Risk stratification tool for children aged under 5 years with suspected sepsis
Last reviewed dd mmm yyyy. Last edited dd mmm yyyy
Risk stratifification tool for children aged under 5 years with suspected sepsis
Category | Age | High Risk criteria | Moderate to high risk criteria | Low risk criteria |
Behaviour | Any | No response to social cues Appears ill to a healthcare professional Does not wake, or if roused does not stay awake Weak high-pitched or continuous cry | Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity Parent or carer concern that child is behaving differently from usual | Responds normally to social cues Content or smiles Stays awake or awakens quickly Strong normal cry or not crying |
Respiratory | Any | Grunting Apnoea Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline | Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline Nasal flaring | No high risk or moderate to high risk criteria met |
Under 1 year | Raised respiratory rate: 60 breaths per minute or more | Raised respiratory rate: 50-59 breaths per minute | No high risk or moderate to high risk criteria met | |
1-2 years | Raised respiratory rate: 50 breaths per minute or more | Raised respiratory rate: 40-49 breaths per minute | No high risk or moderate to high risk criteria met | |
3–4 years | Raised respiratory rate: 40 breaths per minute or more | Raised respiratory rate: 35-39 breaths per minute | No high risk or moderate to high risk criteria met | |
Circulation and hydration | Any | Bradycardia: heart rate less than 60 beats per minute | Capillary refill time of 3 seconds or more Reduced urine output For catheterised patients, passed less than 1 ml/kg of urine per hour | No high risk or moderate to high risk criteria met |
Under 1 year | Rapid heart rate: 160 beats per minute or more | Rapid heart rate: 150-159 beats per minute | No high risk or moderate to high risk criteria met | |
1–2 years | Rapid heart rate: 150 beats per minute or more | Rapid heart rate: 140-149 beats per minute | No high risk or moderate to high risk criteria met | |
3-4 years | Rapid heart rate: 140 beats per minute or more | Rapid heart rate: 130-139 beats per minute | No high risk or moderate to high risk criteria met | |
Skin | Any | Mottled or ashen appearance Cyanosis of skin, lips or tongue Non-blanching rash of skin | Pallor of skin, lips or tongue | Normal colour |
Temperature | Any | Less than 36ºC | ||
Under 3 months | 38°C or more | |||
3-6 months | 39°C or more | |||
Other | Any | Leg pain Cold hands or feet | No high risk or moderate to high risk criteria met |
The UK Sepsis Trust have produced a form for evaluation of possible sepsis for use in primary care (2):
Reference:
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