Download Pediatric Sepsis

Pediatric Sepsis
Dr. S. Veroukis
Pediatric Critical Care
Winnipeg Children’s Hospital
Winnipeg, MB CANADA
Objective
• Review of the 2007 Clinical Practice
Guidelines on Pediatric and Neonatal
Septic Shock
Guidelines
• Aim to standardize care of the septic
patient to decrease mortality
• Expected mortality if guidelines adhered to
are expected to be very low:
– 0-5% for previously healthy children
– 10% for children with chronic illness
Recognizing Sepsis
• Clinical triad: fever, tachycardia,
vasodilation plus change in level of
consciousness and urine output is the
most common presentation of sepsis
• Our hospital has a screening tool
• Used for the febrile patient who also has
changes in vital signs or level of
consciousness
SIRS
• SIRS = Systemic Inflammatory Response
Syndrome
• 2 out of the 4 must be met, and 1 out of
the two must be either a) or b)
– a) core temperature >38.5 degC or <36degC
– b) leukocyte count elevated or depressed or >
10% immature neutrophils
– c) tachycardia, or bradycardia (<1yr old)
– d) tachypnea or need for mechanical
ventilation
Sepsis Definition
• Sepsis is defined as a condition meeting
the SIRS definition in the presence of
suspected or proven infection.
• Septic shock is Sepsis with cardiovascular
dysfunction (hypotension, poor perfusion,
elevated lactate)
Recommendations for Pediatric
Septic Shock
Clinical Diagnosis
• Suspected or proven infection
• Hypothermia or hyperthermia
• Signs of inadequate tissue perfusion:
– Decreased mental status
– Prolonged capillary refill >2sec, diminished pulses,
narrow pulse pressure (cold shock)
– Brisk capillary refill, bounding pulses, wide pulse
pressure (warm shock)
– Decreased urine output <1ml/kg/hr
The First Hour of Resuscitation
(Emergency Room)
• Push 20cc/kg of Crystalloid or Colloid up
to 60cc/kg IV or Intraosseous
• Start antibiotics (eg. Vancomycin,
Cefotaxime)
• Correct hypoglycemia and hypocalcemia
• Need to give fluids until capillary refill and
peripheral pulses are normalized or until
hepatomegaly and/or rales develop
Airway and Ventilation
• During the first hour, the work of
breathing may increase, oxygen saturation
may decrease
• May need to intubate
• 40% of cardiac output is used for work of
breathing
• Recommended medications: atropine and
ketamine(0.5-1.5mg/kg IV or IO)
Fluid Refractory Septic Shock
• Dopamine IV or IO
• May need to start second inotrope
– Cold shock: (low CO, high SVR) choose epinephrine
IV or IO
– If warm shock (high CO, low SVR) choose
norepinephrine
• Need to establish central venous access soon in
order to run inotropes at central concentrations
Cold Shock
• Characterized by
– Tachycardia
– Cold extremities
– Weak pulses, prolonged capillary refill
– Elevated blood pressure with narrow pulse
pressure
– Usually Cardiac Output is low but Systemic
Vascular Resistance (SVR) is high
Warm Shock
• Characterized by
– Tachycardia
– Low BP especially diastolic blood pressure
– Warm extremities, brisk capillary refill
– Bounding pulses
– Wide pulse pressure (from low Diastolic BP)
– Usually a state of high Cardiac Output but
low SVR
Further Therapy
• Maintenance fluids should be started :
– D10WNS solution to run at maintenance
– Ng if intubated
– Foley to accurately measure urine output
– Frequent vitals (hourly)
– Treat temperature
– If intubated needs sedation: most frequent
fentanyl and midazolam infusions
Fluid and Catecholamine Resistant
Shock
• When fluid boluses and inotropes have not
•
corrected poor perfusion, decreased LOC and
urine output
Consider hydrocortisone therapy especially for
those patients at risk:
–
–
–
–
Adrenal or pituitary insufficiency
Purpura fulminans
History of steroid treatment
Dosing: 2-50mg/kg/day (if possible take
random cortisol level first) (should be
>496nmol/L or >18mcg/dL)
Intensive Care
• Patient can be transferred to Intensive
Care at any point
• Central venous access to be established
• Obtain central venous oxygen saturation
(ScvO2)
• Surrogate for cardiac output and tissue
oxygenation
Central Venous Saturation
• If ScvO2 <70% then cardiac output is not
•
sufficient to keep up with the body’s demands
Need to improve oxygen delivery by:
– improving fluid status (fluid boluses)
– Increasing oxygen carrying capacity (packed
RBC transfusion)
– Improving cardiac contractility
(inotropes/vasopressors)
– Improving cardiac output by afterload
reduction (milrinone, dobutamine,
nitroprusside)
Cold Shock with Normal Blood
Pressure
• Titrate fluid and epinephrine to have
ScvO2 >70%
• Maintain Hb>100g/L
• If ScvO2 <70%, add an afterload reducer
like milrinone, nitroprusside, nitroglycerin
Cold Shock with Low BP
• Titrate fluid and epinephrine, to meet ScvO2
•
•
•
>70%
Maintain Hb >100g/L
If still hypotensive consider norepinephrine
If ScvO2 <70% despite fluids, blood transfusion
and increased epinephrine infusion, then
consider afterload reduction (milrinone,
dobutamine)
Warm Shock with Low Blood
Pressure
• Titrate fluid and norephinephrine to
ScvO2>70%
• If still hypotensive, consider vasopressin
or low dose epinephrine
Persistant Catecholamine Resistant
Shock
• Rule out pericardial effusion,
pneumothorax, congenital cardiac lesion
(duct dependent lesion) in a neonate
• Consider thyroid replacement, IVIG
• More fluids, packed RBC, FFP, addition of
other inotropes, pressors, or afterload
reduction
• If not reversed by any of these measures,
consider ECMO (extracorporeal membrane
oxygenation)
Fluid Removal
• Patients will get lots of fluid, even up to
•
•
200cc/kg in 24hr period
Capillary leak from SIRS  edematous skin,
pulmonary edema, ascites and risk of abdominal
compartment syndrome
If kidneys can not produce enough urine, and
patient is 10% fluid overloaded, may use
diuretics, peritoneal dialysis, CRRT to remove
fluid
Outcomes
• Early initiated, goal directed therapy has
made great improvement in pediatric
sepsis survival
• Oliveira et al showed that by following the
recommendations, mortality in pediatric
sepsis was reduced from 39% to 12%
Summary
• Recognizing Sepsis early is important in
decreasing mortality
– Consider sepsis in the patient with fever,
tachycardia, and altered mental status
• Fluid boluses to begin within 5 minutes of
suspecting sepsis
– Bolus 20cc/kg up to 60cc/kg in 15-20mins
– Start antibiotics as soon as possible
Summary
• Start peripheral or central dopamine if
fluid refractory shock
– IV or IO; establish central venous access if
possible
• Titrate fluids, norepinephrine, epinephrine,
packed red blood cells to ensure
– Tachycardia, capillary refill, pulses and BP
normalize
– Lactate within normal, ScvO2>70%
– Urine output >1mg/kg/hr
Summary
• For persistent severe septic shock consider
the following:
– Hydrocortisone
– Thyroid replacement
– ECMO
– IVIG
Thank-you!