Research Applied to Clinical Practice
by Robert C. Knies, RN MSN CEN
Section Editor
Sepsis in Children
Signs and Symptoms of sepsis are highly variable and studies have attempted to find "classic signs" but have been inconclusive (Vincent, 1995). Especially in neonates, sepsis may start with minimal or nonspecific symptoms, and approximately one-third of cases are associated with concurrent meningitis, which is clinically indistinguishable from sepsis (Dashefsky, 1991). Sepsis must be considered in any neonate presenting to an Emergency Department or Urgent Care Center with a rectal temperature greater than 38° C or less than 36° C. Therefore, these patients must be triage classified as Emergent.
The incidence of sepsis shows a bimodal distribution, the first peak is in the neonatal period and the second is around the age of two years. The sepsis rate for infants less than 30 days of age ranges from 1 to 8 per 1000 live births (Hazelzet & DeGroot, 1994; Dashefsky, 1991; Gerdes, 1991; Gladstone, Ehrenkranz, & Edberg, 1990). In infants less than two months, the pathogens were group B streptococci, Escherichia coli, enterococci, and Listeria monctogenes (Dashefsky, 1991; S`aez-Llorens & McCracken, 1993). Recent epidemiological studies have shown a decreasing incidence of H. Influenza, coinciding with the use of Hib vaccine.
The following table lists some of the presenting complaints which studies have shown may indicate or are associated with an eventual diagnosis of sepsis (Zimmerman & Dietrich, 1987; Dashefsky, 1991; Gerdes, 1991; Gladstone, Ehrenkranz, & Edberg, 1990; Buck, Bundschu, & Gallati, 1994).
Signs of Sepsis in Neonates |
(Martinet, LeClerc, Cremer, Leteurtre, Fourier, & Hue, 1997) |
| Fever or hypothermia (even without other S/S). |
| "Not looking well." |
| Tachycardia, bradycardia, shock, or poor perfusion. |
| Respiratory distress, apnea, grunting, cyanotic "spells". |
| Lethargy, irritability, seizures, "full" fontanelle, hypotonia. |
| Feeding difficulties, vomiting, abdominal distention. |
| Diarrhea, jaundice, hepatosplenomegaly. |
| Rash, localized infection. |
The treatment regime is currently under review in many of the journals, especially in view of the spread of managed care and capitation. In the past, common diagnostic protocols included: CBC and differential, Blood cultures, Catheterized urine, and Lumbar puncture for exam of cells, protein, and glucose. Leading ultimately to admission to the hospital in isolation, and initiating intravenous antibiotic therapy, pending culture results. Some providers are advocating only the CBC, and urinalysis in the ED, to determine causation of fever or infection, and only admit to hospital if causation cannot be found. Many providers are commonly ordering intramuscular or intravenous ceftriaxone as a "catch all" and discharging if causation cannot be found (Young, 1995; Ogborn, Soulen, & DeAngelis, 1995). Naturally, these practices have stirred the ranks of pediatric providers across the country, and brought about very heated debate (Baraff, Schriger, Bass, Fleisher, Klien, McCracken, & Powell, 1997; Schriger, 1997; Kramer, 1997).
Needless to say, interventions in neonates need to be more aggressive that those of older children, as their ability to fight infection is significantly compromised due to their developmental status, this is compounded in the premature neonate. As Sheehy (1992), states "any infant under three months of age with a fever should be evaluated as soon as possible to rule out serious bacterial infection." Henceforth, this expected practice for all care-givers in ED’s and UC’s.
For further information on current research in the treatment of Fever in patients of all ages see February 1998’s Patient Care Connection Clinical Practice Challenge: The chilling truth about fevers. By my colleague Kristine Peterson (Critical Care CNS)
References:
Baraff, L.J., Bass, J.W., Fleisher, G.R., Klein, J.O., McCracken, G.H., &
Powell, K.R. (1997). Commentary on practice guidelines. Pediatrics, 100, (1),
134-136.
Buck, C., Bundschu, J., Gallati, H., et al. (1994). Interleukin-6: A sensitive parameter
for the early diagnosis of neonatal bacterial infection. Peidatrics, 93, 54-58.
Dashefsky, B. (1991). Life-threatening infections. Pediatric Emergency Care, &,
244-253.
Gerdes, J.S. (1991). Clinicopathologic approach to the diagnosis of neonatal sepsis. Clinical
Perinatology, 18, 361-381.
Gladstone, I.M., Ehenkranz, R.A., Edberg, S.C., et al. (1990). A ten year review of
neonatal sepsis and comparison with the previous fifty year experience. Pediatric
Infectious Disease Journal, 9, 819-825.
Jafari, H.S., McCracken, G.H. (1992). Sepsis and septic shock: A review for clinicians. Pediatric
Infectious Disease Journal, 11, 739-748.
Kramer, M.S., Shapiro, E.D. (1997). Management of the young febrile child: A commentary on
recent practice guidelines. Pediatrics, 100, (1), 128-134.
Martinot, A., LeClerc, F., Cremer, R., Lereurtre, C., & Hue, V. (1997). Sepsis in
neonates and children: Definitions, epidemiology, and outcome. Pediatric Emergency
Care, 13, (14), 277-281.
Ogborn, C.J., Soulen, J.L., & DeAngelis, C. (1995). Hospitalization vs. outpatient
treatment of young febrile infants: 10-year comparison. Archives of Pediatric &
Adolescent Medicine, 149, 94-97.
S`aez-Llorens, X., McCracken, G.H., (1993). Sepsis syndrome and septic shock in
pediatrics: current concepts of terminology, pathophysiology, and management. Journal
of Pediatrics, 123, 497-508.
Schriger, D.L. (1997). Clinical guidelines in the setting of incomplete evidence. Pediatrics,
100, (1), 136-137.
Sheehy, S.B. (1992). Emergency Nursing: Principles and Practice, 3rd ed. Mosby: St.
Louis.
Vincent, J.L. (1995). The "at risk" patient population. In Sibbald, W.J. &
Vincent, J.L. eds. Update in intensive care and emergency medicine, 19 Clinical trials
for the treatment of sepsis. Springer-Verlag: Berlin.
Young, P.C. (1995). The management of febrile infants by primary-care pediatricians in
Utah: Comparison with published practice guidelines. Pediatrics, 95 (5). 623-627.
Zimmerman, J.J., Dietrich, K.A. (1987). Current perspectives on septic shock. Pediatrics
Clinics of North America, 34, 131-163.
"Research Applied to Clinical Practice: Sepsis in Children"
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Knies, RN MSN CEN [bknies@stevenshealthcare.org]
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