Evolving Definitions and Current Perspectives in Pediatric Sepsis: A Narrative Review
Abstract
Sepsis is a common yet potentially life-threatening condition affecting neonates and children worldwide, with a disproportionately large burden in Low and Middle-Income (LMIC) countries. Accurate estimation of global burden is hindered by a lack of standardisation of diagnostic criteria and scarce population-based data, especially in developing/LMIC countries. This narrative review chronicles the evolution of the definitions of pediatric sepsis and outlines the current perspectives in the management of pediatric septic shock. PubMed/Medline and Google Scholar were searched for relevant articles, until July 2024. The updated recommendations define pediatric sepsis, using a novel scoring matrix- The Phoenix Sepsis Score based on a 4-organ system model, marking a complete transition from Systemic Inflammatory Response Syndrome. Key strategies in the management of septic shock include early recognition, supporting the airway and breathing, blood investigations, source control, hemodynamic management, and supportive therapy. IV fluid bolus therapy, preferably with balanced crystalloids, is indicated only if hypotension is present (all settings), along with abnormal perfusion (only in high-income intensive-care settings). Recent research has shown significantly higher sepsis-attributable mortality with antibiotic institutions, only beyond 330 minutes. For IV fluid refractory shock, Norepinephrine (the first-line vasopressor in septic shock) is preferred in hypotension with vasodilatory shock; Epinephrine is preferred for hypotension with septic myocardial dysfunction. In normotension with persistent hypoperfusion, the inodilators-Dobutamine or Milrinone are indicated. Steroids are not advocated, and (RBC) transfusion is definitely recommended only if the Hb concentration is <5 g/dL. Renal Replacement Therapy remains the mainstay of treatment for established acute kidney injury and diuretic-refractory fluid overload. For pediatric refractory sepsis, veno-arterial Extracorporeal Membrane Oxygenation survival rates over 60% have been demonstrated. Further moderate/high-GRADE evidence is needed to fortify existing protocols, with due pragmatic considerations for resource-poor settings.
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