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NICE Guidelines - Suspected sepsis Recognition, Diagnosis and Management

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Listen to these amazing individuals sharing their stories of sepsis, access the videos on: https://sepsistrust.org/about/about-the-charity/current-campaigns/sepsis-voices/

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We implemented the Sepsis Grab Boxes into paediatric areas 

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RCN standards for assessing, measuring and monitoring vital signs in infants, children and young people

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Take the sepsis quiz and test your knowledge...are you a sepsis superstar?

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Take the sepsis quiz and test your knowledge...are you a sepsis superstar?

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Sepsis is....., Which of the following is NOT a high risk criteria for triggering sepsis in an infant/child?, What is septic shock?

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Our paediatric sepsis podcasts are free to access, and designed as educational resources for health and social care professionals. They explore what sepsis is, the complexities of how to recognise and manage sepsis, what is different about sepsis in children with complex health conditions and much more.

You can also download our learning points for each episode.

Episode 1 - Let's talk about sepsis

Emma Lim and junior doctor Monica Parker talk about what sepsis actually is, the importance of early diagnosis and why sepsis is so hard to spot in children.

Episode 2 - Bugs and drugs part 1

Paediatric Infectious Disease Consultant Andrew Riordan joins Emma Lim to consider the what, why and when of antibiotic choices, investigation and antibiotic stewardship.

Episode 3 - Bugs and drugs part 2

Consultant and Head of Infection Control Lucia Pareja-Cebrian shares what microbiologists really want to hear and how they can help you, from sepsis epidemiology to antibiotic choices and guidelines.

Episode 4 - The child with complex care needs

Caroline Wild, parent and Karen Horridge Neuro-Disability Paediatrician reveal the difficulties experienced by children with complex care needs and their parents when faced with sepsis and how terrifying, and yet intimate, it can be.

Episode 5 - Penicillin allergy, real or not?

Consultant and Associate Lecturer in Paediatric Immunology and Allergy Dr Louise Michaelis joins Emma Lim to discuss penicillin allergy and sepsis. They explore how common penicillin allergy actually is, cross reactivity, alternative choices and de-labelling.

Episode 6 - Management part 1: care bundles and culture

Consultant paediatrician Dr Sachin Mannikar joins Emma Lim to consider what you can do to save a child's life when faced with sepsis. They examine what a care bundle looks like, the management choices, the evidence base and the role of simulation training.

Episode 7 - Management part 2: fluids and fear

Professor of Paediatric Intensive Care Mark Peters and Emma Lim talk about fluids and unpick common fears, examining which fluids to use, when, why and how much and the role and choice of inotropes in paediatric sepsis..

Episode 8 - The future of tests in sepsis

Clinical Senior Lecturer in Paediatric Infectious Diseases Dr Jethro Herberg joins Emma Lim and Monica Parker to explore what's next for sepsis - and what the future of tests and assessment might look like.

Episode 9 - What sepsis means

Junior doctor Monica Parker and Emma Lim join forces to provide an overview of the key learning and take home messages from the Sepsis podcasts series.

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Our paediatric sepsis podcasts are free to access, and designed as educational resources for health and social care professionals. They explore what sepsis is, the complexities of how to recognise and manage sepsis, what is different about sepsis in children with complex health conditions and much more.

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A blood gas (arterial, venous or capillary) is a powerful test that allow clinicians to obtain a lot of information in a short period of time. It requires very little blood and can be run on a point-of-care device. The results are available within a few minutes and may guide the initial management of critically ill infants and young people.

Blood gases can be obtained from a central or peripheral vein (venous blood gas or VBG) or from an artery (arterial blood gas or ABG). Obtaining ABGs tends to be painful but often provides a more accurate indication of oxygenation when compared to VBGs.

Interpretation can be complex and nuanced. There are many approaches, formulas, and equations that you can master but in this post we are providing a very basic approach to interpretation of VBGs with some clinical scenarios to get you started.

Keep in mind:

1. Be cautious not to interpret any lab value in isolation.

2. Always consider the clinical context when interpreting results.

Components of a Blood Gas

Some blood gases also include information such as sodium, potassium, calcium, haemoglobin, haematocrit, glucose, and lactate.

Ultimately, everything comes back to pH and the concept of acids and bases. Physiologically, the body wants to maintain optimum pH for cellular functions and has two main buffering systems to do so:

Lungs help regulate CO 2 and kidneys help regulate HCO 3.

Interpretation

Step 1: Determine acidosis or alkalosis

This is most easily accomplished by looking at the pH.
*Caution*: it is possible to have a normal pH with two disturbances that balance each other out.
Examine the pCO ₂. In a hyperventilating patient the pCO 2 should be less than 35 mmHg (4.6 KPa) because they are blowing off carbon dioxide, leading to a respiratory alkalosis. Whereas in a patient who is not ventilating well the pCO 2 may be greater than 45mmHg (6 KPa) because they are retaining carbon dioxide.

Examine the HCO 3 or bicarbonate. If the patient has a normal PCO ₂ an elevated bicarbonate signals metabolic alkalosis while a lower bicarbonate signals metabolic acidosis.

If there is a metabolic acidosis, calculate the anion gap [Na⁺ - (Cl⁻ + HCO3)]. Use your favourite mnemonic to remember the causes.

Step 3: Is there compensation?

When there is imbalance in acids and bases, the body attempts to correct the imbalance.

If there is a metabolic acidosis (less HCO₃), respiratory rate might increase to help decrease pCO₂. Usually the quickest compensatory mechanism is respiratory.

If there is a respiratory acidosis (increased pCO₂), the kidneys may be triggered to hold onto more HCO3. This compensatory mechanism tends to be slower.

Clinical scenarios

Let's take a look at some simple clinical scenarios to practice blood gas interpretation in the importance of interpreting them in a clinical context. We have purposely simplified these to focus only on the pertinent components.

Diabetic ketoacidosis
Joanie is a 6 year-old girl presenting with abdominal pain, vomiting, and lethargy. Her parents are concerned that although she has been eating and drinking a lot, she has lost weight in the past few weeks and seems to be urinating frequently. On the physical exam, she is tired-appearing. Her breathing is deep and rapid. She is also tachycardic. Her lungs are clear to auscultation bilaterally. You get a venous blood gas:
Interpretation

This is a metabolic acidosis with respiratory compensation. This patient is also hyperglycaemic.

Application

Joanie has a new diagnosis of diabetic ketoacidosis. She is acidotic with a bicarbonate level <15 demonstrating a metabolic acidosis. Her body is trying to compensate for the acidosis by Kussmaul breathing and eliminating CO ₂ which is why her PCO ₂ is low.

Asthma
Peter is a 5 year-old boy with asthma presenting with an acute asthma exacerbation in the setting of a respiratory virus for the past two days. On initial presentation, he is breathing rapidly and wheezing in all lung fields. You start treating him with a nebulized albuterol and IV corticosteroids. When you next check on him, he seems more sleepy but is breathing less rapidly and you can no longer hear any wheezing on his lung exam. A VBG is obtained:
Interpretation

Although these lab values roughly lie within the normal ranges, this blood gas should be worrisome in this clinical context!

Application

In a patient with asthma and respiratory distress who was initially breathing rapidly, we would expect the pCO ₂ to be low because he was hyperventilating. A normalising pCO ₂ on a patient with a severe asthma exacerbation should make you concerned that he is tiring out and retaining CO ₂. A silent lung exam should also bring up red flags that he is no longer moving air in his lungs. You need air movement to hear wheezing!

Sepsis
Diego is a 2 year-old boy presenting with fever, cough, and lethargy. He has had rhinorrhea and cough for the past week. In the past 3 days, he has had very poor appetite and fevers with temperature of up to 39.8°C. He appears very lethargic and is tachycardic with poor perfusion. A VBG is obtained:
Interpretation

This is a metabolic acidosis with some degree of respiratory compensation. However, the lactate is high, suggesting a degree of poor perfusion.

Application

Diego is likely in septic shock given his fever, tachycardia, poor perfusion, and altered mentation with the elevated lactate and acidosis. His body is likely trying to compensate by reducing the acidosis through some degree of hyperventilation.

Keep in mind that sepsis is a clinical diagnosis. The blood gas may help, but lab work should not be necessary for diagnosis.
Have a high suspicion for sepsis and treat it early with fluids and antibiotics!
Neuromuscular disease
Paige is a 16 year-old girl with muscular dystrophy. She uses a wheelchair to move and depends on bilevel airway pressure (BiPAP) at night when she is sleeping. In the past two days, she has developed a worsening cough and congestion. A chest radiograph is obtained that does not show any consolidations. On examination, she is not in any respiratory distress. A VBG is obtained:
Interpretation

There is a respiratory acidosis with metabolic alkalosis.

Application

Patients with a history of neuromuscular weakness and inefficient ventilation may exhibit a degree of baseline respiratory acidosis from CO ₂ retention.

Given the chronic nature of Paige's respiratory acidosis, her body has compensated by retaining more bicarbonate. These blood gas values are not alarming in this clinical context.

Seizure
Oliver is a 2 year old boy presenting with a first-time seizure. He has been seizing for at least 15 minutes. After he received multiple doses of benzodiazepines and a loading dose of levetiracetam, his seizure activity stopped. Unfortunately, he also stopped breathing and was promptly intubated and placed on a ventilator. A VBG obtained shows:
Interpretation

There is a respiratory acidosis due to prolonged hypoventilation from seizure activity. The glucose is elevated but can be expected in the setting of a seizure.

Application

Patients presenting after prolonged seizure activity will likely exhibit respiratory acidosis and elevated pCO ₂. There is no time for the kidneys to compensate in this acute setting so bicarbonate should be normal. Many patients may spontaneously recover after a post-ictal period.

Oliver was in status epilepticus and required intubation. We can help lower his pCO 2 by increasing the respiratory rate or tidal volume on the ventilator.
Pay attention to the electrolytes on the blood gas in seizing patients as hypoglycaemia and hyponatraemia may be the cause of the seizure and should be corrected.
Selected Resources:

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A blood gas (arterial, venous or capillary) is a powerful test that allow clinicians to obtain a lot of information in a short period of time. It requires very little blood and can be run on a point-of-care device. The results are available within a few minutes and may guide the initial management of critically ill infants and young people.

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If you have ideas of how to improve sepsis care please comment below!

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If you have ideas of how to improve sepsis care please comment below!

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Spotting the signs of sepsis - Healthier together

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Spotting the signs of sepsis - Healthier together

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https://www.what0-18.nhs.uk/parentscarers/worried-your-child-unwell/sepsis-spotting-signs

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Re-ACT Talks: Spotting Sepsis in the Sick Child

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The Paediatric Sepsis Roadshow Is Back - for 1 day only!

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The Paediatric Sepsis Roadshow Is Back - for 1 day only!

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Think Sepsis - A film for all healthcare workers involved in the care of sick children

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How To Guide - Completing Sepsis Screening Tools

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How To Guide - Completing Sepsis Screening Tools

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Melissa Mead UK Sepsis Trust Guest Speaker - (Emotional Video)

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Melissa Mead UK Sepsis Trust Guest Speaker - (Emotional Video)

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During Sepsis Awareness week we had Melissa Mead a guest speaker from the UK Sepsis Trust share her personal story of losing her son to sepsis to improve knowledge of sepsis. This video is an emotional watch but shows why we should always consider sepsis seriously!

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Under 5 years of age Sepsis Screening Tool

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Under 5 years of age Sepsis Screening Tool

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12-16 years of age Sepsis Screening Tool

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12-16 years of age Sepsis Screening Tool

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WPR50320 Safe Discharge of Sepsis Patients