Managing a Child With Fever & Sepsis

A 5-year-old boy presents with a 24-hour history of fever, reduced oral intake and progressive lethargy. He is previously well and fully immunized.

Initial assessment shows :

• Temperature 39.6°C, 
• HR 158/min, 
• RR 40/min,
• SaO2 95% (air),
•  BP 70/40, 
• central capillary refill time 4 seconds.

He is lethargic but opens his eyes in response to his mother’s voice. On examination, he has a
purpuric rash on his trunk, and there are no other specific abnormal findings. After two 20 mL/kg
boluses of normal saline, he remains clinically unchanged.

Which ONE of the following statements best describes the next treatment he should be given?
A. He should be given activated protein C
B. He should be given IV hydrocortisone
C. He should be given inotropes if central IV access has been obtained
D. He should be given inotropes through peripheral or central IV access
E. He should continue to be given boluses of normal saline until there is a clinical response

Answer:
D. He should be given inotropes through peripheral or central IV access.

Discussion: This child is most likely to have meningococcal septicaemia and is in fluid-refractory shock. Initial management is assessment and resuscitation.
Broad-spectrum antibiotics (in this age group, a third generation cephalosporin) should also be given.
In a child who remains shocked after 40 mL/kg of fluid resuscitation, a further bolus should be given. The child should be urgently discussed with a Pediatric ICU specialist and further management be guided by them, in conjunction with the local anesthetist. The child should be intubated and ventilated (even in the absence of respiratory indications) as pulmonary oedema can be anticipated due to capillary leak caused by sepsis.
In addition, inotropes should be commenced at this stage. Dopamine can be administered peripherally and adrenaline can be given via IO or central IV access. Noradrenaline can also be given via central IV access. Giving continuing fluid boluses without additional support will not be sufficient to
maintain tissue perfusion.
Cohort studies show that a delay in the use of inotropic therapies is associated with major increases in mortality risk. Inotrope therapy may be required to sustain perfusion pressure, even when hypovolaemia has not yet been resolved. Choice of agent depends on the clinical assessment of the child, type of IV/IO access available and local PICU expertise.

While steroids may also be used in children with fluid-refractory shock, they may also be given in those who remain in shock after inotropic support has been given, particularly if there is any evidence of adrenal insufficiency.

Randomized-controlled trials of activated protein C and other biological therapies show no benefit in
children or adults.

Current management of sepsis therefore consists of basic ABC management, organ-specific support (e.g. ventilation, inotropes, renal support), antibiotics and source control.