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Paediatric Sepsis
1:15am: 3 year old female arrives at Triage with HR 180, RR 35, looks tired. Has had URTI symptoms for past couple of days.
1:25am: ICU/Paeds Reg called by ED doctor saying can you come and have a look
1:35am:You make your first assessment HR 180
Quiet, tired, opens eyes
Mod respiratory distress
Cap refill 4 seconds
WHAT DO YOU DO?
Why are we worried about it?
Still remains significant cause of morbidity and mortality
5-30% of paediatric patients with sepsis will develop septic shock
Mortality rates in septic shock are 20-30% (up to 50% in some countries)
Recognition
Most people dont recognise shock
Resuscitation must be done in a proactive time-sensitive manner
Every minute counts golden hour
Every hour without appropriate resuscitation and restoration of blood pressure increases mortality risk by 40%
How do we define it
Systemic Inflammatory Response Syndrome
Infection
Sepsis
Severe Sepsis
Septic Shock
Systemic Inflammatory Response Syndrome
Presence of 2 of the following criteria:
Core Temp >38.5 or < 36 degrees
Mean HR > 2SD for age or persistent elevation over 0.5-4hrs
If < 1yr old: bradycardia HR < 10th centile for age
Mean RR > 2 SD above normal for age
Leucocyte abnormality
SEPSIS
SIRS in presence of suspected or proven infection
Severe Sepsis
Sepsis + one of the following CV organ dysfunction
ARDS
2 or more organ dysfunction
Septic Shock
Sepsis + CV organ dysfunction
Cardiovascular dysfunction
Despite >40ml/kg Isotonic fluid bolus in 1 hour: Decrease in BP 5 seconds
Core-peripheral temp gap >3 degrees
Risk factors for Sepsis in Children
< 1 year of age
Very low birthweight infants
Prematurity
Presence of underlying illness eg chronic lung, cardiac conditions, malignancy
Co-morbidities
Boys
Genetic factors
What makes you suspect shock?
Clinical Manifestations
Fever
Increased HR
Increased RR
Altered mental state
Skin: Hypoperfusion
Decreased capillary refill
Petechiae, purpura
Cool vs warm.
Cold Shock Warm Shock
HR Tachycardia Tachycardia
Peripheries Cool Warm
Pulses Difficult to palpate Bounding
Skin Mottled, pale Flushed
Capillary refill Prolonged Blushing
Mental state Altered Altered
Urine Oliguria Oliguria
Blood Pressure in Children
This is main difference with adults.
Blood pressure does not fall in septic shock until very late.
CO= HR x SV
HR in children much higher therefore BP falling is late.
Pulse pressure is often useful
Normal: Diastolic BP > systolic BP.
Investigations
Basic bloods:
CBC, EUC, LFT, CMP, Coags, Glucose
Inflammatory markers: PCT, CRP
Acid- Base status
Venous or arterial blood gas:
Lactate
Base deficit
Investigations
Septic Work up
Urine, blood, sputum cultures
Viral cultures: throat, NPA, faeces,
Never do CSF in shocked patient
Imaging:
CXR, CT, MRI, PET scan, ECHO, Ultrasound
MANAGEMENT
General Principles
Early Recognition
Early and appropriate antimicrobials
Early and aggressive therapy to restore balance between oxygen delivery and demand
Early and goal directed therapy
What is Goal Directed Therapy?
Based on studies in adults initially Use fluid resuscitation, vasoactive infusions,
oxygen to aim to restore balance between oxygen delivery and demand
Goals: Capillary refill < 2 seconds Urine ouptut > 1ml/kg/hr Normal pulses Improved mental state Decreased lactate and base deficits Perfusion pressures appropriate for age
Recognise decreased mental status and perfusionMaintain airway and establish access
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Responsiveness Fluid Refractory shock
O min
5 min
15 min
Observe in PICU
Recognise decreased mental status and perfusionMaintain airway and establish access
Vascular Access: Only few minutes to be spent on obtaining IV access Need to use IO if cant get access May need to put 2 x IO in
Intubation + Ventilation Clinical assessment of work of breathing , hypoventilation or impaired
mental state Up to 40% of cardiac output is used for work of breathing Volume loading and inotrope support is recommended before and during
intubation Recommended: Ketamine, atropine and short acting neuromuscular
blocking agent.
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Resuscitation: Needs to be given as push May need to give up to 200mls/kg Give fluid until perfusion improves.
Which Fluids Isotonic vs collloid Most evidence extrapolated from adults Wills et al
RCT of cystalloid vs colloid in children with dengue fever No difference between the two groups.
Fluid Refractory Shock15min
Begin dopamine or peripheral adrenaline
Establish central venous access
Establish arterial access
Titrate Adrenaline for cold shock and noradrenaline for
warm shock to normal MAP-CVP and SVC sats>70%
Catecholamine resistant shock 60 min
Catecholamine Resistant Shock
At Risk of adrenal insufficency give hydrocortisone
Not at Risk - dont give hydrocortisone
Normal Blood Pressure
Cold Shock
SVC < 70%
Low Blood Pressure
Cold Shock
SVC < 70%
Low Blood
Pressure
Warm Shock
Add vasodilator or
Type III PDE inhibitor
Titrate volume and
adrenalineTitrate volume &
Noradrenaline
Consider
Vasopressin
ECMO
Drug Dose Comments
Dopamine 2-20mcg/kg/min Historically 1st choice in kids
Alpha, beta and dopamine receptor
activation
Can be given peripherally
Dobutamine 5-10mcg/kg/min Chronotropic as well as inotropic
Afterload reduction
Adrenaline 0.05- 1mcg/kg/min Initially increases contractility/heart
rate
High doses increase PVR
Noradrenaline 0.05 1 mcg/kg/min
Vasopressor
Increases PVR
Milrinone 0.25-
0.75mcg/kg/min
Phosphodiesterase inhibitor
Afterload reduction
Rivers et al, NEJM 2001 Single Centre , RCT in Emergency Department Goal directed vs standard care in septic adults in
first 6 hours in ED Goal directed therapy consisted of
CVP 8-12mmHg MAP > 65mmHg Urine output >0.5ml/kg/hour ScVO2 > 70%
Showed significant decrease in mortality Cristisms: control group had higher mortality rate
and benefits may be because group was monitored more closely
Ceneviva et al, Pediatrics 1998
Single centre, 50 children
Used goal directed therapy : CI 3.3-6Lmin/m2 in children with fluid refractory shock
Mortality from sepsis decreased by 18% when compared to 1985 study
De Oliveira ICM 2008
RCT , single centre
Use of 2002 guidelines with continous central venous O2 saturation monitoring and therapy directed to maintain ScVO2 > 70%
Mortality decreased from 39% to 12 %,
Number needed to treat 3.6
Brierley and Carcillo CCM 2009
Update of 2002 guidelines for goal directed therapy
Look at all studies who had adopted 2002 guidelines and their success.
Reported studies that showed decrease in mortality with adoption of 2002 guidelines.
New changes : Inotrope via peripheral access
Fluid removal considered early
What about Hydrocortisone?
Controversial
Rational is that there is hypothalamic-pituitary adrenal axis dyfunction in patients with septic shock
Current recommendations: If child is at risk of adrenal insufficency and remains in
shock should receive hydrocortisone
At risk defined as purpura fulminans, congenital adrenal hyperplasia, recent steroid exposure, hypothalamic/pituitary abnormality
Evidence Controversial
Annane D JAMA 2002 Multicentre , RCT looked at use of hydrocortisone and
fludrocortisone in septic shock.
Corticus Trial, NEJM 2008 Mutlicentre, RCT
Hydrocortisone vs placebo in septic shock
No significant difference in mortality
Many criticisms Inadequate power
Selection bias
Evidence- paediatrics
No RCT in paediatric patients with sepsis
Markovitz : PCCM 2005
Retrospective cohort study , 6000 paediatric patients
Systemic steriods associated with increased mortality
But no control in place for severity of illness or for dose.
Other treatment
Maintain Glucose control
Nutrition
Maintain Hb > 10g/dL
GI protection
Early CVVH
Activated Protein C
Inhibits factors Va and VIIIa prevent generation of thrombin
Decreased inflammation through inhibition of platelet activation, neutrophil recruitment
Initially had popularity as possible treatment option in septic shock
Concern with it is risk of serious haemorrhage
RESOLVE Study, Lancet 2007
RCT, multicentre, international study in 477 children with severe sepsis.
Compared APC to placebo for 96 hrs
Primary end point: time to complete organ failure resolution
Study stopped early as interim analysis showed no benefit
More bleeding in APC group but not significantly different
ECMO
Study published this month from RCH Melbourne
Looked at ECMO use in paediatric septic shock
96% had at least 3 organ failure and 35% had a cardiac arrest prior to ECMO
23 patients with refractory septic shock received central ECMO
17 (74%) patients survived to be discharged from hospital.