Residency · Residency · Medicine-Pediatrics

Sepsis Recognition and Management: Pediatric and Adult Paradigms

Introduction

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It remains a leading cause of morbidity and mortality in both children and adults. While the underlying pathophysiology is similar, definitions, recognition criteria, and resuscitation protocols differ significantly between pediatric and adult populations. The med-peds physician must be fluent in both paradigms.

Definitions

Adult Sepsis (Sepsis-3, 2016)

Sepsis: Infection plus organ dysfunction defined by an increase of 2+ points in the SOFA score. Septic shock: Sepsis plus vasopressor requirement to maintain MAP 65 mmHg and lactate >2 mmol/L despite adequate fluid resuscitation. qSOFA (Quick SOFA): Altered mentation, SBP 100 mmHg or less, RR 22 or more (screening tool, not diagnostic)

Pediatric Sepsis (Phoenix Criteria, 2024)

Pediatric sepsis: Infection plus organ dysfunction defined by Phoenix Sepsis Score 2+ (respiratory, cardiovascular, coagulation, neurologic domains) Pediatric septic shock: Sepsis with cardiovascular dysfunction (vasoactive requirement or lactate >5 mmol/L) Replaces the prior 2005 consensus definitions that used SIRS criteria.

Key Differences

Adult Sepsis-3 abandoned SIRS criteria; pediatric definitions have now followed. Pediatric vital sign thresholds are age-dependent. Hypotension is a late finding in children; tachycardia and poor perfusion are earlier signs.

Pathophysiology

Infection triggers innate immune response: cytokine release, complement activation, coagulation cascade. Pro-inflammatory cascade: TNF-alpha, IL-1, IL-6 lead to vasodilation, endothelial dysfunction, capillary leak. Organ dysfunction results from microcirculatory failure, cellular hypoxia, and mitochondrial dysfunction. Children have greater physiologic reserve but can deteriorate rapidly once compensatory mechanisms fail.

Recognition

Adult Warning Signs

Fever or hypothermia with suspected infection; Tachycardia, tachypnea, hypotension; Altered mental status; Elevated lactate (>2 mmol/L); New organ dysfunction (rising creatinine, bilirubin, coagulopathy).

Pediatric Warning Signs

Tachycardia disproportionate to fever; Delayed capillary refill (>3 seconds) or flash capillary refill; Altered mental status (irritability, lethargy); Decreased urine output; Mottled or cool extremities (cold shock) vs. warm, flushed skin (warm shock).

Screening Tools

Adult: qSOFA, NEWS (National Early Warning Score), institutional sepsis alerts. Pediatric: Pediatric early warning scores (PEWS), age-adjusted vital sign parameters.

Management: The First Hour

Adult Sepsis Bundle (Surviving Sepsis Campaign)

Measure lactate; remeasure if initial lactate >2 mmol/L. Obtain blood cultures before antibiotics. Administer broad-spectrum antibiotics within 1 hour of recognition. Begin 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L or more. Apply vasopressors if hypotensive after initial fluid resuscitation (norepinephrine first-line)

Pediatric Sepsis Bundle

Obtain blood cultures; administer broad-spectrum antibiotics within 1 hour. Fluid resuscitation: 10-20 mL/kg isotonic crystalloid boluses; reassess after each bolus. Avoid excessive fluid: reassess for signs of fluid overload (hepatomegaly, rales, worsening respiratory status) Vasoactive agents: Epinephrine for cold shock; norepinephrine for warm shock. Consider stress-dose hydrocortisone for catecholamine-resistant shock.

Antibiotic Selection

Common Empiric Regimens

Source-Specific Considerations

Tailor antibiotics once source is identified. De-escalate based on culture results and clinical improvement. Duration typically 7-10 days; procalcitonin-guided de-escalation reduces antibiotic exposure.

Fluid Resuscitation: Evolving Evidence

FEAST trial (pediatric, resource-limited): Fluid boluses increased mortality in febrile children with impaired perfusion in Africa. CLASSIC trial (adult): Restrictive fluid strategy was noninferior to liberal fluids in adult septic shock. Current consensus: Fluid resuscitation remains essential but requires frequent reassessment for response and fluid overload. Balanced crystalloids (lactated Ringer's) may be preferred over normal saline.

Vasopressor and Inotrope Considerations

Adults: Norepinephrine first-line; add vasopressin as second agent; dobutamine for low cardiac output. Children: Epinephrine or norepinephrine first-line depending on shock phenotype; milrinone for low cardiac output with high SVR. Central access preferred but peripheral vasopressors acceptable in emergency.

Adjunctive Therapies

Corticosteroids: Hydrocortisone 200 mg/day IV for adults with refractory shock; stress-dose for children with suspected adrenal insufficiency. Blood transfusion: Target hemoglobin 7 g/dL in adults; less clear threshold in children. Source control: Drain abscesses, remove infected devices. Glucose management: Avoid hypoglycemia (especially in neonates and young children)

Clinical Pearls

Sepsis is a medical emergency; every hour of delayed antibiotics increases mortality by approximately 4%. In children, hypotension is a late sign; do not wait for it to diagnose shock. The Phoenix Sepsis Score provides a standardized, globally applicable definition for pediatric sepsis. Reassess frequently after each fluid bolus; more is not always better. Med-peds physicians on call must be comfortable managing both pediatric and adult sepsis protocols simultaneously.

References

1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
2. Schlapbach LJ, Watson RS, Sorce LR, et al. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024;331(8):665-674.
3. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Med. 2021;47(11):1181-1247.
4. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection (FEAST). N Engl J Med. 2011;364(26):2483-2495.

For the intern

At 3am when sepsis is suspected, act immediately: obtain blood cultures from two sites, start broad-spectrum antibiotics within one hour, and begin fluid resuscitation while frequently reassessing perfusion. For adults, push 30 mL/kg crystalloid rapidly if hypotension or lactate is elevated; for children, give 10-20 mL/kg boluses with reassessment after each to avoid fluid overload. Draw lactate and repeat if elevated. Start norepinephrine for adults or epinephrine for pediatric cold shock if they remain hypotensive after initial fluids. Everything else—source identification with imaging, vasopressin as a second agent, stress-dose steroids for refractory shock, critical care consultation—can be initiated in the first hour but refined as the night progresses. Do not delay antibiotics waiting for imaging or confirmatory tests.

Common pitfalls

• Waiting for hypotension in children: Tachycardia, delayed capillary refill, and altered mental status indicate shock before blood pressure drops; pediatric compensatory mechanisms mask hypotension until late decompensation occurs
• Over-resuscitating with fluids: Continuing boluses without reassessing for hepatomegaly, rales, or worsening oxygenation causes harm; recent evidence favors cautious fluid administration with frequent clinical reassessment
• Delaying antibiotics for imaging: The one-hour antibiotic window starts at recognition of possible sepsis, not after CT confirms the source; obtain cultures and start empiric coverage immediately
• Wrong vasopressor choice: Children in cold shock need epinephrine for inotropic support, not norepinephrine alone; warm shock responds better to norepinephrine

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