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Sepsis - in children - Þórólfur Guðnason Sepsis - definitions - • Bacteremia • Septicemia • Sepsis - (SIRS) – systemic response to an infection; localized, in the blood or focus not found • Sepsis syndrome - severe sepsis • Septic shock • MODS Sepsis - definitions Infectious agent Localized In the blood Sepsis Sepsis - definitions - • Sepsis – infection + Two or more of the following: – temperature >38C or <36 C – tachycardia (>2 SD above nl) – tachypnea (>2 SD above nl) – WBC >12.000, <4.000, or >10% band forms Sepsis - definitions Infectious agent Localized In the blood Sepsis Sepsis syndrome / severe sepsis Sepsis - skilgreiningar - • Sepsis syndrome / severe sepsis - sepsis + at least one of the following: - acute CNS changes - hypoxemia - elevated lactate in plasma - oliguria Sepsis - definitions Infectious agent Localized In the blood Sepsis Sepsis syndrome Septic shock Sepsis - definitions - Septic shock sepsis syndrome / severe sepsis + progressive hypotension / hypoperfusion Multiorgan dysfunction syndrome (MODS) DIC, ARDS, renal failure, hepatic failure, CNS dysfunction, myocardial dysfunction Sepsis - definitions Infectious agent Localized In the blood Sepsis Sepsis syndrome Septic shock Death Sepsis - pathophysiology Infectious agents or parts of... Hormones Immune system Cytokines Coagulation system Sepsis/Sepsis syndrome Enzymes Endothelium damage Sepsis - clinical symptoms - • Age <3 months - non-specific, sometimes afebrile, NB fever !!!! - mottled skin, irritability • Age >3 months - fever, tachypnea, tachycardia - poor perfusion - petechial rash - irritability Sepsis - epidemiology - • 700.000 cases per year in USA (all ages) • 20-70% positive blood cultures (all ages). • Mortalitet - sepsis/sepsis syndrome • 35% all ages • children 10% - septic shock/MODS • >90% Sepsis - treatment - • Consider: Age, circumstances, origin of infection 0-1 mo. gram neg. bacteria gr. B streptococci enterococci Listeria staph. aureus Herpes simplex Ampicillin and aminoglycosides or 3rd gen. cephalosporins ?? Acyclovir Sepsis - treatment 1-3 mo. meningococci pneumococci gram neg. bacteria gr. B streptococci enterococci Listeria staph. aureus Ampicillin and 3rd gen. Cephalosporins or Aminoglycosides Sepsis - treatment >3 mo. meningococci pneumococci (gram neg. bacteria) 3rd gen. cephalosporins Children at hospitals staph. aureus, gram neg. bacteria, fungi Immune deficiency gram neg. bacteria, staph. aureus, fungi Foreign bodies staphylococci Sepsis - immunomodulating treatment Infection ACTH / endorphins Parts of microorganism TNF, IL-1, IFN complement activation Increased coagulation Kallikrein - kinin stimulation Activation of endothelial cells and WBC. Secondary mediators IL, PAF o. fl endothelial damage vasodilation SHOCK Death Stimulation of PMN´s endothelial damage capillary leak Sepsis - immunomodulating treatment • Protein C • • • • • • • • • • Tissue factor Polyclonal IgG anti-LPS (anti-lipid A) Steroids anti-TNF anti-IL-1 Nitric oxide Naloxon CD-18 monoclonal Ab pentoxyfyllin Sepsis - treatment - - fluids - vasopressors - oxygen - acid-base - respirator - platelets - plasma - plasma exchange ?? - nutrition How can outcome be improved ? • Outcome not improved for several years ? • Improve diagnosis – clinical – laboratory • Preventive measures – vaccinations
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