Microbiol. 2020;58(7):e01851-19. doi:10.1128%2FJCM.01851-19

Emergency Medical Services for Children Innovation and Improvement Center.

Puopulo K, Lynfield R, Cummings JJ. Management of infants at risk for Group B Streptococcal disease. Pediatrics. 2019;144(2):e20191881. doi:10.1542/peds.2019-1881

Weiss S, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med. 2020;21(2):e51-106. doi:10.1097/PCC.0000000000002198