What is sepsis?

Sepsis is a whole body inflammatory reaction to infection, usually pathogens in the blood and generally bacteria.

Clinical features include the following:

• Temperature less than 36°C or greater than 38°C
  
• Low blood pressure (late sign in children)
  
• Tachycardia
  
• Tachypnoea
  
• Limb pain
  
• Change in behaviour
  
• Rash
  
• Cyanosis.

Stabilization of the infant or child

Often, procedures are carried out on sick children and medical professionals lose sight of the basics while they are concentrating on a task, for example taking blood. A shocked, septic, shut-down sick child requires stabilization and continuous assessment of their ABCDE (airway, breathing, circulation, disability and exposure).

It is dangerous to begin any procedure on an unstable child as the procedure may exacerbate a problem and make the infant or child deteriorate further.

Sick infants do not like being handled. They are usually hypoxic, will become increasingly distressed and their tachycardia and tachypnoea may advance. They may deteriorate further and become bradycardic and apnoeic.

Blood tests

Full blood count, C-reactive protein (CRP) blood glucose and cultures can be taken from intravenous (IV) access or intraosseous (IO) access (although usually only enough bone marrow is obtained to carry out a blood sugar assessment). If bone marrow is sent to the laboratory, it is important to indicate that it is not venous blood, as it will look different under the microscope.

If enough blood is obtained, a blood gas assessment is helpful to indicate how acidotic the infant or child is.

The blood test results should be available quite quickly but the cultures take 48 hours to be processed.

Urine

A clean catch urine is recommended and this can cause some challenges, depending on the age and sex of the child. It may sometimes be necessary to obtain a catheter or a suprapubic sample from the infant or child.

Stool sample

This is easier to obtain from an infant’s nappy, but if there are frequent abnormal stools, taking a sample is quite simple. Remember personal protection equipment at all times.

Chest X-ray

Ensure the infant or child is stable, has a parent and/or member of staff with them and the X-ray is carried out in a timely manner to help prevent hypothermia and possible deterioration from increased handling.

Results are available fairly quickly and help in the differential diagnosis of sepsis from pneumonia.

Lumbar puncture for CSF sample

This is often contraindicated in a child who is neurologically unstable as it can have catastrophic consequences. It is unlikely that physicians will suggest a lumbar puncture when the patient is unstable, and it should always be questioned if considered.

If a lumbar puncture is required, ensure an ABCDE assessment is carried out before commencing the procedure, ensure it is done in a safe environment with emergency equipment ready including oxygen, bag valve mask, suction and resuscitation trolley in case of further deterioration.

In an infant, observe the airway and breathing continuously, as the position of the infant has the potential to occlude the airway. It may be advisable to ask the parent to step outside the room while the procedure is being undertaken. In an older child, consider analgesia and provide reassurance as it can be a frightening and painful procedure.

Specimens usually take 48 hours to be cultured.

Swabs

Swabs of wound sites, pegs, catheters, discharging ears, noses and throats can be useful in identifying the source of infection and are painfree and quick. The results take 24–48 hours to culture.

Consent

Parental verbal consent should be obtained if at all possible and documented in the notes. A child that is Fraser competent may also consent to a procedure, but also has the right to refuse. The involvement of parents, carers and play specialists may be required.