The systemic inflammatory response syndrome (SIRS) is a widespread inflammatory

response that may or may not be associated w/ infection. The presence of 2 or more of
the following criteria (one of which must be abnormal temperature or leukocyte count)
defines SIRS:
1. Core temperature of >38.5 C or < 36 C
2. Tachycardia, defined as a mean heart rate more than 2 SD above normal for
age, or for children younger than one yr of age, bradycardia defines as a mean
heart rate <10th percentile for age.
3. Mean respiratory rate more than 2 SD above normal for age or mechanical
ventilation for an acute pulmonary process.
4. Leukocyte count elevated or depressed for age, or > 10% immature neutrophils.

Definitions:
Sepsis: the systemic inflammatory response syndrome in the presence of suspected or
proven infection constitutes sepsis.
Severe sepsis: sepsis is considered severe when it is assosciated w/ cardiovascular
dysfxn, acute respiratory distress syndrome (ARDS), or dysfxn in 2 or more other organ
systems as defined in multiple organ failure.
Septic shock: septic shock refers to sepsis w/ cardiovascular dysfxn that persists despite
the administration of 40 mL/kg of isotonic fluid in 1 hr.
Evidence of inadequate tissue perfusion & oxygen delivery w/ or w/out hypotension
often accompanies sepsis in children. Tachycardia is a sensitive, though non-specific,
indicator often seen in early stages of shock. Hypotension is a late sign of shock b/c
infants & children are better able to maintain BP w/ increase in HR, SVR & venous tone.
Refractory septic shock: there are 2 types of refractory septic shock: fluid-refractory
septic shock exists when cardiovascular fxn persists despite at least 60 mL/kg of fluid
resuscitation; and catecholamine-resistant septic shock exists when shock persists
despite therapy w/ dopamine 10 mcg/kg per min &/or direct-acting catecholamines
(epinephrine, norepinephrine).
Risk factors for septic shock:
1. age younger than 1 month
2. serious injuries (eg, major trauma, burns or penetrating wounds)
3. chronic debilitating medical conditions (eg, static encephalopathy w/ quadriplegia
& frequent aspiration pneumonia, uncorrected congenital heart disease, short gut
syndrome)
4. host immunosuppression
5. large surgical incisions
6. in-dwelling vascular catheters or other invasive devices
7. urinary tract abnormalities w/ frequent infection

Rapid recognition of signs of inadequate tissue perfusion:

1. Fever
2. Tachy/bradycardia
3. Decreased peripheral pulses compared w/ central pulses
4. Mottled or cool extremities
5. Flash or >3 second capillary refill
6. Dry mucus membranes, sunken eyes, & decreased urine output.
7. Tachypnea, bradypnea, or apnea
8. Hypotension
9. Altered mental status (irritability, anxiety, confusion, lethargy, somnolence, apnea)
10.
Hypothermia (especially neonates)
Simultaneous search for infectious source to distinguish non-infectious from septic shock.
Suggested labs: blood glucose, ABG or VBG, CBC w/ differential, blood lactate, serum
electrolytes, BUN & serum Cr, ionized blood Ca++, serum total bilirubin & alanine
aminotransferase, PT & PTT, INR, fibrinogen & D-diimer, blood culture, UA, urine culture,
CRP, ESR
Physiologic indicators & target goals:
1. Quality of central & peripheral pulses (strong, distal pulses equal to central pulse)
2. Skin perfusion (warm, w/ capillary refill < 2 seconds)
3. Mental status (normal mental status)
4. Urine output (1 mL/kg per hr, up to 40 mL per hr, once effective circulating
volume is restored)
5. BP (SBP at least 5th percentile for age: 60 mm Hg <1 month of age, 70 mm Hg + 2
X age in yrs in children 1 month to 10 yrs of age, 90 mm Hg in children 10 yrs or
older)
6. Lactate (< 4 mmol/L or 10% decrease per hr until normal)
7. Central venous oxygen saturation 70%