Case history
Case history #1
A previously well 1-year-old girl presents to the accident and emergency department with a history of lethargy and fever for 24 hours. She recently had symptoms suggestive of a viral upper respiratory tract infection. Her parents report that for a few hours prior to presentation she had become drowsy and difficult to rouse. They also report that they had noticed a rash developing on her trunk and limbs shortly before presentation. On initial assessment the following features are identified: reduced level of consciousness (response to painful stimulus only); tachycardia (heart rate 190 beats per minute); prolonged capillary refill time (>5 seconds peripherally); cold peripheries (core-toe temperature gap >10°C [>18°F]); fever (core temperature 39°C [102°F]); tachypnoea (respiratory rate 40 beats per minute) and grunting on expiration; and a widespread, non-blanching, purpuric rash on the trunk and limbs.
Case history #2
A 2-week-old preterm male neonate develops transient apnoeas and bradycardic episodes while in the neonatal intensive care unit. He had been born at 30 weeks' gestation after spontaneous onset of preterm labour. He had required intubation and mechanical ventilation for 48 hours following birth for neonatal respiratory distress syndrome. Standard dosing of surfactant was administered during this time. He required respiratory support with continuous positive airway pressure for 1 week after his extubation, and was cycling on and off high-flow oxygen therapy at the time of this event. He had established full enteral feeding after a period of parenteral feeding via a percutaneous central venous catheter (long-line). The long-line was still in situ at the time of this event, and was planned for removal that day. In addition to the apnoeas and bradycardias, it was noted that he had temperature instability and increased capillary refill time (>3 seconds); both of these features were a change from the previous observation trends.
Other presentations
The typical presentation of sepsis varies according to the age of the child. Whereas older children often present with a focus of infection, infants and neonates usually present with non-specific symptoms and signs. For example, the early signs of sepsis in preterm infants are often apnoeas and bradycardias.[11] In the neonatal population, including preterm infants, any change from the patient's normal pattern of observations should raise the suspicion of sepsis.
Septic shock commonly presents as vasoconstrictive ('cold') shock with profound peripheral vasoconstriction and impaired myocardial contractility. However, another mode of presentation is vasodilatory ('warm') shock characterised by systemic vasoplegia (dilated peripheral vasculature and 'flash' capillary refill) with a high cardiac output and bounding pulses. Studies suggest that this mode of presentation is more common in hospital-acquired sepsis.[12]
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