Fever & Sepsis

Core Assessment Strategies for Fever and Sepsis

Fever is one of the most common presenting complaints in pediatric emergency departments. Identifying which febrile child has a serious bacterial infection (SBI) or is progressing to sepsis is a core competency for the Certified Emergency Nurse (CEN).^[1] This section focuses on evidence-based risk stratification, early recognition of sepsis, and the initial management bundle that drives improved outcomes. High-yield exam concepts include the Pediatric Assessment Triangle (PAT), age-specific vital sign thresholds for systemic inflammatory response syndrome (SIRS), and the stepwise application of sepsis screening tools.^[2]

Clinical Terminology for Sepsis and SBI

• Fever in Children: Generally defined as a rectal temperature ≥100.4°F (38°C).^[3] The height of fever alone does not reliably predict serious illness, but the duration and pattern can guide risk assessment.
• Serious Bacterial Infection (SBI): Includes urinary tract infection, bacteremia, meningitis, pneumonia, osteomyelitis, and septic arthritis. Neonates (≤28 days) are at highest risk.^[1]
• Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection.^[2] In pediatrics, the 2012 International Pediatric Sepsis Consensus Conference definitions are commonly referenced, though the Sepsis-3 definitions are increasingly applied in adolescents.^[4]
• Systemic Inflammatory Response Syndrome (SIRS): The presence of at least two of four criteria (one must be abnormal temperature or leukocyte count) – see key vital signs below.
• Septic Shock: Sepsis with cardiovascular dysfunction refractory to fluid resuscitation (≥40–60 mL/kg of isotonic crystalloid within the first hour) or requiring vasoactive medications.^[2]

Stratifying Risk and Initiating Sepsis Bundles

1. Risk Stratification by Age Group

The emergency nurse must apply three distinct age-based approaches to fever evaluation:^[1][3]

• Neonates (0–28 days): Full septic workup – CBC with differential, blood culture, urinalysis, urine culture, lumbar puncture, and chest X-ray if respiratory symptoms present. Admit for empiric antibiotics (ampicillin + gentamicin or cefotaxime).
• Infants 29–60 days: Risk-stratify using the Rochester Criteria or validated predictive models. Low-risk infants (well-appearing, no focal infection, normal labs) may be managed as outpatients with close follow-up.^[3]
• Children 3–36 months: Generally well-appearing children with fever <39°C and no source can be observed; those with fever ≥39°C and no source should have a urinalysis and urine culture.
• Older children (>36 months): Workup is guided by symptoms and exposure history.

2. Pediatric Sepsis Screening and Recognition

Use a structured screening tool immediately upon arrival. Common tools include PEWS (Pediatric Early Warning Score) and the Sepsis Bundle approach.^[2][5]

1. Perform the Pediatric Assessment Triangle (PAT): Appearance (tone, interactivity, consolability), work of breathing (retractions, grunting, nasal flaring), and circulation (skin color, pallor, mottling).
2. Obtain vital signs and document age-specific SIRS criteria. A fever ≥38.5°C or hypothermia <36°C counts as one criterion.
3. Screen for organ dysfunction: Altered mental status, hypotension (late sign in children), tachycardia, prolonged capillary refill >2 seconds, decreased urine output, respiratory distress, or petechial/purpuric rash.
4. Activate the sepsis response if sepsis is suspected (SIRS + suspected or confirmed infection). Initiate the first-hour bundle.^[2]

3. The Sepsis First-Hour Bundle

Adapted from the Surviving Sepsis Campaign guidelines for children:^[2][5]

• Give supplemental oxygen to maintain SpO₂ ≥94%.
• Obtain IV/IO access and draw blood cultures, lactate, CBC, and basic metabolic panel.
• Administer fluid bolus of 20 mL/kg isotonic crystalloid (NS or LR) over 5–10 minutes. Repeat up to 60 mL/kg while reassessing for signs of fluid overload (hepatomegaly, rales, respiratory distress).
• Administer broad-spectrum antibiotics – common choices: ceftriaxone (non-neonates) or ampicillin + cefotaxime/gentamicin (neonates). Consider vancomycin if concerns for MRSA.
• If shock persists after 40–60 mL/kg, start a vasoactive infusion (e.g., epinephrine or norepinephrine via central line, or intraosseous if needed).
• Monitor urine output (goal ≥1 mL/kg/hr).

Clinical Indicators and Vital Sign Thresholds

Age-Specific Vital Sign Thresholds for SIRS (Pediatric Sepsis Consensus)^[4]

Essential Laboratory Studies for Fever Evaluation

• Complete Blood Count (CBC) with differential: Look for leukocytosis or leukopenia. A left shift (bands >10%) increases concern for bacterial infection. In neonates, WBC <5,000 or >15,000 is associated with higher risk of SBI.^[1]
• Blood culture: Gold standard for identifying bacteremia. Draw before antibiotics if possible, but do not delay antibiotics if access is difficult.
• Urinalysis and urine culture: Most common source of SBI in infants. Obtain via catheterization (not bag) in non-toilet-trained children.^[3]
• Lumbar puncture: Indicated for neonates ≤28 days, infants 29–60 days with abnormal labs or ill appearance, and any child with meningeal signs (nuchal rigidity, bulging fontanelle, seizures).^[1]
• Lactate: Elevated lactate (>2 mmol/L) suggests tissue hypoperfusion. Serial lactate measurements guide resuscitation success.^[2]
• Chest X-ray: If respiratory symptoms, hypoxia, or suspicion of pneumonia.
• Procalcitonin (if available): More specific than CRP for distinguishing bacterial from viral infection. A negative procalcitonin can help safely defer antibiotics in low-risk febrile infants.^[3]

First-Hour Interventions and Nursing Care

Emergency Department Nursing Interventions

• Fever management: Antipyretics (acetaminophen 15 mg/kg/dose or ibuprofen 10 mg/kg/dose) primarily for comfort. Do not delay the septic workup for fever control.^[3]
• Rapid fluid resuscitation: Use a push-pull technique with a 20 mL syringe and three-way stopcock to deliver 20 mL/kg in <10 minutes. Monitor for signs of fluid overload.
• Antibiotic timing: Administer within one hour of recognition of sepsis. Delays are associated with increased mortality.^[2]
• Vasoactive support: If shock persists despite 40–60 mL/kg, start dopamine (5–20 mcg/kg/min) or epinephrine (0.05–0.3 mcg/kg/min). Central line insertion is preferred but may be placed via IO initially.
• Temperature regulation: Cover hypothermic infants with warm blankets or use a radiant warmer. Hyperthermic children can be cooled with tepid sponging if needed, but avoid shivering.
• Family communication: Provide frequent updates. Explain the need for procedures (catheter, LP) clearly and calmly. Encourage presence if stable.

Preventing Fluid Overload and Missed Infections

• Fluid overload in sepsis: Hepatomegaly, pulmonary edema, and worsening respiratory distress. Stop fluid boluses if these develop; prepare for possible intubation.^[5]
• Missed meningitis: Always consider lumbar puncture in neonates and ill-appearing infants. Empiric antibiotics should cover Listeria in newborns.
• Inappropriate antibiotic delay: The most common cause of poor sepsis outcomes. Prioritize blood culture collection but do not withhold antibiotics for prolonged IV attempts.
• Recognition of compensated vs. decompensated shock: Tachycardia and prolonged cap refill occur before hypotension. Do not wait for hypotension to escalate care.^[2]
• Petechiae/purpura: If petechiae are below the nipple line (in infants) or palpable, immediately consider meningococcemia and administer empiric ceftriaxone.

Frequently Tested Sepsis Management Points

• Memorize the SIRS criteria by age – the exam will ask you to identify whether a given set of vitals meets SIRS definition for a specific age group.
• Know the three-tier fever evaluation: Neonates (full workup + admit), 29–60 days (use low-risk criteria), >60 days (source-guided).
• First-hour bundle steps: Oxygen, blood cultures, lactate, fluids (20 mL/kg up to 60 mL/kg), broad-spectrum antibiotics, reassess for vasopressors.
• Common test question: "A 2-week-old with fever of 38.6°C, WBC 4,800, ill appearance. What is the priority?" Answer: Full septic workup and empiric antibiotics.
• Mnemonic for SIRS criteria in children: "TWO C’s" – Temperature (abnormal), White count (abnormal), Heart rate (tachy or brady), Respiratory rate (tachypnea).
• Remember that hypotension is a late sign in children – do not rely on it to diagnose shock. Tachycardia and prolonged cap refill are earlier indicators.
• Vasoactive drug of choice in warm shock (normal cap refill) vs. cold shock: Norepinephrine for warm shock; epinephrine or dopamine for cold shock.^[2]

References & Sources

1. Baskin, M. N., & O'Rourke, E. J. (2021). Pediatric Emergency Medicine: A Comprehensive Study Guide (8th ed.). McGraw-Hill. https://doi.org/10.1036/1260464520
2. Weiss, S. L., Peters, M. J., Alhazzani, W., Agus, M. S. D., Flori, H. R., Inwald, D. P., ... & Tissières, P. (2020). Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Medicine, 46(Suppl 1), 10–67. https://doi.org/10.1007/s00134-019-05878-6
3. Pantell, R. H., Roberts, K. B., Adams, W. G., Dreyer, B. P., Kuppermann, N., & O'Leary, S. T. (2021). Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics, 148(2), e2021052228. https://doi.org/10.1542/peds.2021-052228
4. Goldstein, B., Giroir, B., & Randolph, A. (2005). International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatric Critical Care Medicine, 6(1), 2–8. https://doi.org/10.1097/01.PCC.0000149131.72248.E6
5. Davis, A. L., Carcillo, J. A., Aneja, R. K., Deymann, A. J., Lin, J. C., Nguyen, T. C., ... & Zucker, H. A. (2017). American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Critical Care Medicine, 45(6), 1061–1093. https://doi.org/10.1097/CCM.0000000000002425