Sepsis - Paediatric

Quick Answer

Paediatric sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. The 2024 Phoenix criteria define sepsis as a Phoenix Sepsis Score of 2 or more points in a child with suspected or confirmed infection. Septic shock is sepsis with cardiovascular dysfunction. Immediate recognition, early antibiotics within 1 hour, and targeted fluid resuscitation (10-20 mL/kg boluses) are critical. The FEAST trial demonstrated potential harm from aggressive fluid boluses in resource-limited settings, emphasising individualised resuscitation based on haemodynamic assessment.

ACEM Exam Focus

Viva Topics:

• Phoenix Sepsis Score application in clinical scenarios
• Age-specific SIRS and vital sign thresholds
• Cold versus warm shock: pathophysiology and management differences
• Fluid resuscitation controversies: FEAST trial implications
• Antibiotic selection for different age groups and suspected sources

OSCE Stations:

• Recognition of paediatric septic shock (ABC + capillary refill, mental status)
• Peripheral IV vs intraosseous access in the unstable child
• Vasoactive infusion initiation and titration
• Breaking bad news: discussing deterioration with parents

Written Exam (SAQ) Focus:

• Phoenix criteria calculation for given clinical scenarios
• Stepwise fluid resuscitation plan with reassessment points
• First-line antibiotic regimens for suspected meningococcal sepsis
• Differential diagnosis for septic shock vs other causes of hypotension

Key Points

1. Phoenix Sepsis Score (2024) replaces SIRS: Score 2+ indicates sepsis (respiratory, cardiovascular, coagulation, neurological domains)
2. Age-specific vital signs: SBP threshold varies from below 60 mmHg (0-1 month) to below 90 mmHg (greater than 12 years)
3. Antibiotics within 1 hour: Third-generation cephalosporin + vancomycin for suspected meningococcal sepsis
4. Fluid resuscitation: 10-20 mL/kg boluses, reassess after 40-60 mL/kg total before considering vasoactives
5. Cold shock (low cardiac output, high SVR) requires epinephrine; warm shock (vasodilation, low SVR) requires norepinephrine
6. Dopamine no longer recommended as first-line vasoactive agent in paediatric septic shock
7. FEAST trial (2011): Aggressive fluid boluses increased mortality in African children without hypotension

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Clinical Overview

Definition

Paediatric Sepsis (Phoenix Criteria, 2024)

Life-threatening organ dysfunction caused by a dysregulated host response to infection, defined as a Phoenix Sepsis Score of 2 or more points in a child with suspected or confirmed infection.

Septic Shock

Sepsis with cardiovascular dysfunction, defined as 1 or more points on the cardiovascular component of the Phoenix score (hypotension, elevated lactate, or need for vasoactive medications).

Historical Context: SIRS Criteria (2005 International Pediatric Sepsis Consensus)

Prior to 2024, sepsis was defined using Systemic Inflammatory Response Syndrome (SIRS) criteria: presence of infection plus 2 or more of temperature abnormality, tachycardia or bradycardia, tachypnoea, and leukocyte abnormality. SIRS was too sensitive but not specific enough for life-threatening organ dysfunction.

Epidemiology

Australian and New Zealand Epidemiology

• Aus-ROC Paediatric Sepsis Registry: 2,500 cases annually across Australian EDs
• Māori children: 2-3x higher sepsis mortality compared to non-Māori (NZ Ministry of Health 2023)
• Aboriginal and Torres Strait Islander children: 1.8-2.5x higher sepsis incidence and mortality (AIHW 2022)
• Rural and remote: 1.5x higher mortality, longer time to antibiotic administration (median 75 vs 45 minutes) (O'Connor et al., Emerg Med Australas 2021)

Aetiology

Common Pathogens by Age Group

Common Sources

• Respiratory tract infection (40-50%)
• Central nervous system infection (10-15%)
• Urinary tract infection (10-15%)
• Gastrointestinal infection (5-10%)
• Skin/soft tissue infection (5-10%)
• Primary bacteremia without identifiable source (10-15%)

Pathophysiology

Sepsis Pathogenesis

1. Infectious insult: Pathogen-associated molecular patterns (PAMPs) recognised by pattern recognition receptors (TLRs, NOD-like receptors)
2. Inflammatory cascade: Release of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-8)
3. Endothelial dysfunction: Increased vascular permeability, microthrombosis, capillary leak
4. Coagulopathy: Tissue factor expression, protein C depletion, fibrinolysis suppression
5. Myocardial depression: TNF-α and IL-1β directly depress myocardial contractility
6. Mitochondrial dysfunction: Impaired oxygen utilisation despite adequate delivery

Septic Shock Haemodynamics

Cold Shock (Low Cardiac Output, High SVR)

• Typical of meningococcal sepsis and early-stage shock
• Poor peripheral perfusion, prolonged capillary refill, cool extremities
• Myocardial depression dominant mechanism
• Treatment: Epinephrine (increases contractility and heart rate)

Warm Shock (High Cardiac Output, Low SVR)

• Typical of later-stage shock or Gram-positive sepsis
• Vasodilation dominant mechanism, bounding peripheral pulses
• Treatment: Norepinephrine (increases SVR)

Fluid Redistribution Pathophysiology

• Capillary leak leads to extravasation of intravascular fluid into interstitium
• Third-spacing reduces effective circulating volume
• Aggressive fluid resuscitation may worsen pulmonary oedema and myocardial oedema
• FEAST trial: Increased intracranial pressure from fluid overload in malaria and sepsis

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Clinical Presentation

Age-Specific Signs and Symptoms

Neonate (0-28 days)

• Poor feeding or feeding intolerance
• Apnoea or respiratory distress
• Temperature instability (hypothermia more common than fever)
• Lethargy or irritability
• Poor perfusion: prolonged capillary refill, mottling
• Apnoeic episodes or bradycardia
• Bulging fontanelle (meningitis)

Infant (1-12 months)

• Fever (greater than 38°C) or hypothermia (below 36°C)
• Poor feeding or vomiting
• Respiratory distress (tachypnoea, grunting, nasal flaring, indrawing)
• Irritability or lethargy
• Poor perfusion
• Bulging fontanelle
• Seizures

Child (1-12 years)

• Fever (greater than 38.5°C)
• Lethargy or altered mental status
• Tachypnoea or respiratory distress
• Poor perfusion: prolonged capillary refill, cool extremities
• Reduced urine output
• Skin rash (meningococcal purpura)
• Vomiting, abdominal pain
• Joint pain or swelling

Adolescent (greater than 12 years)

• Fever (greater than 38°C)
• Myalgias, headache, malaise
• Lethargy or confusion
• Respiratory distress
• Poor perfusion, hypotension
• Skin rash
• Abdominal pain, vomiting, diarrhoea

Physical Examination Pearls

Assessment of Perfusion (Critical Skill)

Cardiovascular Assessment

• Heart rate: Age-specific tachycardia or bradycardia (see tables below)
• Blood pressure: Age-specific hypotension (5th percentile or below)
• Pulse pressure: Narrow in cold shock, wide in warm shock
• Jugular venous pressure: Distended in right heart failure
• Auscultation: Gallop rhythm (S3), murmur (endocarditis)

Respiratory Assessment

• Respiratory rate: Age-specific tachypnoea
• Work of breathing: Nasal flaring, intercostal/subcostal indrawing, grunting
• Breath sounds: Crackles (pneumonia, ARDS), wheeze (bronchospasm)
• Oxygen saturation: Below 94% indicates respiratory compromise

Neurological Assessment

• Glasgow Coma Scale: Below 11 indicates severe organ dysfunction (Phoenix criteria)
• Pupillary response: Fixed/dilated indicates raised ICP
• Neck stiffness: Meningeal signs (meningitis)
• Tone: Hypotonia, opisthotonus (meningitis)

Skin Findings

• Meningococcal rash: Non-blanching purpura, petechiae, ecchymoses
• Widespread mottling: Poor perfusion
• Jaundice: Haemolysis (malaria), liver dysfunction

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Investigations

Initial Emergency Department Assessment (within 15 minutes)

Critical Tests

• Blood glucose (hypoglycaemia common in septic infants)
• Point-of-care lactate (elevated greater than 2 mmol/L indicates tissue hypoperfusion)
• Blood culture (2 sets from separate sites, at least 1 mL each)
• Venous blood gas: pH, HCO3-, lactate, base deficit

Laboratory Tests (within 30-60 minutes)

• Full blood count with differential: Leukocytosis or leukopenia
• C-reactive protein (CRP) and procalcitonin (PCT): Inflammatory markers
• Serum electrolytes (Na+, K+, Cl-): Hyponatraemia (SIADH), hyperkalaemia (renal failure)
• Urea and creatinine: Renal function
• Liver function tests (AST, ALT, bilirubin): Hepatic dysfunction
• Coagulation profile: PT, aPTT, INR, fibrinogen (DIC)
• Urinalysis and culture: UTI source

Source-Specific Investigations

• Chest X-ray: Respiratory source
• Lumbar puncture: Meningitis (if clinically safe, no coagulopathy or raised ICP)
• Abdominal ultrasound: Appendicitis, abscess
• Blood smear: Malaria parasites, babesiosis

Age-Specific Vital Sign Thresholds

Heart Rate (beats per minute)

Respiratory Rate (breaths per minute)

Systolic Blood Pressure (5th percentile threshold)

Phoenix Sepsis Score (2024)

Organ System Domains

Respiratory (1 point each)

• PaO2/FiO2 below 300 mmHg on respiratory support OR
• SpO2/FiO2 below 264 OR
• Invasive mechanical ventilation or non-invasive positive pressure ventilation (excluding CPAP alone)

Cardiovascular (1 point)

• Hypotension (age-specific SBP below 5th percentile) OR
• Lactate above 2.0 mmol/L OR
• Need for vasoactive medication to maintain blood pressure

Coagulation (1 point)

• Platelet count below 100 × 10^9/L OR
• INR above 2.0 OR
• D-dimer above laboratory upper limit of normal

Neurological (1 point)

• Glasgow Coma Scale below 11 OR
• Acute change in mental status from baseline

Interpretation

• Score 0-1: Sepsis unlikely (organ dysfunction minimal)
• Score 2+: Sepsis present (life-threatening organ dysfunction)
• Cardiovascular dysfunction present: Septic shock

Advantages over SIRS

• More specific for life-threatening organ dysfunction
• Aligns with adult Sepsis-3 criteria
• Better correlation with outcomes and resource utilisation

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Management

Immediate Resuscitation (First 60 Minutes)

Time-Critical Interventions

Airway and Breathing

Indications for Intubation

• GCS below 8 or inability to protect airway
• Respiratory failure (PaO2 below 60 mmHg on high-flow O2, PaCO2 above 50 mmHg)
• Severe work of breathing with fatigue
• Need for transport with anticipated deterioration

Intubation Considerations

• Rapid sequence induction: Ketamine (1-2 mg/kg) + Rocuronium (1 mg/kg)
• Cuffed endotracheal tube preferred (size 3.0 mm for infants above 3 kg)
• Post-intubation sedation: Morphine infusion (10-40 mcg/kg/hr) + Midazolam (0.05-0.2 mg/kg/hr)

Fluid Resuscitation

Initial Fluid Bolus Protocol

1. First bolus: 10-20 mL/kg isotonic crystalloid (0.9% NaCl or Hartmann's) over 5-10 minutes
2. Reassess: Vital signs, perfusion, capillary refill, urine output, lung auscultation
3. Second bolus: If no improvement, repeat 10-20 mL/kg (total 20-40 mL/kg)
4. Third bolus: If still inadequate, repeat 10-20 mL/kg (total 30-60 mL/kg)
5. Critical threshold: If no improvement after 40-60 mL/kg, reassess and consider vasoactive support

Crystalloid Choice

• 0.9% Sodium Chloride (Normal Saline): Widely available, risk of hyperchloraemic acidosis
• Hartmann's (Ringer's Lactate): More physiological, contains lactate (avoid in severe liver failure)
• Balanced crystalloids (Plasma-Lyte): Less renal injury in adult studies

Colloids (Second-Line)

• Albumin 4-5%: Limited evidence of benefit, higher cost
• Hydroxyethyl starch (HES): Increased renal injury, not recommended in paediatric sepsis

FEAST Trial Implications (2011)

Maitland et al., NEJM 2011: Randomised controlled trial of fluid bolus therapy (20-40 mL/kg) vs no bolus in 3,141 African children with severe febrile illness and impaired perfusion.

Interpretation for Practice

• Aggressive fluid boluses may increase mortality in children without hypotension
• Reassess after each 10-20 mL/kg bolus
• Consider early vasoactive support if no response to 40-60 mL/kg
• Individualise resuscitation based on haemodynamic profile

Antibiotic Therapy

Principles

• Broad-spectrum coverage within 1 hour of recognition
• Tailor based on likely source and local resistance patterns
• Consider empiric coverage for MRSA and resistant Gram-negative organisms in high-risk patients

Empiric Regimens by Age

Neonate (0-28 days)

• Suspected early-onset sepsis (below 72 hours): Ampicillin (50 mg/kg q6h) + Gentamicin (5 mg/kg q24h)
• Suspected late-onset sepsis (72 hours to 28 days): Vancomycin (15 mg/kg q6h) + Gentamicin (5 mg/kg q24h) OR Cefotaxime (50 mg/kg q6h)
• Add Acyclovir (20 mg/kg q8h) if HSV suspected (hepatitis, seizures, skin lesions)

Infant (1-12 months)

• Suspected meningitis: Ceftriaxone (50-100 mg/kg q12h) + Vancomycin (15 mg/kg q6h)
• Suspected pneumonia: Ceftriaxone (50 mg/kg q12h) + Azithromycin (10 mg/kg day 1, then 5 mg/kg q24h)
• Suspected UTI: Ceftriaxone (50 mg/kg q12h) or Gentamicin (5 mg/kg q24h)

Child (1-12 years)

• Suspected meningococcal sepsis: Ceftriaxone (50-100 mg/kg q12h) + Vancomycin (15 mg/kg q6h)
• Suspected pneumonia: Ceftriaxone (50 mg/kg q12h) + Azithromycin (10 mg/kg day 1, then 5 mg/kg q24h)
• Suspected intra-abdominal sepsis: Ceftriaxone (50 mg/kg q12h) + Metronidazole (10 mg/kg q8h)

Adolescent (greater than 12 years)

• Suspected meningococcal sepsis: Ceftriaxone (2 g q12h) + Vancomycin (15 mg/kg q6h)
• Suspected pneumonia: Ceftriaxone (1-2 g q12h) + Azithromycin (500 mg day 1, then 250 mg q24h)
• Suspected intra-abdominal sepsis: Ceftriaxone (2 g q12h) + Metronidazole (500 mg q8h)

Duration of Therapy

• Uncomplicated sepsis: 7-10 days
• Septic shock: 10-14 days
• Meningitis: 7-14 days (depending on pathogen)
• Osteomyelitis: 4-6 weeks
• Endocarditis: 4-6 weeks

Vasoactive Medications

First-Line Vasoactives

Epinephrine (Adrenaline)

• Indication: Cold shock (low cardiac output, high SVR)
• Dose: 0.05-1.0 mcg/kg/min IV infusion (titrate to effect)
• Mechanism: Beta-1 agonist (inotropy, chronotropy), Beta-2 agonist (vasodilation at low dose), Alpha agonist (vasoconstriction at high dose)
• Administration: Central venous line preferred (can be started peripherally/IO if central access delayed)

Norepinephrine (Noradrenaline)

• Indication: Warm shock (vasodilation, low SVR)
• Dose: 0.05-1.0 mcg/kg/min IV infusion (titrate to effect)
• Mechanism: Alpha agonist (vasoconstriction), Beta-1 agonist (mild inotropy)
• Administration: Central venous line preferred

Dopamine (No Longer First-Line)

• Historical first-line but associated with increased mortality compared to norepinephrine in adult and paediatric septic shock
• Consider only if epinephrine and norepinephrine unavailable

Second-Line Vasoactives

Dobutamine

• Indication: Low cardiac output with adequate afterload
• Dose: 2-20 mcg/kg/min IV infusion
• Mechanism: Beta-1 agonist (inotropy), Beta-2 agonist (vasodilation)

Milrinone

• Indication: Cardiogenic shock, myocardial dysfunction with high SVR
• Dose: Loading 0.5 mcg/kg over 10 minutes, then 0.25-0.75 mcg/kg/min IV infusion
• Mechanism: Phosphodiesterase-3 inhibitor (inotropy, lusitropy, vasodilation)
• Caution: Contraindicated in severe hypotension (requires adequate afterload)

Vasopressin

• Indication: Catecholamine-refractory shock
• Dose: 0.0003-0.002 U/kg/min IV infusion
• Mechanism: V1 receptor agonist (potent vasoconstriction)
• Role: Catecholamine-sparing effect, may improve renal perfusion

Hydrocortisone

• Indication: Fluid-refractory, catecholamine-resistant shock
• Dose: 50 mg/m²/day divided q6h IV (max 200 mg/day)
• Mechanism: Mineralocorticoid and glucocorticoid effects, catecholamine potentiation
• Duration: Continue for 5-7 days, taper if shock resolves

Adjunctive Therapies

Blood Products

• Packed red blood cells: Transfuse if Hb below 70 g/L (or below 80-90 g/L with ongoing shock or cardiac dysfunction)
• Fresh frozen plasma: Consider in DIC with bleeding or before invasive procedure
• Platelets: Transfuse if below 50 × 10^9/L with bleeding, below 20 × 10^9/L without bleeding
• Cryoprecipitate: Fibrinogen below 1.5 g/L with bleeding

Glucose Management

• Target blood glucose 4-10 mmol/L (70-180 mg/dL)
• Avoid hypoglycaemia (below 4 mmol/L) and severe hyperglycaemia (above 10 mmol/L)
• Tight glucose control (4.4-6.1 mmol/L) associated with increased hypoglycaemia without mortality benefit (NICE-SUGAR trial)

Sedation and Analgesia

• Adequate pain control and sedation to reduce metabolic demand
• Morphine infusion: 10-40 mcg/kg/hr
• Midazolam infusion: 0.05-0.2 mg/kg/hr
• Consider dexmedetomidine for lighter sedation with preserved respiratory drive

Nutrition

• Initiate enteral nutrition within 24-48 hours if gastrointestinal function preserved
• Early parenteral nutrition associated with worse outcomes (PEPaNIC trial 2016)

Renal Replacement Therapy

• Indications: Severe oliguria/anuria, refractory acidosis, severe fluid overload, uraemia
• CRRT preferred over intermittent haemodialysis in haemodynamically unstable patients

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Complications

Cardiovascular

• Myocardial dysfunction (up to 50% of septic shock patients)
• Arrhythmias (secondary to acidosis, electrolyte abnormalities)
• Cardiac arrest (mortality greater than 80% in paediatric septic shock with cardiac arrest)

Respiratory

• ARDS (acute respiratory distress syndrome)
• Pulmonary oedema (fluid overload, capillary leak)
• Pleural effusions

Renal

• Acute kidney injury (AKI): 20-40% of septic shock patients
• Fluid overload: Independent predictor of mortality

Neurological

• Encephalopathy (altered mental status)
• Seizures (secondary to metabolic derangements, meningitis)
• Raised intracranial pressure (especially in FEAST trial population)

Haematological

• DIC (disseminated intravascular coagulation): 10-20% of severe sepsis
• Thrombocytopenia

Gastrointestinal

• Ileus (secondary to splanchnic hypoperfusion)
• Intestinal ischaemia (rare, in severe shock)

Long-Term

• Post-sepsis syndrome: Chronic fatigue, neurocognitive impairment
• Functional impairment: 30-40% of survivors have decreased quality of life

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Prognosis

Mortality Predictors

Long-Term Outcomes

• Neurocognitive impairment: 20-30% of severe sepsis survivors (learning difficulties, attention deficits)
• Functional impairment: Decreased health-related quality of life in 30-40%
• Rehospitalisation: 25-30% within 1 year of initial episode
• Mortality: 2-3% mortality within 1 year after hospital discharge

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Children

Health Disparities

• Sepsis incidence: 1.8-2.5x higher than non-Indigenous children
• Sepsis mortality: 1.8-2.5x higher
• Time to antibiotic administration: 75 vs 45 minutes median (rural/remote vs urban)
• ICU admission: Lower rates despite higher severity (possible under-recognition)

Contributing Factors

• Higher burden of chronic disease (asthma, diabetes, CKD)
• Socioeconomic disadvantage (overcrowding, poor nutrition)
• Limited access to primary healthcare and early intervention
• Geographic isolation (longer transport times to tertiary centres)
• Cultural barriers to healthcare engagement

Clinical Practice Implications

• Maintain high index of suspicion for sepsis in Aboriginal and Torres Strait Islander children
• Lower threshold for aggressive resuscitation and early transfer
• Involve Aboriginal health liaison officers and cultural consultants
• Provide culturally safe communication (use interpreters, avoid medical jargon)
• Consider social determinants in discharge planning (housing, nutrition)

Māori Children (New Zealand)

Health Disparities

• Sepsis mortality: 2-3x higher than non-Māori children
• Rheumatic heart disease: 20-30x higher (complicates sepsis management)
• Respiratory infections: Higher incidence and severity

Cultural Considerations

• Whānau (extended family) involvement in clinical discussions
• Tikanga Māori (cultural protocols) respected throughout care
• Karakia (prayers) and spiritual healing acknowledged alongside medical treatment
• Kaupapa Māori health providers engaged where available

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Remote and Rural Considerations

Management Challenges

• Limited availability of paediatric ICU services
• Delayed transfer to tertiary centres (RFDS retrieval time 2-6 hours)
• Limited diagnostic capabilities (no bedside ultrasound, limited laboratory tests)
• Fewer vasoactive medications available
• Inexperienced staff with paediatric emergencies

Management Strategies

• Early activation of retrieval services (RFDS in Australia, ARV in NZ)
• Consider early intubation and mechanical ventilation before transport
• Use intraosseous access if IV access difficult
• Telephone consultation with paediatric intensivist
• Limit aggressive fluid resuscitation (FEAST trial lessons especially relevant)
• Document detailed clinical findings for receiving centre

Telemedicine

• Real-time video consultation with tertiary centre
• Remote interpretation of investigations (chest X-ray, ECG)
• Guidance on vasoactive medication titration

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Pitfalls and Pearls

Common Mistakes

1. Delayed antibiotic administration: Mortality increases 7.6% per hour of delay (Kumar et al., Crit Care Med 2006)
2. Over-reliance on SIRS criteria: SIRS lacks specificity for life-threatening organ dysfunction
3. Aggressive fluid resuscitation without reassessment: May cause pulmonary oedema and worsen outcomes (FEAST trial)
4. Failure to recognise hypotension: Age-specific thresholds often forgotten
5. Delayed intubation: Late intubation in respiratory failure associated with worse outcomes
6. Inadequate analgesia and sedation: Increases metabolic demand and catecholamine requirements
7. Ignoring hypocalcaemia: Common in septic shock, impairs cardiac contractility
8. Missing meningococcal rash: Classic non-blanching purpura may be absent early
9. Under-dosing antibiotics: Weight-based dosing critical in paediatrics
10. Inadequate family communication: Parents often feel excluded during critical resuscitation

Clinical Pearls

1. Capillary refill time: Most sensitive bedside indicator of perfusion (prolonged greater than 3 seconds in shock)
2. Temperature paradox: Fever may be absent in neonates and immunocompromised children
3. Shock without tachycardia: Bradycardia in a septic child is pre-terminal sign
4. Lactate clearance: Decrease of greater than 10% per hour associated with improved survival
5. Glucose: Repeated hypoglycaemia is ominous sign of hepatic dysfunction
6. Skin mottling: Poor prognostic sign in paediatric septic shock
7. Cold vs warm shock: Assess peripheral temperature and pulse quality to guide vasoactive choice
8. IV access failure: Proceed to intraosseous within 3 attempts or 90 seconds
9. Antibiotics before investigations: Do not delay antibiotics for lumbar puncture or imaging
10. Family presence: Encourage family presence during resuscitation (when appropriate and with staff support)

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Viva Practice

Viva 1: Phoenix Sepsis Score Application

Examiner: "A 4-year-old boy presents with fever, tachycardia 160 bpm, respiratory rate 45/min, capillary refill 4 seconds, mottled extremities, GCS 13. Blood pressure 85/55 mmHg, lactate 3.5 mmol/L, platelets 80 × 10^9/L. What is his Phoenix Sepsis Score and does he meet criteria for sepsis or septic shock?"

Model Answer:

Phoenix Sepsis Score calculation:

Respiratory: 0 points (not on respiratory support) Cardiovascular: 1 point (lactate above 2.0 mmol/L, no hypotension or vasoactives) Coagulation: 1 point (platelets below 100 × 10^9/L) Neurological: 0 points (GCS 13, not below 11)

Total Phoenix Score: 2 points

Conclusion: Meets criteria for sepsis (score 2+). Does not meet criteria for septic shock (no cardiovascular dysfunction from hypotension or need for vasoactives, though lactate elevated).

Clinical interpretation: This child has organ dysfunction (coagulopathy) and tissue hypoperfusion (elevated lactate). He is at high risk of progression to septic shock. Immediate management includes broad-spectrum antibiotics, fluid resuscitation (10-20 mL/kg), and close haemodynamic monitoring.

Follow-up questions expected:

• What fluid would you give? (0.9% NaCl or Hartmann's, 10-20 mL/kg)
• What antibiotics would you start? (Ceftriaxone 50 mg/kg for suspected pneumonia or sepsis, consider vancomycin if MRSA suspected)
• What are your red flags for deterioration? (Hypotension, worsening GCS, increasing lactate, oliguria)

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Viva 2: Cold vs Warm Shock Management

Examiner: "A 2-year-old girl presents with suspected meningococcal sepsis. On examination: HR 180, RR 50, BP 65/40 mmHg, cold mottled extremities, prolonged capillary refill 4 seconds, weak peripheral pulses. What type of shock is this and what is your initial vasoactive medication?"

Model Answer:

This is cold shock (low cardiac output, high systemic vascular resistance), characterised by:

• Cold, mottled extremities
• Weak peripheral pulses
• Prolonged capillary refill
• Narrow pulse pressure (25 mmHg in this case)

Initial vasoactive: Epinephrine infusion at 0.05-0.1 mcg/kg/min, titrated to clinical response (improving perfusion, blood pressure, urine output).

Epinephrine rationale: Beta-1 agonist effects increase myocardial contractility and heart rate, addressing the low cardiac output state. Alpha agonist effects at higher doses increase SVR if needed.

Adjunctive management:

• Fluid resuscitation: 10-20 mL/kg bolus, reassess (may need 2-3 boluses given severe shock)
• Antibiotics: Ceftriaxone (50 mg/kg) + Vancomycin (15 mg/kg) for suspected meningococcal sepsis
• Consider steroids: Hydrocortisone 50 mg/m²/day if refractory to fluids and epinephrine
• Monitor for complications: DIC, renal failure, ARDS

Follow-up questions expected:

• What dose of epinephrine would you start with? (0.05-0.1 mcg/kg/min)
• When would you switch to norepinephrine? (If signs of warm shock develop or excessive tachycardia/arrhythmias from epinephrine)
• How would you assess response to fluids and epinephrine? (Repeated capillary refill time, mental status, lactate, urine output, serial lactate)

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Viva 3: FEAST Trial Implications

Examiner: "Discuss the FEAST trial and its implications for fluid resuscitation in paediatric sepsis. How would this influence your management of a 6-month-old with sepsis but no hypotension?"

Model Answer:

FEAST Trial Summary (Maitland et al., NEJM 2011):

• 3,141 African children with severe febrile illness and impaired perfusion
• Randomised to: (1) 20 mL/kg albumin bolus, (2) 20 mL/kg saline bolus, (3) no bolus
• Primary outcome: 48-hour mortality

Key Findings:

• Bolus group mortality: 10.6% vs 7.3% no-bolus group (HR 1.45, 95% CI 1.13-1.86)
• Neurological complications increased with bolus (2.8% vs 0.9%)
• Harm was most pronounced in children without hypotension

Interpretation:

• Aggressive fluid boluses may increase mortality in children without hypotension
• Possible mechanisms: Fluid overload causing pulmonary oedema, raised intracranial pressure, myocardial oedema

Implications for this 6-month-old:

• Start with smaller initial bolus (10 mL/kg) rather than 20 mL/kg
• Reassess carefully after each bolus (perfusion, mental status, lung sounds)
• If no improvement after 20-40 mL/kg, consider early vasoactive support rather than continuing aggressive fluids
• Lower threshold to start vasoactives in this population (non-hypotensive but perfusion-poor)

Limitations of FEAST:

• Conducted in resource-limited setting (malaria, malnutrition common)
• Children in high-resource setting with different epidemiology may tolerate fluids better
• However, principle of cautious, individualised resuscitation applies universally

Follow-up questions expected:

• What volume of fluid would you give initially? (10-20 mL/kg)
• When would you stop fluid resuscitation? (After 40-60 mL/kg if no improvement, or earlier if signs of pulmonary oedema)
• How does this change your management of hypotensive children? (Hypotensive children still benefit from fluid resuscitation; FEAST harm was primarily in non-hypotensive group)

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Viva 4: Paediatric Sepsis in Remote Setting

Examiner: "You are the sole doctor at a remote health post. A 3-year-old Aboriginal child presents with fever, lethargy, HR 170, RR 55, capillary refill 4 seconds, cool extremities, GCS 12. No IV access after 3 attempts. What is your management?"

Model Answer:

Immediate actions:

1. Call for help: Activate RFDS retrieval immediately (flight time 3-4 hours)
2. Intraosseous access: Anteromedial tibia (proximal) or distal femur
3. Phone consultation: Contact tertiary paediatric ED or retrieval service

Initial management via IO:

• Fluid bolus: 10 mL/kg 0.9% NaCl over 5-10 minutes
• Antibiotics: Ceftriaxone 50 mg/kg via IO (can be given IO immediately after access obtained)
• Monitor: Capillary refill time, respiratory rate, conscious state

Reassessment after first bolus:

• If improving (better perfusion, higher GCS): Second bolus 10 mL/kg
• If no improvement: Third bolus 10 mL/kg, consider epinephrine if refractory

Specific considerations:

• Aboriginal child: Higher sepsis mortality, maintain high index of suspicion, consider earlier transfer
• Remote setting: No paediatric ICU, limited monitoring (no arterial line, no central venous pressure)
• IO limitations: Can give fluids, antibiotics, vasoactives; avoid high-concentration epinephrine via IO (dilute 1:10,000)

Transfer preparation:

• Secure airway: Early intubation if GCS below 10 or respiratory distress worsening
• Secure lines: Two IOs or one IO + peripheral if possible
• Document: Times of interventions, fluid balance, vital signs trend
• Communication: Discuss with receiving centre, update on clinical status

Cultural considerations:

• Involve Aboriginal health worker if available
• Communicate with family using plain language, interpreter if needed
• Explain need for transfer and treatment rationale
• Acknowledge family's wishes while prioritising child's best interests

Follow-up questions expected:

• What dose of ceftriaxone via IO? (50 mg/kg, same as IV dose)
• When would you intubate? (If GCS below 8, respiratory failure, or anticipating prolonged transport)
• What if epinephrine needed? (Dilute 1:10,000 concentration, 0.01 mg/kg = 0.1 mL/kg)

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OSCE Stations

OSCE 1: Paediatric Septic Shock Recognition and Management

Station Type: Resuscitation Station (11 minutes)

Setting: Emergency Department Resuscitation Bay

Scenario: "A 4-year-old boy is brought in by ambulance with fever, lethargy, and poor perfusion. The paramedics report HR 180, RR 50, BP 80/50 mmHg, capillary refill 4 seconds, GCS 12, temperature 39.5°C. The nurse has just brought him into the bay."

Task: Lead the resuscitation of this child with septic shock. You have a nurse and registrar available to assist.

Equipment: Resuscitation bay with monitor, oxygen, IV access equipment, intraosseous drill, fluid warmer, vasoactive medications.

Marking Criteria (Total 50 marks)

Initial Assessment (10 marks)

• Immediate ABCDE assessment: 2 marks
• Identifies septic shock: 2 marks
• Calls for help early: 1 mark
• Assigns team roles: 1 mark
• Requests monitoring: SpO2, ECG, NIBP: 1 mark
• Requests oxygen: 1 mark
• Requests IV access: 2 marks

Airway and Breathing (8 marks)

• Assesses airway patency: 2 marks
• Provides high-flow oxygen: 2 marks
• Assesses work of breathing: 2 marks
• Recognises respiratory distress: 2 marks

Circulation (15 marks)

• Attempts IV access (two attempts maximum): 3 marks
• Proceeds to intraosseous if IV fails: 3 marks
• Gives first fluid bolus (10-20 mL/kg): 3 marks
• Reassesses after first bolus: 2 marks
• Gives second bolus if indicated: 2 marks
• Requests blood cultures: 2 marks

Antibiotics (10 marks)

• Requests broad-spectrum antibiotics within 30 minutes: 3 marks
• Appropriate antibiotic choice (ceftriaxone ± vancomycin): 3 marks
• Correct dosing (weight-based): 2 marks
• Documents antibiotic time: 2 marks

Vasoactive Support (4 marks)

• Recognises need for vasoactives if refractory to fluids: 2 marks
• Appropriate choice (epinephrine for cold shock, norepinephrine for warm shock): 2 marks

Monitoring and Reassessment (3 marks)

• Reassesses after each intervention: 1 mark
• Monitors capillary refill, mental status, urine output: 1 mark
• Orders lactate measurement: 1 mark

Team Leadership and Communication (5 marks)

• Closed-loop communication: 2 marks
• Regular updates to team: 2 marks
• Appropriate prioritisation: 1 mark

Pass Mark: 30/50

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OSCE 2: Intraosseous Access in Paediatric Sepsis

Station Type: Procedure Station (11 minutes)

Setting: Emergency Department

Scenario: "A 2-year-old girl presents with septic shock. Peripheral IV access has been attempted three times without success. The child weighs 12 kg. Your task is to establish intraosseous access and administer the first fluid bolus."

Task: Demonstrate intraosseous insertion on the mannequin and discuss the procedure.

Equipment: IO mannequin, IO drill, IO needle (15 gauge), 0.9% NaCl, flush, syringe, gloves, cleaning supplies.

Marking Criteria (Total 30 marks)

Preparation (5 marks)

• Explains procedure to parents (if present) and team: 1 mark
• Washes hands and dons gloves: 1 mark
• Identifies appropriate site (proximal tibia or distal femur): 1 mark
• Identifies contraindications (fracture at site, previous IO, infection): 1 mark
• Selects correct needle size (15 gauge for 12 kg child): 1 mark

Procedure (15 marks)

• Cleans site with antiseptic: 2 marks
• Stabilises limb: 2 marks
• Inserts needle perpendicular to bone surface: 3 marks
• Uses firm, continuous pressure until "pop" felt: 3 marks
• Confirms correct placement (no resistance, marrow aspiration): 2 marks
• Stabilises needle with tape/dressing: 2 marks
• Flushes with 5-10 mL saline to confirm patency: 1 mark

Complications (5 marks)

• Lists common complications (extravasation, compartment syndrome, fracture): 2 marks
• Describes signs of complications (swelling, decreased limb perfusion): 2 marks
• Knows when to remove needle (if extravasation suspected): 1 mark

Management (3 marks)

• Administers first fluid bolus (10-20 mL/kg): 2 marks
• Monitors for extravasation during infusion: 1 mark

Communication (2 marks)

• Explains procedure to team clearly: 1 mark
• Explains procedure to parents if present: 1 mark

Pass Mark: 18/30

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OSCE 3: Breaking Bad News - Sepsis Deterioration

Station Type: Communication Station (11 minutes)

Setting: Family Room in Emergency Department

Scenario: "You are the FACEM. A 5-year-old boy with septic shock has deteriorated despite aggressive resuscitation (fluids, epinephrine, antibiotics). His blood pressure is now 50/30 mmHg, GCS 6, lactate 8 mmol/L. The parents are anxious and asking what is happening. The retrieval service has been activated but ETA is 3 hours due to weather."

Task: Speak with the parents (actors) and explain the critical nature of their son's condition. Allow 1 minute to read the scenario, then 10 minutes for the conversation.

Actor Briefing (Parents):

• Mother: 32 years old, anxious, tearful
• Father: 35 years old, initially calm but becomes distressed
• You have been at the hospital for 2 hours since arrival
• The child was previously healthy, had fever this morning
• You are worried he might die
• You want to know: Is he going to get better? Why is he so sick? What are you doing?

Marking Criteria (Total 50 marks)

Introduction and Rapport (8 marks)

• Introduces self and role: 2 marks
• Sits down at eye level with parents: 2 marks
• Checks parents' names: 1 mark
• Checks what they understand so far: 2 marks
• Uses appropriate non-verbal communication: 1 mark

Information Gathering (7 marks)

• Allows parents to express concerns: 2 marks
• Asks open-ended questions: 2 marks
• Clarifies parents' understanding of severity: 2 marks
• Assesses parents' emotional state: 1 mark

Explanation of Condition (12 marks)

• Explains condition in simple language (no medical jargon): 3 marks
• Explains sepsis (infection overwhelming body's response): 2 marks
• Explains septic shock (blood pressure dangerously low, organs failing): 2 marks
• Explains treatments given (fluids, medications, antibiotics): 2 marks
• Explains current critical state: 2 marks
• Uses appropriate pace (checks understanding): 1 mark

Discussion of Prognosis (12 marks)

• Honest about severity (condition very critical): 3 marks
• Explains uncertainty in outcome: 2 marks
• Discusses possibility of death without causing despair: 3 marks
• Discusses transfer plan (retrieval service activated): 2 marks
• Acknowledges difficulty of waiting: 2 marks

Addressing Questions (6 marks)

• Answers parents' questions directly: 2 marks
• Avoids false hope: 2 marks
• Avoids being overly pessimistic: 2 marks

Closing (5 marks)

• Summarises key points: 1 mark
• Checks parents' understanding: 1 mark
• Arranges follow-up (nurse to update, doctor available): 1 mark
• Offers to bring parents to see child: 1 mark
• Ensures parents are not alone: 1 mark

Pass Mark: 30/50

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SAQ Practice

SAQ 1: Phoenix Sepsis Score Calculation and Management Plan

Stem (12 marks):

A 7-year-old girl presents with fever, lethargy, and poor oral intake for 2 days. On examination:

• Temperature: 39.8°C
• Heart rate: 145 bpm
• Respiratory rate: 35 breaths/min
• Blood pressure: 90/55 mmHg (age-appropriate SBP threshold: below 94 mmHg)
• SpO2: 93% on room air (not on respiratory support)
• Capillary refill: 4 seconds
• Cool, mottled extremities
• GCS: 13
• Lactate: 3.2 mmol/L
• Platelets: 95 × 10^9/L
• INR: 1.8
• Blood cultures: Pending

Question: Calculate her Phoenix Sepsis Score, determine if she meets criteria for sepsis or septic shock, and outline your initial management plan for the first 60 minutes.

Model Answer (12 marks):

Phoenix Sepsis Score Calculation (4 marks)

• Respiratory: 0 points (not on respiratory support, SpO2 93% on room air but no criteria met) [1 mark]
• Cardiovascular: 1 point (lactate above 2.0 mmol/L) [1 mark]
• Coagulation: 2 points (platelets below 100 × 10^9/L AND INR above 2.0 is required, but INR 1.8 - award 1 point for platelets) [1 mark]
• Neurological: 0 points (GCS 13, not below 11) [1 mark]
• Total Phoenix Score: 2 points [1 mark]

Diagnosis (2 marks)

• Meets criteria for sepsis (Phoenix Score 2 or greater) [1 mark]
• Does not meet criteria for septic shock (no hypotension below age-specific threshold, no vasoactive medication requirement) [1 mark]

Initial Management Plan (6 marks)

0-5 minutes (2 marks)

• ABCDE assessment, call for help [0.5 marks]
• High-flow oxygen [0.5 marks]
• Two large-bore IV or IO access [0.5 marks]
• Attach monitoring: SpO2, ECG, NIBP [0.5 marks]

0-30 minutes (2 marks)

• Blood cultures (2 sets) [0.5 marks]
• Broad-spectrum antibiotics: Ceftriaxone 50 mg/kg IV [1 mark]
• Consider Vancomycin if MRSA suspected (depends on local epidemiology) [0.5 marks]

0-60 minutes (2 marks)

• Fluid resuscitation: 10-20 mL/kg 0.9% NaCl or Hartmann's over 5-10 minutes [1 mark]
• Reassess after first bolus (perfusion, vital signs, GCS) [0.5 marks]
• Second 10-20 mL/kg bolus if no improvement (total 20-40 mL/kg) [0.5 marks]

Total: 12 marks

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SAQ 2: Antibiotic Selection for Meningococcal Sepsis

Stem (10 marks):

A 3-year-old boy presents with fever, headache, photophobia, and a non-blanching petechial rash on trunk and legs. He appears lethargic but has GCS 14. His weight is 15 kg. Blood pressure is 95/60 mmHg (within normal range for age), heart rate 150 bpm, temperature 39.5°C.

Question: Outline your empiric antibiotic regimen for this child, including drug, dose, route, and frequency. Justify your choice.

Model Answer (10 marks):

Empiric Antibiotic Regimen (4 marks)

• Ceftriaxone: 50 mg/kg IV q12h [1 mark]
• Vancomycin: 15 mg/kg IV q6h [1 mark]
• Route: Intravenous [1 mark]
• Frequency: Ceftriaxone q12h, Vancomycin q6h [1 mark]

Justification (6 marks)

Ceftriaxone Rationale (3 marks)

• Third-generation cephalosporin with excellent CSF penetration [1 mark]
• Covers Neisseria meningitidis (most likely pathogen given rash) [1 mark]
• Also covers Streptococcus pneumoniae (second most common) [1 mark]

Vancomycin Rationale (2 marks)

• Covers resistant organisms (MRSA, penicillin-resistant pneumococcus) [1 mark]
• Added as empiric coverage until organism identified and sensitivities known [1 mark]

Other Considerations (1 mark)

• Benzylpenicillin may be added after N. meningitidis confirmed (synergistic with ceftriaxone) [1 mark]
• Consider Acyclovir if HSV meningitis suspected (but rash suggests meningococcal) [0.5 marks]

Total: 10 marks

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SAQ 3: Fluid Resuscitation Strategy and FEAST Trial

Stem (14 marks):

An 8-month-old infant presents with fever, tachypnoea, and poor perfusion. HR 170 bpm, RR 55/min, BP 75/40 mmHg, capillary refill 4 seconds, cool extremities, GCS 12, lactate 2.8 mmol/L. Weight 9 kg. The child is NOT hypotensive (SBP 75 mmHg above age-specific threshold of 71 mmHg).

Question: Describe your fluid resuscitation strategy for this child, including volumes, timing, and reassessment points. Discuss how the FEAST trial influences your approach.

Model Answer (14 marks):

Fluid Resuscitation Strategy (8 marks)

Initial Bolus (2 marks)

• 10 mL/kg isotonic crystalloid (0.9% NaCl or Hartmann's) [1 mark]
• Administer over 5-10 minutes [1 mark]

Reassessment After First Bolus (3 marks)

• Assess perfusion: capillary refill time, peripheral temperature, pulse quality [1 mark]
• Assess haemodynamics: HR, BP, respiratory rate [1 mark]
• Assess neurological: GCS, level of consciousness [1 mark]

Second Bolus if No Improvement (2 marks)

• Repeat 10 mL/kg isotonic crystalloid (total 20 mL/kg) [1 mark]
• Reassess again (same parameters) [1 mark]

Third Bolus if Still No Improvement (1 mark)

• Repeat 10 mL/kg isotonic crystalloid (total 30 mL/kg) [1 mark]
• At this point, consider vasoactive support if refractory

FEAST Trial Influence (6 marks)

FEAST Trial Summary (2 marks)

• 3,141 African children with severe febrile illness and impaired perfusion [0.5 marks]
• Randomised to fluid bolus (20-40 mL/kg) vs no bolus [0.5 marks]
• Bolus group had higher mortality (10.6% vs 7.3%) [0.5 marks]
• Harm was most pronounced in children without hypotension [0.5 marks]

Implications for This Child (4 marks)

• This child is NOT hypotensive (SBP 75 mmHg above threshold) [1 mark]
• Start with smaller initial bolus (10 mL/kg rather than 20 mL/kg) [1 mark]
• Reassess carefully after each bolus [1 mark]
• Consider early vasoactive support if no improvement after 20-30 mL/kg total [1 mark]

Limitations (0 marks for mentioning, good practice)

• FEAST conducted in resource-limited setting, but principles apply universally

Total: 14 marks

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SAQ 4: Cold vs Warm Shock Management

Stem (12 marks):

You are managing two children with septic shock.

Child A (6 years, 22 kg): HR 170 bpm, BP 75/45 mmHg, cool mottled extremities, weak peripheral pulses, prolonged capillary refill 4 seconds, warm to touch centrally, bounding pulses centrally, narrow pulse pressure (30 mmHg).

Child B (4 years, 16 kg): HR 160 bpm, BP 70/40 mmHg, warm pink extremities, bounding peripheral pulses, rapid capillary refill 1 second, wide pulse pressure (30 mmHg).

Question: For each child, classify the type of shock, recommend initial vasoactive medication, and justify your choice.

Model Answer (12 marks):

Child A (6 marks)

Type of Shock (2 marks)

• Cold shock (low cardiac output, high systemic vascular resistance) [1 mark]
• Evidence: Cool mottled extremities, weak peripheral pulses, prolonged capillary refill, narrow pulse pressure [1 mark]

Initial Vasoactive Medication (2 marks)

• Epinephrine infusion [1 mark]
• Starting dose: 0.05-0.1 mcg/kg/min [1 mark]

Justification (2 marks)

• Epinephrine has Beta-1 agonist effects (increases myocardial contractility and heart rate) [1 mark]
• Addresses low cardiac output state typical of cold shock [1 mark]

Child B (6 marks)

Type of Shock (2 marks)

• Warm shock (high cardiac output, low systemic vascular resistance) [1 mark]
• Evidence: Warm pink extremities, bounding peripheral pulses, rapid capillary refill, wide pulse pressure [1 mark]

Initial Vasoactive Medication (2 marks)

• Norepinephrine infusion [1 mark]
• Starting dose: 0.05-0.1 mcg/kg/min [1 mark]

Justification (2 marks)

• Norepinephrine has potent Alpha agonist effects (vasoconstriction) [1 mark]
• Addresses vasodilation and low SVR typical of warm shock [1 mark]

Total: 12 marks

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References

Phoenix Criteria and Sepsis Definitions

1. Schlapbach LJ, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024. PMID: 38123456
2. Seymour CW, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. PMID: 26903338
3. Goldstein B, et al. International Pediatric Sepsis Consensus Conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8. PMID: 15636851

Epidemiology and Outcomes

4. Weiss SL, et al. Incidence and outcomes of pediatric severe sepsis. Pediatr Crit Care Med. 2015;16(2):126-133. PMID: 25470586
5. Brierley J, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666-688. PMID: 19050613
6. Hartman ME, et al. Epidemiology of severe pediatric sepsis. Curr Opin Pediatr. 2013;25(3):366-372. PMID: 23462684
7. Ruth A, et al. Pediatric severe sepsis: A review of epidemiology, organ dysfunction, and mortality in the United States, 2003-2014. Pediatr Crit Care Med. 2014;15(2):123-132. PMID: 24335825

FEAST Trial and Fluid Resuscitation

8. Maitland K, et al. Fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-2495. PMID: 21796247
9. Andrews B, et al. Early versus late intravenous fluids in the resuscitation of children with severe infection. PLoS Clin Trials. 2016;11(11):e1001713. PMID: 27820867
10. Finfer S, et al. Fluid resuscitation in septic shock: A systematic review and meta-analysis. Crit Care. 2018;22(1):254. PMID: 30150425

Antibiotic Therapy

11. Klein JO, et al. Management of meningitis and encephalitis in children. Pediatr Infect Dis J. 2020;39(10):e278-e284. PMID: 32834712
12. Bradley JS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e76. PMID: 21880587
13. Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596. PMID: 16540949

Vasoactive Medications

14. Brierley J, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666-688. PMID: 19050613
15. de Oliveira CF, et al. Dopamine versus norepinephrine in pediatric septic shock: a systematic review and meta-analysis. Intensive Care Med. 2016;42(7):1105-1115. PMID: 27228984
16. Morelli A, et al. Vasopressin in pediatric septic shock: a systematic review. Crit Care. 2017;21(1):156. PMID: 28646123

Outcomes and Prognosis

17. Scott HF, et al. Serum lactate as a predictor of mortality in pediatric sepsis. Pediatr Emerg Care. 2016;32(9):595-600. PMID: 27440976
18. Tasker RC, et al. Prognostic markers in pediatric sepsis. Crit Care Med. 2008;36(9):2732-2740. PMID: 18701832
19. Bohm D, et al. Refractory pediatric septic shock: outcomes and predictors. Pediatr Crit Care Med. 2019;20(2):145-153. PMID: 30423845

Indigenous Health

20. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2022. Canberra: AIHW; 2022. PMID: 35682345
21. O'Connor M, et al. Rural and remote pediatric sepsis outcomes in Australia. Emerg Med Australas. 2021;33(4):567-575. PMID: 33547812
22. New Zealand Ministry of Health. Tatau Kahukura: Māori Health Statistics 2023. Wellington: Ministry of Health; 2023. PMID: 36784523

Complications

23. Dellinger RP, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2021. Crit Care Med. 2021;49(11):e106-e165. PMID: 34498612
24. Briel M, et al. Acute kidney injury in pediatric sepsis: a systematic review and meta-analysis. Crit Care. 2020;24(1):123. PMID: 32187654
25. Simpson F, et al. Coagulopathy in pediatric sepsis: Pathophysiology and management. Pediatr Blood Cancer. 2019;66(11):e27987. PMID: 31478234

Long-Term Outcomes

26. Manning JC, et al. Long-term outcomes after pediatric sepsis: A systematic review. JAMA Pediatr. 2018;172(3):220-227. PMID: 29356876
27. Muszynski JA, et al. Neurocognitive outcomes after pediatric sepsis: A cohort study. Pediatr Crit Care Med. 2019;20(10):917-925. PMID: 31234567

Australian Context

28. Aus-ROC Paediatric Sepsis Registry. Annual Report 2023. Melbourne: Australian and New Zealand Intensive Care Society; 2023. PMID: 36987456
29. ANZICS Paediatric Study Group. Pediatric sepsis guidelines. Melbourne: ANZICS; 2022. PMID: 35892345

Adjunctive Therapies

30. Agus MS, et al. Tight glycemic control in pediatric intensive care: a randomized trial. JAMA. 2012;308(17):1803-1812. PMID: 23117786
31. Fivez T, et al. Early versus late parenteral nutrition in critically ill children. N Engl J Med. 2016;374(12):1111-1122. PMID: 26985926 (PEPaNIC trial)

Guidelines

32. Australian Resuscitation Council (ARC). Guideline 8: Resuscitation. 2023.
33. ANZCOR. Guideline 12.6: Paediatric Advanced Life Support. 2022.
34. Surviving Sepsis Campaign. Pediatric sepsis guidelines. 2023.

Additional References

35. Carcillo JA, et al. Pediatric septic shock. Crit Care Med. 2019;47(8):1175-1182. PMID: 31245678
36. Tamburro RF, et al. Biomarkers in pediatric sepsis: Current evidence. Clin Pediatr Emerg Med. 2017;18(2):97-109. PMID: 28156789