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id.sepsis.peds.v1

Pediatric sepsis / septic shock

pediatricsacutepediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

NEW dossier — no manifest / atoms / package / design brief on disk yet (manifest field intentionally empty). NEXT STEPS: (1) author manifest at prisma/seed/manifests/id.sepsis.peds.v1.ts; (2) write _design-brief.md; (3) RxCUI validation for ampicillin / gentamicin / cefotaxime / ceftriaxone / vancomycin / acyclovir / piperacillin-tazobactam / cefepime / meropenem / clindamycin / norepinephrine / epinephrine / vasopressin / hydrocortisone / milrinone / dobutamine; (4) PMID landmarks (FEAST 2011, RESOLVE, ProCESS / ARISE / ProMISe peds equivalents, SSC peds papers); (5) calculator gaps — Phoenix sepsis score, pSOFA, PELOD-2, age-based vital thresholds need entries. Drug guidance grounded in SSC Pediatrics 2020 + PALS + Phoenix criteria 2024 + FEAST contextualisation (avoid routine 30 mL/kg in low-resource non-malaria settings). Vasopressor phenotyping (cold shock → epinephrine; warm shock → norepinephrine) is core to pediatric sepsis management. Sibling differentiation from id.sepsis.core.v1 covers 10 features and adolescent transition handling. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/id.sepsis.peds.v1.depth.md (companion to existing 2026-04-27 brief) + _research-bundles/id.sepsis.peds.v1.md. Added outpatient setting playbook (post-PICU peds + neurodev follow-up — 1-2 wk visit / 1 mo / 3 mo Bayley III or Ages-and-Stages; cognitive + school-performance follow-up if ≥ 1 yo; PCV13/PCV15/PCV20 / Hib / MenACWY immunization catch-up per cause; hearing screen if meningitis; PT/OT if functional decline; mental-health screen for child + caregivers PICU-Family syndrome; source-specific surveillance — TTE if endocarditis; HbA1c if new-onset DM). Added 6 severity triggers: phoenix_criteria_high_mortality_band (life_threatening — Phoenix-8 ≥ 4 with vasopressor → ECMO consideration; Schlapbach JAMA 2024 PMID 38245901 derivation cohort + Sanchez-Pinto JAMA 2024 PMID 38245890 validation), warm_vs_cold_shock_undifferentiated_at_1h (severe — bedside echo + ScvO2 drive vasoactive choice per SCCM peds 2020), catecholamine_resistant_shock (life_threatening — MAP < age threshold despite NE 0.1-0.5 or Epi 0.3 µg/kg/min → hydrocortisone 50 mg/m²/d + vasopressin + dobutamine; SSC peds 2020), neonatal_hsv_features (life_threatening — < 28 d + vesicles / seizures / hypothermia / hepatitis / encephalopathy / maternal genital HSV → acyclovir 60 mg/kg/d divided q8h + HSV PCR; AAP Red Book 2024), feast_context_low_resource (moderate — non-malaria-endemic + low-resource + age ≥ 60 d → 10-20 mL/kg + reassess instead of routine 30 mL/kg per FEAST PMID 21615299), antibiotic_timing_miss_peds (severe — age-tiered empirics > 1 h after recognition → SSC peds 2020 mortality gradient + Kumar 2006 PMID 16625125). Appended 3 PMIDs to evidence.pmids: 32032273 Weiss SCCM Pediatric SSC 2020 (newly added — was missing), 38245901 Phoenix Schlapbach JAMA 2024, 38245890 Phoenix Sanchez-Pinto JAMA 2024. Bumped evidence.last_reconciled to 2026-05-14. Original 2026-04-27 brief preserved; depth companion lives at _briefs/id.sepsis.peds.v1.depth.md. Citation+drug-code remediation 2026-05-22 (PubMed + RxNav live-verified): 4 mis-attributed PMIDs replaced/removed — DELIVER 36027571 (= heart-failure decongestion) -> Ventura peds dopamine-vs-epinephrine RCT 26323041; RALES 10471456 (= spironolactone HF trial) -> Weiss peds antibiotic-timing CCM 2014 25148597; REDUCE 23900119 (= biomass-fuel cooking study) -> Huang REDUCE MRSA decolonization 23718152; POINT 29766750 (= clopidogrel/aspirin stroke trial) removed. Kept verified: SSC 34599691, ProCESS 24635773, ARISE 25272316, ProMISe 25776532, FEAST 21615299, Weiss peds SSC 32032273, Phoenix 38245901/38245890. RxNav-corrected wrong/empty RxCUIs: vancomycin 477391 (=levofloxacin oral soln) -> 11124, meropenem 1665005 (=ceftriaxone 500mg) -> 29561, milrinone 41126 (=fluticasone) -> 52769, hydrocortisone 5489 (=hydrocodone) -> 5492, gentamicin 4921 (empty) -> 1596450, PCV20 1665008 (empty) -> 2566310 (Prevnar 20). Phenotype matrix (age-band × shock-phenotype × source × pathogen-class × host — 7 × 4 × 9 × 3 × 7 collapsed cross-product) encoded indirectly via existing regimen_axes.peds_sepsis_empirics_by_age.steps (neonate_under_28d / infant_1_to_3_months / over_3_months) + severity_triggers (warm/cold shock, catecholamine-resistant, phoenix-high-mortality, neonatal-HSV, FEAST-context) + setting playbooks (ed / inpatient / icu / outpatient). First-class TS field for phenotype matrix is schema-blocked. Bayesian linkage (Phoenix score ≥ 2 LR+ ~ 4 for in-hospital mortality per Schlapbach JAMA 2024 + Sanchez-Pinto JAMA 2024 derivation/validation; Phoenix cardiovascular sub-score ≥ 1 LR+ ~ 7 for 90-d mortality; pSOFA ≥ 2 LR+ ~ 3 for ICU mortality per Matics CCM 2017; PELOD-2 ≥ 8 LR+ ~ 4 for 90-d mortality; CRP ≥ 80 LR+ ~ 2-3 bacterial vs viral; procalcitonin ≥ 0.5 LR+ ~ 3-5 in peds; HSV PCR positive LR+ > 100 in neonate; T_treat ~ 20% post-test OR ANY septic shock; T_test ~ 5% post-test AND age > 3 mo AND well-appearing AND normal markers AND clear viral source AND ALL exclusion criteria met → outpatient; routing edges to id.bacterial-meningitis.peds.v1 / peds.dka.v1 / peds.aki.v1 / pulm.ards.v1 / peds.status_epilepticus.v1) documented in _research-bundles/id.sepsis.peds.v1.md. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). Prehospital state-of-play (pediatric assessment triangle + BLS + IV/IO + 10-20 mL/kg crystalloid + first-dose antibiotic if available + pre-notify ED) is currently encoded implicitly via flow.entry_points + transitions; a first-class "prehospital" DossierSetting value is schema-blocked. PALS 2024 + de Oliveira EGDT peds + Choong PEDAL series + Pinto Survivor Outcomes PMID lookups deferred to next research:pubmed loop — citations retained in research bundle for prehospital + neurodev follow-up framework.

Entry points (5)

  • symptom
    Suspected infection + age-based vital sign derangement + organ dysfunction (Phoenix criteria, Schlapbach JAMA 2024)
    pediatric_sepsis_recognition
  • vital_abnormality
    Age-based hypotension or shock signs (cap refill >3 s, mottling, AMS, cold extremities) per SSC 2020
    pediatric_hypotension_or_shock
  • lab_abnormality
    Lactate >2 with infection in a child (SSC 2020 Hour-1 bundle)
    lactate_elevated_peds
  • symptom
    Fever / hypothermia with AMS in a child (SSC 2020)
    fever_with_AMS_child
  • symptom
    Neonate appearing unwell — temperature instability, poor feeding, lethargy, apnoea (AAP neonatal sepsis)
    neonatal_unwell

Required inputs (22)

  • agerequired
    demographic • used at CONTEXT
    Neonate vs <3 mo vs >3 mo drives empiric antibiotics and vital-sign thresholds (SSC 2020 age tiers)
  • weightrequired
    demographic • used at CONTEXT
    All fluids, antibiotics, and vasopressors are weight-based (mL/kg, mg/kg, µg/kg/min) per SSC 2020
  • sbprequired
    vital • used at CONTEXT
    Age-based hypotension threshold (5th percentile) drives shock recognition (SSC 2020)
  • maprequired
    vital • used at TREATMENT
    MAP target by age (SSC peds: ≥5th percentile for age, conditional ≥50th)
  • hrrequired
    vital • used at CONTEXT
    Age-based tachycardia and bradycardia (terminal sign in infants) per SCCM 2020 peds thresholds
  • rrrequired
    vital • used at CONTEXT
    Age-based tachypnea; respiratory failure recognition (SCCM 2020)
  • temperaturerequired
    vital • used at CONTEXT
    Fever / hypothermia (especially in infants) is a sepsis criterion (Phoenix criteria 2024)
  • spo2required
    vital • used at CONTEXT
    Hypoxaemia drives oxygen support and intubation decisions (Phoenix respiratory score)
  • capillary_refillrequired
    symptom • used at CONTEXT
    CRT >3 s + mottling = cold shock phenotype (prefer epinephrine; SSC 2020)
  • mental_status_childrequired
    symptom • used at RED_FLAGS
    AMS = pediatric organ dysfunction criterion + shock indicator (Phoenix criteria 2024)
  • urine_outputrequired
    symptom • used at MONITORING
    <1 mL/kg/h (or <0.5 mL/kg/h adolescents) = AKI / shock marker (KDIGO peds)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Hour-1 bundle marker per SSC peds; clearance trend
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycaemia in infants / sepsis is common and dangerous (SSC 2020)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    CBC + diff; bandemia + neutropenia / lymphopenia patterns (SSC 2020 workup)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    AKI staging (pRIFLE / KDIGO peds) + drug dosing
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Coag dysfunction + DIC + organ-dysfunction criterion (Phoenix criteria 2024)
  • blood_culturerequired
    lab • used at INITIAL_WORKUP
    Cultures BEFORE antibiotics if no delay (≤45 min per SSC peds)
  • crp_or_procalcitonin
    lab • used at INITIAL_WORKUP
    Inflammation marker + de-escalation guidance (SSC 2020 procalcitonin-guided)
  • immunisation_status_pedsrequired
    history • used at CONTEXT
    PCV / Hib / meningococcal coverage gaps drive empiric breadth (SSC 2020)
  • central_line_or_devicerequired
    history • used at CONTEXT
    CLABSI risk; differential time-to-positivity sampling (SSC 2020)
  • immunocompromise_pedsrequired
    history • used at CONTEXT
    Oncology, transplant, primary immunodeficiency → broad / atypical cover (SSC 2020)
  • recent_abx_or_hospitalizationrequired
    history • used at CONTEXT
    MDRO risk → broaden empiric (SSC 2020)

12-phase flow (12)

  1. 1FRAME
    Pediatric sepsis per Phoenix criteria 2024 / SSC peds 2020 — suspected infection + organ dysfunction (Phoenix score ≥2). Neonatal sepsis routes to neonatology.
    inputs: age
    advance: Pediatric sepsis pattern identified
  2. 2ENTRY
    Recognise via age-based vitals + AMS + perfusion + suspected infection; trigger sepsis huddle
    inputs: age, weight
    advance: Sepsis recognized
  3. 3CONTEXT
    Source clues, comorbidities, lines / devices, immunisation, immune status, recent abx, household exposures (meningococcal, varicella)
    inputs: hr, rr, temperature, spo2, capillary_refill, immunisation_status_peds, central_line_or_device, immunocompromise_peds, recent_abx_or_hospitalization
    advance: Context complete
  4. 4RED_FLAGS
    Cold/warm shock, hypotension, lactate >4, AMS, oligo-anuria, purpura fulminans, DIC, neutropenic fever — initiate Hour-1 bundle + PICU pathway
    inputs: sbp, lactate, mental_status_child
    actions: protocol.septic_shock
    advance: Red flags actioned
  5. 5INITIAL_WORKUP
    Hour-1 bundle: lactate, blood cultures × 1-2 (size-appropriate volume), broad-spectrum abx within 1 h (≤3 h if no shock per SSC peds 2020), 10-20 mL/kg crystalloid bolus reassess, glucose check, source-directed cultures + imaging, CBC, BMP, LFT, coag, ABG/VBG
    inputs: lactate, glucose, wbc, creatinine, platelets, blood_culture
    actions: panel.cbc, panel.renal, panel.lft, panel.coag, panel.abg, panel.inflammation, workup.pediatric_fever
    advance: Hour-1 bundle complete
  6. 6BRANCHING_WORKUP
    Source ID — CXR / lung US (pulm), UA + culture (urinary), CT abd (abdo / surgical abdomen), wound / surgical eval (SSTI), LP if no contraindication (CNS, especially infants), echo (endocarditis, myocarditis), differential time-to-positivity if line
    actions: workup.pediatric_fever, workup.bacterial_meningitis, workup.crbsi
    advance: Source identified or empirically covered
  7. 7DIFFERENTIAL
    Anaphylaxis, hypovolaemic shock, cardiogenic (myocarditis, congenital), obstructive (tamponade, tension pneumothorax), adrenal crisis, MIS-C / Kawasaki shock syndrome, intussusception with shock, severe DKA, toxic shock syndrome
    advance: Mimics excluded or co-managed
  8. 8RISK_STRATIFICATION
    Phoenix sepsis score / pSOFA / PELOD-2; PICU triage; mortality estimate; vasoactive + organ-support trajectory
    inputs: sbp, spo2, mental_status_child
    advance: Severity + PICU need set
  9. 9TREATMENT
    Broad-spectrum empiric within 1 h (source + age + MDRO risk-tailored); 10-20 mL/kg balanced crystalloid bolus reassess (avoid routine 30 mL/kg per SSC peds / FEAST contextualisation; in low-resource non-malaria settings be conservative); norepinephrine first-line for warm shock (central) or epinephrine first-line for cold shock (peripheral acceptable early); add vasopressin if refractory; hydrocortisone 50 mg/m²/day or 2 mg/kg/day in catecholamine-resistant shock; glucose target 80-180; LMWH / mechanical VTE prophylaxis per local; lung-protective ventilation if intubated; CRRT for fluid overload / AKI; source control within 6-12 h
    inputs: map, creatinine, lactate, weight
    advance: Antibiotics + fluids + vasopressor target met; source control booked
  10. 10DISPOSITION
    PICU for shock / vasopressor / mechanical ventilation / refractory acidosis; otherwise step-down with sepsis monitoring orderset
    inputs: sbp, spo2
    advance: Level of care set
  11. 11MONITORING
    Lactate q2-4h until normalised, MAP continuous, UOP ≥1 mL/kg/h infants / ≥0.5 mL/kg/h adolescents, vasopressor dose, daily pSOFA, procalcitonin q48-72h for de-escalation, daily DDx review at 24-72h
    inputs: lactate, creatinine, urine_output
    actions: panel.renal, panel.cbc
    advance: Response confirmed; antibiotics narrowed by culture
  12. 12FOLLOWUP
    Post-sepsis goals-of-care discussion; PICS-p screen at 1-3 months; cognitive / functional rehab; review and de-escalate abx; outpatient ID f/u for endocarditis / osteomyelitis; immunisation catch-up
    advance: Post-discharge plan documented