EMERGENCY Stabilization must take priority over completion of the diagnostic workup. Restoration of oxygenation and perfusion are the first priorities in the initial management of sepsis. An ill-appearing child should be provided high-flow oxygen and monitoring of heart rate, respirations, and blood pressure, and oxygen saturation should be initiated. Attention to airway patency should continue throughout the assessment, with particular emphasis during procedures such as lumbar puncture. Secure vascular access should be obtained early and, in the setting of signs of poor perfusion, fluid resuscitation performed with 20 mL/kg boluses of normal saline with serial reassessments. In such cases, an indwelling Foley catheter should be placed to ensure adequate response to fluid resuscitation by establishment of urine output of 1 to 2 mL/kg/h. In young infants in particular, hypoglycemia should be identified early by bedside testing and corrected with intravenous 25% dextrose (D25 or 25 gm/100 mL) 0.5-g/kg bolus(es). Endotracheal intubation and mechanical ventilation are indicated if a patient is judged to have advanced respiratory or circulatory failure and neurologic compromise with potential for loss of airway control. Intubation should also be considered for septic-appearing patients who require interhospital transport. If serial fluid bolus therapy does not restore evidence of adequate perfusion, inotropic support with dopamine in the setting of normal blood pressure or epinephrine in hypotensive states is indicated.

The diagnostic evaluation of septic-appearing infants in the ED should include cultures of the blood, urine, and CSF. Diarrheal stool should be stained for white blood cells and cultured, if present. A complete blood count, electrolyte panel, and determination of blood glucose level are routinely indicated. A chest x-ray and arterial blood-gas measurement are indicated for signs of respiratory distress or critical illness. Liver functions, coagulation studies, and fibrin split product analysis should be considered for critically ill children.

Antibiotic therapy should initiated in the ED as soon as possible and should not be withheld pending lumbar puncture if the patient is unstable. Antibiotic selection is made according to the likely age-related pathogens (T.a,ble..J.1..8.-.5). In the first 2 months of life, ampicillin 100 mg/kg and either cefotaxime or ceftriaxone 50 mg/kg IV are indicated. Adequate initial therapy for children 3 months and older is cefotaxime or ceftriaxone 50 mg/kg IV. Because of the widespread emergence of penicillin-and cephalosporin-resistant strains of S. pneumoniae, vancomycin 15 mg/kg IV should be considered as part of initial therapy for critically ill, septic children, particularly in the setting of an underlying immune deficiency state. 37 In endemic areas during the summer and early fall, chloramphenicol 25 mg/kg IV should be considered for children with possible Rocky Mountain spotted fever. Care must be taken to monitor patients following antibiotic administration for abrupt vascular collapse due to acute bacterial lysis with release of endotoxins.

ADMISSION All children with suspicion for bacterial sepsis should be admitted for monitoring and treatment pending culture results. Disposition decision making for a possibly septic child must specifically include choice of the appropriate pediatric inpatient unit. A child with limited suspicion for sepsis who is alert and requires no cardiorespiratory stabilization in the ED may be admitted to a pediatric floor unit for antibiotic therapy pending culture results. A child with evidence of cardiorespiratory or neurologic compromise requiring stabilization in the ED should be admitted to a pediatric intensive care unit (PICU) because of the risk of progression of disease. If interhospital transfer to a PICU is necessary, a pediatric transport team should be utilized.

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