One subtle change helped this nurse recognize sepsis. Here's how a SickKids team responded quickly
Summary:
A subtle change in two-year-old Vincent’s behaviour helped his nurse recognize that something wasn’t right. Learn how close observation, partnership with his family and early escalation helped his care team respond quickly to sepsis.
The first thing you notice about Vincent is his feet.
The smiling two-year-old is what his mother, Stefanie Nigro, and grandmother, Rosa Nigro, describe as “feet first.” When he gets excited, he stretches out his legs and throws his bare feet high above his head, inviting his care team to play with his tiny toes. It’s a small quirk that brings laughter and joy to anyone in a room with him.
“His legs and feet are everywhere,” they say. “It’s like his handshake.”
It also says something about the relationships that have grown here over a year of treatment for Vincent’s leukemia. His care team knows him well, particularly those little routines that make him smile, behaviours that signal he's feeling better or subtle changes that tell them he isn’t feeling himself.
Those small details would become critically important when Vincent developed sepsis.
Vincent, who also has Down Syndrome, had recently received delayed intensification chemotherapy in May and was in the vulnerable period when his immune system was recovering. After two days with a fever due to a possible central line infection, he seemed to be turning a corner.
His heart rate and breathing were normal. He had been irritable for the last few days but was now able to be consoled and was watching his iPad again, all small signs that suggested he was beginning to feel more like himself.
These were the things Nate Kulasinghe, Registered Nurse (RN) on 8A, was monitoring in Vincent the past three consecutive nights while on shift that week. On paper, and for many clinicians, it would seem like Vincent was improving.
But sepsis rarely follows a script.
Sepsis occurs when the body has an extreme response to infection, leading to life-threatening organ dysfunction. Recognizing it can be difficult in any patient. In toddlers and young children who cannot yet describe how they feel, or in children who communicate differently, subtle changes may be the earliest clue that something is wrong. And that’s exactly what Nate picked up on.
After completing their assessment that day, Nate noticed Vincent's feet and hands felt slightly cooler than they had the previous two nights. Through conversations with Vincent's family, Nate already knew cold feet were normal for him. But cold hands were not.
Taken together with Vincent's recent fever on Friday, and previously positive blood culture result on Saturday, it was enough for Nate to look more closely, having decided to check Vincent’s capillary refill again.
“Because I’d had him the last two nights, I knew how quickly his capillary refill should be. It was only a little bit slower than I remembered it being, so while I wasn’t concerned, I thought, ‘there could be something happening here.’"
Nate decided to reassess Vincent’s blood pressure every 15 to 20 minutes instead of keeping to the routine order for four-hour vital signs check.
Nate also brought Stefanie and Rosa into that closer monitoring, asking them to share if Vincent became difficult to wake. The two explained that Vincent was sleeping more, and eating less.
Rather than dismissing the subtle changes, Kulasinghe shared these observations with the overnight physician and charge nurse so everyone had a common understanding of the situation, even while Vincent appeared stable. By bringing others into the assessment early, the team was ready to respond as the clinical picture evolved.
“Nate and other staff members were bouncing ideas off each other. They were very transparent in what was taking place. I felt comfortable knowing they were in control,” says Rosa.
About an hour later, Vincent’s blood pressure dropped significantly.
Because Kulasinghe caught this change early, the team was able to quickly escalate care, bringing the resident, fellow and Critical Care Response Team (CCRT) to the bedside before transferring Vincent to the Paediatric Intensive Care Unit (PICU). There, Vincent received the advanced support he needed.
If the team hadn't acted so fast, the consequences could’ve been life-threatening, because sepsis can lead to multi-organ failure and death if not recognized early and treated promptly.
As Vincent’s care intensified in the PICU, Kulasinghe stayed with the family and helped them understand what was happening.
“Thank you is not even enough,” Stefanie says, her voice cracking with emotion.
"Nate wasn’t just there for us. Nate was there with us. They knew we were scared, and they stayed.”
Vincent returned to the oncology unit about 36 hours later, after his blood pressure stabilized and his condition improved.
"Nate’s recognition of illness and escalation of care likely saved this child's life," says Dr. Deborah Schonfeld, Medical Lead for the Sepsis Program, working alongside Kathleen Andres, NP, Clinical Lead, and Tiffany Yam, RN, Program Lead and Clinical Nurse Specialist.
Cases like this illustrate why early recognition of sepsis relies on more than identifying classic signs. Getting to understand a child's baseline, bringing the family into monitoring, and escalating concerns early can make all the difference.
“Nate didn't doubt their intuition. And they were right,” says Stefanie. “They would rather be proven wrong than not do anything.”
When reflecting on the experience, Kulasinghe says the case reinforced how differently sepsis can present in one patient compared to another.
"Usually when kids are going septic, we expect they will have a high heart rate, a high breathing rate and a fever. If I hadn't had a suspicion that something could be going on, the next set of vitals would have been four hours away after Vincent’s blood pressure dropped,” says Kulasinghe.
A system designed to support early intervention
While septic shock is less common in children than in adults, it remains an exceptionally high-stakes condition.
“We see about four to five documented cases of septic shock monthly at SickKids, which could be an underestimate,” says Kathleen Andres, NP, Clinical Lead for the Sepsis Program.
Because paediatric clinicians encounter it less often than many other conditions, teams can be less familiar or less prepared to recognize and respond when it does occur.
“Even after years of work focused on sepsis, I’m still humbled by how quickly it can evolve and how unexpectedly it can present. That’s exactly why we need systems that help us recognize concern early and act fast,” says Andres.
Sepsis in paediatric patients can be especially challenging to recognize. Yet, it remains a significant cause of morbidity and mortality in children.
To support earlier recognition and faster intervention, the Sepsis Program team has launched a new clinical pathway to support sepsis recognition and management, which replaces the former pathway last implemented in 2017.
The refreshed resources align with the 2026 International Pediatric Sepsis Guidelines, reflect new operational definitions of sepsis and aim to support more consistent recognition, escalation and management across the organization.
The new sepsis pathway shows that early intervention isn’t about confirming whether a child has sepsis. It's about recognizing when something doesn't fit, and acting before deterioration occurs.
“We want all patients, caregivers and staff to feel supported to escalate any concern. Not every child who gets on the pathway will have sepsis, but the important thing is they will get the early intervention they need,” says Erin Vandeven, Associate Chief of Nursing Practice.