Pediatric Sepsis: Are you Prepared?

Case Study

You’re working a typical weekend and just settling down for a safety nap when the tones go off. You and your partner are called to transport an infant from a rural facility to a level one pediatric facility that is having difficulty breathing.

You get to the bedside and find a 4-month-old that is lethargic and listless. Her airway is patent, and breathing is rapid, labored with retractions. Her skin is flushed and hot to the touch, her pulse is rapid, weak, and her capillary refill time is delayed. Blood pressure is 62/37, HR 172, RR 62, lung sounds are rhonchi in the right lower lobe, and oxygen saturations on 2lpm via nasal cannula is 88%. She has one peripheral IV, 24 G, that is saline-locked. According to your length-based tape, she is in the pink zone, weighing 6kg.

As you continue your assessment, the sending facility’s nurse tells you that the infant had been treated for an ear infection four days ago, and according to the parent, she has been getting worse the last two days. She hasn’t been feeding, and she has had fewer wet diapers. In addition, you are informed of the following lab results, and the nurse tells you that RSV, Covid, and Influenza swabs are pending, along with cultures.

Chem Panel

Sodium 137

Potassium 3.2↓

Chloride 101

Calcium 8.2

Glucose 42↓

BUN 18

Creatinine 0.8

CO2 7.8↓

CBC

WBC 22.4↑

Hbg 14.2

HCT 37

Plt 203

Venous Gas

PH 7.01↓

CO2 37

HCO3 8↓

Lactate 8.3↑

If you and I are on the same page, we’re thinking that this kiddo is sick. What do you think needs to be addressed and what are your initial priorities?

Resuscitation

Let’s resuscitate before we do anything else. A good place to start would be addressing the oxygenation status. We can increase the supplemental oxygen the patient is receiving by a couple of liters and see if that helps. Raising the head of bed could help too, if she’s lying flat. Otherwise, we can switch to a mask or a high-flow nasal cannula. If she starts to tucker out, we can always assist ventilations with a BVM, NPA, and Peep while continuing to resuscitate prior to securing an airway or RSI. And while we’re at it, let’s attach end tidal to the BVM.

The next thing that we should address is the patient’s blood glucose level of 42. For a 4-month-old D10 would be a good choice. If you don’t have D10 the easier thing to do is ask the sending facility for a bag of it. If they don’t have one, you can make it by pulling 50ml out of a 250ml bag of Normal Saline and adding one amp of D50 to the bag of Normal Saline. This will equal 25 grams of Dextrose in 250ml of fluid.

Take Out 50ml and Add 

Figure: Making D10

You can give her a dose of 0.5g/kg or 30ml of D10 for a total dose of 3 grams. Following that, make sure to reassess her glucose and check if it’s within normal range. You can always give additional glucose if needed to maintain homeostasis. One could hope that once you have addressed the hypoglycemia that she will perk up and was the main item causing her to be lethargic and listless.

Let’s look at the patient’s fluid status next. Her blood pressure is low, heart rate is high, and capillary refill time is delayed. Her mother reported fewer wet diapers than normal as well. We can start out with a bolus of Normal Saline at 20ml/kg. According to the American Academy of Pediatrics, you can always give additional fluid boluses because only one bolus won’t correct the patient’s hemodynamic status if she is severely dehydrated or has significant fluid loss. Be sure to continue to monitor vital signs and lung sounds and don’t wait to start a vasopressor if needed.

When delivering the fluid boluses, in the case of severe hypovolemia, give the fluid as rapidly as possible. You can do this by drawing up the 120mls and giving it to her as an IV push. Another option is placing it on a pump at 999ml/hr and the bolus will be administered between 7 and 8 minutes.

The one thing I don’t advise is leaving a bag of Normal Saline running wide open and walking away. This is a potential safety risk for your patients and leaves them open to fluid overload, pulmonary edema, and or cardiac arrest.

Since we’re discussing delivering fluid boluses an resuscitation of this patient, we should address IV/IO access. Right now, she only has one line and it’s a 24g. Like I previously mentioned, we need to deliver the fluid boluses as fast as possible. How easy to you think that’s going to be with a 24g IV catheter? You’ll be able to administer about 20ml per minute through it. This is why I advocate for the use of IOs when rapid resuscitation is needed. Because she is non-weight bearing, the distal femur is a great site to use. It’s a larger bone and easier to stabilize versus the proximal tibia. Once an IO is placed, you have a 15g and will be able to administer the fluid boluses more appropriately at approximately 200ml per minute.

Another consideration during the resuscitation of this patient is the addition of a vasopressor. There is a strong likelihood that this patient is going to need support in addition to fluid boluses to maintain proper perfusion while addressing the underlying disease process. If you are having to administer a third fluid bolus, you should be initiating a vasopressor. Because this patient is experiencing a distributive shock secondary to an infectious process, the administration of Nor-Epi would be first choice. The dose would begin at 0.05mcg/kg/min. Ensure you are continuously monitoring the patient’s hemodynamics/vital signs and titrate as needed.

Epinephrine can be used as an alternative first line vasopressor if Nor-Epi isn’t available or if the patient is showing signs of myocardial dysfunction. The initial dose would be 0.1mcg/kg/min. Vasopressin is a common secondary agent used for pediatric sepsis and dosing is ranged between 0.0003-0.001units/kg/min. It is worth mentioning that the utility of Vasopressin in pediatric sepsis is not fully known. Additional research needs to be conducted. 

Airway & Ventilator Management

Now that we have fully resuscitated the patient, we can assess if we will need to secure an airway. We can assess the interventions we have done and if they have had any positive effect on improvement of oxygenation. What did we have to do to maintain adequate oxygenation during our resuscitation phase and did the patient’s mental status improve at all?

Another way we can assess is by looking at her work of breathing and listening to lung sounds. Utilizing the Silverman-Anderon score is a good tool to determine the severity of the severity of any distress. Scores can vary between 0, which is no distress at all and 10, the highest severity. The scores fall into three categories.

0–3: Mild or no respiratory distress

4–6: Moderate distress – monitor closely, consider interventions

7–10: Severe distress – likely requires positive pressure ventilation, and intubation should be considered

Figure: Silverman Anderson Score

If you decide to secure the patient’s airway, prepare your equipment and medications, accordingly, utilizing your length-based tape or if you have another pediatric guide available and an intubation checklist. Make sure you have alternative airways out and ready to go, in addition to medications drawn up and doses confirmed. I would also advise you to have Atropine out in case the patient bradys down during the intubation attempt. Lastly, before you proceed with the intubation discuss with your partner what the lowest O2 and heart rate cut off point, where you will stop the procedure and reoxygenate before attempting again. 

Following securing the patient’s airway, we should get her dialed in on the ventilator. Selecting a pressure mode will be safer than volume. This is so we can prevent barotrauma or bronchopulmonary dysplasia. A peak inspiratory pressure of 20 and a peep of 5 is a good place to start. Monitor your exhaled tidal volumes and your flows to make sure she isn’t breath stacking and is receiving an adequate volume of 6-8ml/kg. Infants usually require higher minute ventilation than adults at approximately 200-300ml/kg/min of ideal body weight. So, if we are getting volumes of 8ml/kg, we can start with a respiratory rate between 25 and 36. I suggest that you start at the low end first and tweak from there.

You might be asking me how I got to those numbers, so let’s break it down.

She is 6kg ideal body weight.

Minute Ventilation: 200ml/kg/min = 200 x 6 = 1,200ml/min

Tidal Volume : 8ml/kg = 8 x 6 = 48ml

Respiratory Rate: Minute Ventilation/Tidal Volume = 1,200/48 = 25 breaths/min

I also suggest that you maximize her tidal volume before increasing the respiratory rate. This is because she has a small airway/ETT that increases resistance during the inspiratory phase of ventilation and causes the peak pressure to be reached quicker. If we increase respiratory rate that takes time away from the inspiratory phase, leading to having to deliver breaths faster and will cause the peak pressure to be reached quicker and will reduce the volume being delivered.

Ventilating infants can be tricky, so take your time and get it right. This is going to be the safest thing to do for your patient. 

Additional Considerations

If the patient isn’t showing signs of hypovolemia after fluid resuscitation and potential initiation of vasopressors, having maintenance fluids running is a good idea to maintain homeostasis and proper perfusion. According to the American Academy of Pediatrics, isotonic fluids should be used for maintenance. This was changed in 2018 when it was discovered that hypotonic solutions were creating issues with hyponatremia and negatively affecting morbidity and mortality. Also, if the child hasn’t had proper nutritional intake, the addition of Dextrose is recommended. You can ask the sending facility for a bag of Dextrose 5% with 0.9 Saline, again to make things easy for yourself, so you don’t have to mix it.

Below, you will find a cheat sheet on calculating the amount of fluid a child should receive every hour using the “4-2-1 Rule” based on the Holliday-Segar Method. She is 6kg, so we can run maintenance fluids at 24ml/hr. Please ensure that the maintenance fluids are on a pump.

Figure: Holliday-Segar Method

Let’s take a closer look at the patient’s venous blood gas. She is in a metabolic acidosis state with a PH of 7.01 and HCO3 of 8. Because of this, we may need to revisit our ventilator settings and closely monitor her ETCO2 levels. We need to make sure we are continuing to compensate for her. If we don’t, we can worsen her condition. If we use Winter’s formula, we can calculate what her ETCO2 should be.

Winter’s Formula = (1.5 x HCO3) + 8 ± 2

(1.5 x 8) + 8 ± 2

12 + 8 ± 2 = 18 to 22

Now we know we should increase the patient’s minute ventilation to keep her ETCO2 between 18 and 22.

Another thing that needs to be addressed is the patient’s potassium level. We know that if we continue to compensate for her metabolic acidosis, the patient’s potassium will begin to shift back into the cells. Ideally, for every change of 10mmHg of ETCO2 the potassium will shift 0.6mEq in the same direction. Meaning if we decrease the patient’s ETCO2, this will decrease the serum amount of potassium, which is already on the lower end at 3.2. For this reason, we need to administer potassium. This can be done via IV and dosing for pediatrics is 0.5-1mEq/kg/hr, which means we can safely give the patient 3-6mEq over an hour.

Lastly, we need to consider antibiotic therapy. There are cultures pending, however antibiotics haven’t been administered yet. It is recommended that pediatric patients should receive broad spectrum antibiotics within the first hour of identification of sepsis when the pathogen hasn’t been identified yet. For newborns up to 8 weeks of age Ampicillin and Gentamicin are recommended. Any other pediatric patient should receive third-generation cephalosporins such as Ceftriaxone. Ceftriaxone for pediatrics is dosed at 50mg/kg or for our patient 300mg and should be administered over 30 minutes. You can do this by adding the Ceftriaxone to a 50ml bag of Normal Saline and put it on a pump. You could also dilute the Ceftriaxone in a syringe and put it on a pump via a half set. 

Conclusion

Phew, this was a tough case and you should give yourself a pat on the back! I know that pediatrics can be a challenging patient population to take care of. Children aren’t supposed to be sick or injured. Take a breath, stay calm, and utilize all the resources at your disposal to increase cognitive offload. Specifically for this patient there are multiple moving pieces and things that need to be addressed. Just remember to prioritize ABCs and proper resuscitation. If you address things in a timely manner and continue to support hemodynamics and treat the underlying disease or infectious process, this patient will have a good outcome. 

“The moral responsibility of the healer is to step inside the patients' experiences and accompany them through the worst moments with empathy and expertise" -Dr. Paul Farmer 

References

Ceftriaxone Dosage Guide with Precautions. (2025). Drugs.com. https://www.drugs.com/dosage/ceftriaxone.html

Hedstrom, A. B., Gove, N. E., Mayock, D. E., & Batra, M. (2018). Performance of the Silverman Andersen Respiratory Severity Score in predicting PCO2 and respiratory support in newborns: a prospective cohort study. Journal of Perinatology, 38(5), 505–511. https://doi.org/10.1038/s41372-018-0049-3

IV Catheter Sizes and Flow Rates. (2025). Nursingcenter.com. https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/iv-catheter-sizes-and-flow-rates

Kight, B. P., & Waseem, M. (2023). Pediatric Fluid Management. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560540/

Miranda, M., & Nadel, S. (2023). Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations. Current Pediatric Reports, 11(2), 29–39. https://doi.org/10.1007/s40124-023-00286-3

Respiratory Support in Neonates and Infants - Pediatrics. (2025). Merck Manual Professional Edition. https://www.merckmanuals.com/professional/pediatrics/respiratory-problems-in-neonates/respiratory-support-in-neonates-and-infants#Mechanical-Ventilation_v45152913

Weiss, S. L., & Fitzgerald, J. C. (2023). Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics, 153(1). https://doi.org/10.1542/peds.2023-062967