Paediatric sepsis: diagnosis, antimicrobial treatment and source control — formative SAQs

1. Phoenix classification

This child has suspected infection (fever, cough, probable pneumonia) with life-threatening organ dysfunction. His circulatory failure — impaired perfusion, oliguria and a raised lactate — gives him at least one Phoenix cardiovascular point, so he meets both sepsis and septic shock. A normal-range blood pressure does not exclude shock; children are hypotensive late because they compensate with tachycardia and vasoconstriction. [1] [2]

2. First-hour bundle

I would assign a team leader, call the senior paediatric and critical-care teams, attach monitoring and estimate his weight. I would draw two blood cultures from separate sites and a lactate before antibiotics only because it will not delay the first dose; I would add urine and, if stable, cerebrospinal fluid cultures when safe. I would give the first broad-spectrum, weight-based antibiotic within one hour of recognising sepsis — a third-generation cephalosporin, with vancomycin if resistant organisms are possible per local guidance. [3]

For fluids I would give a 10 mL/kg crystalloid aliquot and reassess immediately, repeating only if shock persists and he remains fluid-responsive, and stopping at a locally agreed ceiling rather than chasing a target. This is cold shock, so if he remains poorly perfused I would start adrenaline (epinephrine) as the first vasoactive, titrated to perfusion and age-appropriate mean arterial pressure. [3] [12]

3. Reassessment loop and escalation triggers

After every intervention I would reassess mental state, perfusion, capillary refill, pulse quality, lactate trend, liver size, breath sounds and urine output. I would stop fluids and start or escalate vasoactives if he develops new hepatomegaly, a gallop rhythm, bilateral crackles, a rising lactate despite fluids, or persistent shock with signs of fluid overload. I would involve PICU early and request retrieval before local capability is exceeded. [3] [11]

4. Evidence for a cautious fluid approach

The FEAST trial showed that fluid boluses increased mortality in African children with severe infection, although that population lacked intensive-care rescue; the Fluids in Shock pilot then showed that a restricted-bolus strategy is feasible. Together these support aliquots with reassessment and a ceiling, applied with judgement to the resources that can rescue the child, rather than an uncritical drive to a fixed volume. [8] [9]