Sepsis: What the Pediatric Anesthesiologist Needs to Know

Shawn Jackson MD PhD, Ethan Sanford MD, Justin L. Lockman MD MSEd

I just loved the Olympics and was amazed that the triathletes were going to swim in the river Seine. Was it safe? And because today’s PAAD is about sepsis, I asked Dr. Glaucomflecken to weigh in. Myron Yaster MD

Original Article:

Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):665-674. doi: 10.1001/jama.2024.0179. PMID: 38245889; PMCID: PMC10900966.

Despite many advances in technology and pharmacology, in 2024 sepsis remains the leading cause of death in children globally. Even in resource-rich healthcare systems that feature rapid diagnostics, cutting-edge treatments and near-limitless supportive care (mechanical and otherwise), sepsis remains a major contributor to pediatric morbidity and mortality. As pediatric anesthesiologists, sepsis – and efforts to prevent or treat it – is a routine aspect of our day-to-day workload. Incision and drainage (tonsillar, orbital, brain, lung, abdominal, etc.), appendectomies, bowel resections for necrotizing enterocolitis, and central line removals represent just some of the cases we are involved with to achieve source control and mitigate the sequelae of sepsis. And that doesn’t even include all the surgical site infection antimicrobial prophylaxis we give – a discussion for a different day!

Today’s Pediatric Anesthesia Article of the Day focuses on the new sepsis guidelines that were published this year in JAMA on behalf of the Society of Critical Care Medicine (SCCM) Pediatric Sepsis Definition Task Force.¹ These new guidelines were first presented at the SCCM national meeting this winter and represent a major change in sepsis diagnostic criteria. The core goal of these scoring systems is to define the risk of poor outcomes (death, ECMO) in children with known or suspected infections. The label of sepsis is, then, an identifier of risk. This idiom is important because anesthesiologists are frequently asked to judge the perianesthetic risks against risks of not proceeding with procedures/diagnostics. Children with sepsis carry an elevated risk of death, therefore we should be wary of delaying an anesthetic which will help treat or diagnosis the infection.

Pediatric sepsis was previously defined by a combination of an infectious source and the infamous SIRS (systemic inflammatory response syndrome) criteria.² The SIRS criteria were easy to apply and consisted of 1) heart rate, 2) temperature, 3) respiratory rate, and 4) abnormal white blood cell count. A patient meeting two of these criteria was often labeled as ‘SIRS-y’ and if there was a source for possible infection, they met the criteria for sepsis. However, these criteria, while easy to apply, lacked specificity. Case in point, many postoperative surgical patients meet SIRS criteria during routine postoperative care in the PACU despite having unremarkable OR courses and recoveries. Add an infectious source (e.g., appendicitis), and - by the old criteria – all of these patients had sepsis.

Highlighting the need for new criteria to diagnose pediatric sepsis, leading sepsis investigators from around the world met to develop the Phoenix Sepsis Score. The Phoenix Sepsis Score is a composite 4-organ system model that has undergone testing already.  It has been shown to be not only both sensitive and specific for sepsis (which is important for research efforts), but perhaps more importantly: increasing Phoenix Sepsis Scores more accurately predict the risk of morbidity and mortality (Table 1).

Table 1: Components of Phoenix Sepsis Score

Respiratory

              Lower PaO₂/FiO₂ (or SpO₂/FiO₂) ratio

Cardiovascular

              Need for vasoactive infusions

              Decreased mean arterial pressure

              Lactic acidosis

Coagulopathy

Platelets (decreased)

INR (elevated)

D-dimer (elevated)

Fibrinogen (decreased)

Neurological

              Glasgow Coma Score (decreased)

Patients with suspected sepsis and who accumulate 2 or more points on the Phoenix Sepsis Score meet criteria for a diagnosis of sepsis. If at least 1 of those points is from the cardiovascular system, the patient meets criteria for septic shock. Notably, the term ‘severe sepsis’ should no longer be used as the authors felt that all cases of sepsis include end-organ dysfunction and represent a severe disease state.

So what does the pediatric anesthesiologist need to know about sepsis? Patients with sepsis require treatment and they need it fast. This not only includes antibiotics and fluids, but also source control whenever possible. When children with sepsis or septic shock have an identified source (central line infection, abscess, etc), time is of the essence, and we should safely and thoughtfully expedite care. The risks posed by NPO times, mild laboratory abnormalities, or other common considerations in elective cases likely aren’t as important to the patients outcome as rapid treatment in these medical/surgical emergencies. We should also be prepared to deal with development (or worsening) of septic shock while these patients are under our care. 

We would encourage all PAAD readers also to be thoughtful about ASA Physical Status Classification and “E” status for patients as well; we suspect there is systematic under-classification of severity of illness, and the new Phoenix criteria should help us all be more accurate with our documentation.  If you haven’t see the PAAD about ASA Physical Status, you can find it here: https://ronlitman.substack.com/p/the-asa-ps-classification-system.

While we are on the topic of sepsis, it is worth also highlighting some recent basic research pertinent to anesthesiologists. Volatile anesthetic agents are ubiquitous in our field and we continue to discover new ways in which they effect our health and physiology. In this instance, volatile anesthetics may play an important role in sepsis due to their immunomodulatory effects. The lab of pediatric anesthesiologist Koichi Yuki found that sevoflurane significantly improved outcomes in septic mice (and overall bacterial loads) when compared with isoflurane – and even those without an anesthetic exposure.³ While this work has yet to be translated into human trials, we should recognize that our role as anesthesiologists affects multiple facets of patient care in ways we may not even realize!

Send your thoughts and comments to Myron who will post in a Friday reader response. 

References

1.          Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024;331: 665-674. doi: 10.1001/jama.2024.0179

2.          Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6: 2-8. doi: 10.1097/01.PCC.0000149131.72248.E6

3.          Koutsogiannaki S, Hou L, Babazada H, et al. The volatile anesthetic sevoflurane reduces neutrophil apoptosis via Fas death domain-Fas-associated death domain interaction. FASEB J. 2019;33: 12668-12679. doi: 10.1096/fj.201901360R