PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

9. Sepsis

Statement 9a (Sepsis recognition and initial management)

Sepsis can be defined as the systemic response to infection.

% Agree	% Disagree	Result
84.4%	3.1%	Included

Position	Comments
Neuro	Never heard it so defined; but it sounds reasonable
Paed	A septic condition could be defined as a systemic response to infection
PICU	There is now internationally agreed terminology for what you are calling sepsis. See the literature on ‘sepsis syndrome’
Endo	?any more detail needed
PICU	a straightforward definition - helpful

Statement 9b

(i) In a child with a reduced conscious level, sepsis should be assumed if two or more of the following is present:

a body temperature of >38 C or <36 C or history of fever at home

tachycardia

tachypnoea

a change in white cell count to >12000 cu mm or <4000 cu mm

% Agree	% Disagree	Result
81.3%	0%	Included

Position	Comments
PICU	all non specific
Neuro	white cell count changes may be delayed
ED P	Suspected and treated but not necessarily assumed
Paed	treat for sepsis “yes” continue to consider other causes though ie assume nothing
Metab	“are present” (sp)
Endo	?if body temp >38/<36 or history and one of other features – In DKA raised HR, RR and probably raised WCC but no sepsis
PICU	1,2+3 are too linked. 4 is independent
Paed	WCC >15000 or <4000, evidence of shock, raised CRP

(ii) In a child with a reduced conscious level, sepsis should be assumed if there is a non-blanching petechial or purpuric skin rash

% Agree	% Disagree	Result
90.1%	3.0%	Included

Position	Comments
Neuro	other thisns should be considered too…NAI, ITP + ic hemaerrage
ED P	Suspected but not assumed, could be NAI
Paed	NAI? coagulation abnormalities? ITP? Treat with antibiotics, of course. Do not “assume”
PICU	pattern of rash may affect this. practically ab’s will be given. vasculitis poss. vomiting in SVC distribution without fever

Statement 9c

(i) In a child with a reduced conscious level and suspected sepsis, broad spectrum antibiotics should be started intravenously after appropriate cultures have been taken.

% Agree	% Disagree	Result
91.2%	0%	Included

Position	Comments
PICU	Again there are agreed treatments here – see the red book and the CMO recommendation to GPs etc. Parenteral does not necessarily mean IV in the first instance.
ED	or before if patient not near a secondary care facility
Radiol	Treat first (eg GP) before culture (if needed)
Neuro S	As long as no delay to taking cultures: won’t GP/paramedics have given some already?
PICU	often LP will have to wait

(ii) In a child with a reduced conscious level and suspected sepsis, microbiological advice should be sought for second line antibiotics if there is a poor response to treatment.

% Agree	% Disagree	Result
0%	85.3%	Included

Position	Comments
ED	at what stage?
Paed	Yes but should we define how long to wait before defining poor response
ED P	Depends on how long you give for there to be no response, and is more long term presumably, but discussion is always helpful, depending on what was first line
Paed	How far down line is “poor response” defined?
PICU	micro advice practically occurs with enquiry re results 1^st set culture. need to inform of clinical presentation early

(iii) A child with a reduced conscious level and suspected sepsis should be closely observed for and treated for signs of shock.

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
PICU	judgements carefully made. decreased consciousness leading to CVS changes verses decreased consciousness because of sepsis

(iv) A child with a reduced conscious level and suspected sepsis could have another underlying diagnosis and should have the core investigations requested (“core investigations” will be defined as the investigations agreed upon in Statement 7d)

% Agree	% Disagree	Result
94.1%	0%	Included

Position	Comments
ED	depends on clinical context – Senior input to care perhaps more importnat
Endo	No need for ammonia/lactate/amino acids if clinical improvement with resp support, antibiotics, fluids
PICU	age dependent

(iv) A child with a reduced conscious level and suspected sepsis should be reviewed by an experienced paediatrician within the first hour of presentation. (The definition of “an experienced paediatrician” should be decided by individual departments when the guideline is implemented at a local level)

% Agree	% Disagree	Result
94.6%	0%	Included

Position	Comments
Paed	It should be ASAP rather than within the first hour of presentation
Neuro	depends on what an experienced [paed definition is
ED P	At least middle grade but not necessarily consultant
Paed	SpR

(v) A referral to a paediatric intensive care unit should be considered within the first hour of presentation in a child with a reduced conscious level and suspected sepsis.

% Agree	% Disagree	Result
68.6%	8.6%	Excluded

Position	Comments
PICU N	Only if clinical indicators suggest that level of care
Paed	Depends on severity
PICU	after initial resuscitation-
ED P	If there is no response or worsening etc-
Neuro	it may be too early to see a response…considering it is always good
Metab	I would have assumed that statement correct
ED P	Depending on GCS, initial response to treatment + airway management
Neuro	Discussion certainly
Endo	Or HDU depending on facilities pending possible transfer
Paed	Ab’s + fluid may immediately perk child up
PICU	not all depend on response Rx and diagnosis
Paed	discussion with rather than referral to