ENW-Masthead2.gif (25553 bytes)

bar_Turquoise_and_Gray.jpg (1480 bytes)

Research Applied to Clinical Practiceimgtchr1.gif (1235 bytes)
by Robert C. Knies, RN MSN CEN
Section Editor

bar_Turquoise_and_Gray.jpg (1480 bytes)
Sepsis in Children
bar_Turquoise_and_Gray.jpg (1480 bytes)

        Although most acute infections in children usually respond to appropriate treatment or improve without intervention, some severe infections can progress to lethal complications, such as septicemia and septic shock. In infants younger than one year, especially those less than three months of age, mortality rates approach 50% (Jafari & McCracken, 1992). Therefore, when a febrile neonate presents to an Emergency Department (ED) or Urgent Care (UC), a full work-up is indicated and admission to a hospital is the current standard practice.

       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"
[http://ENW.org/Research-SepticKid.htm]
is a webarticle by  Robert C. Knies, RN MSN CEN [bknies@stevenshealthcare.org]
©Robert C. Knies, RN MSN CEN
presented by Emergency Nursing World ! [http://ENW.org]
Tom Trimble, RN [Tom@ENW.org] ENW Webmaster
ENW
name, logos, and layout ©Tom Trimble, RN


 
 

Clinical Articles Special Articles

Links

2003 ASA
"Difficult Airway Practice Guidelines"

Airway 10 Commandments
Action Plan for Airway Hell!

Using Anesthesia Bags
Optimizing Mask Ventilation
Sedation Guidelines
Sedation Principles
Sedation Checklist

Aphorisms, Maxims, and Pearls
Discharge Instructions
I.V. Starts -Improving Your Odds!
Pediatric Hints -An ABC
Tips & Tricks -from Other Nurses
Manipulative Behaviors by Patients

Heat Emergencies
End Tidal CO2 Monitoring
in CPR: A Predictor of Outcome

Fix This Airway!
Crises in Airway Management

Bioterrorism References
Electrolytes
Headache & Stroke
Outsize Patients
--a big nursing challenge!

The Poisoned Patient
Respiratory Encounters (I Can't BREATHE! Part I)

Respiratory Encounters (I Can't BREATHE! Part II)

 

Internet Starter Set
Quick Subject Guide
Basic Desktop References
Medical Links
-  (Addiction Medicine to Gerontology)
Medical Links
- (Gov't to Medical Organizations)
Medical Links
- (Medical Records to Primary Care)
Medical Links
- [Psych. to Wilderness]
Nursing Links
[General]
Emergency Nursing Links
Pre-Hospital Links

- [Ambulance to EMS Web Pages]

Pre-Hospital Links
[Fire to Special Purpose Care Organizations]
Just for Fun Links
 
ENW !  urges help to
victims of recent disasters
American Red Cross  
donate page
 



supports and recommends

FREE EMERGENCY MEDICINE TALKS

   Emergency Medicine education for everyone.
 

MP3 files provided by: Joe Lex, MD
 


Fabulous Places!  --  Fabulous Conferences!
Check frequently for updates

   

Plan for the Year Ahead!  
Meetings & Symposia

                   Meetings of 2013

 
 
Clinical Research Behind the Scenes at ENW! The World of Emergency Nursing
Meet the Editor
Temperature Management
Gastric Decontamination

Thermometry in Acute Care
Latest Research in Resuscitation

Septic Children
ACT
INR
Carbon Monoxide
Malignant Hyperthermia
Geriatric Thermoregulation
SSRI's
"
Orthostatics"
NG Tubes
RSV
Defibrillation
Disclaimer  Applies to all portions of this site!

Policies of this Website

Information for Authors

The Emergency Nursing
& Emergency Nursing World ! FAQ


ENW is Listed@

What's This All About?

Tom Trimble's Tale
Library of Resources & Solutions
CPEN Review - Putting
 It All Together

Bedlam Among the Bedpans
Veinlite EMS
Body Piercing Removal Kit
& Training Program

Emergency Nursing 5-Tier
Triage Protocols
Emergency Newborn Care
Quick Reference to Triage
Quick-E Guides
The Emergency Nursing "Cool Web-Find!"
Honor Gallery of Previous Winners
An 1895 Look At Nursing
Beatitudes For Leaders
E-Mail Lists & Usenet Groups

Emergency Nursing WebLinks
Emergi-Lexicon
Em-Nsg-L: The Emergency Nursing List
Humor
Night-Shift Survival Tips
Old-Aid -Archaic & Obsolete
University-Level Emergency Nursing Education
Words & Thoughts
 
California ENA Website ENW! Supports ENA  

is now
http://www.CalENA.US

We Support

Use this button to
go to ENA's sit
e

Emergency
Nursing World !
is an independent entity and
NOT a component

of
ENA

 

 

 
Google


WWW ENW.org

Emergency

Nursing World !