Pediatric Sepsis Dr. Indumathy Santhanam MD,DCH Professor and Head, Paediatric Emergency Department Institute of Child Health & Hospital for Children, Madras Medical College-India

Definition of sepsis Life threatening organ dysfunction Dysregulated host response Infection

Sepsis-induced organ dysfunction may be occult Its presence should be considered in any patient presenting with infection Unrecognized infection may be the cause of new-onset organ dysfunction. ? Possibility of underlying infection

Criteria to recognise sepsis “Organ dysfunction: Increase “Sequential [Sepsis-related] Organ Failure Assessment” (SOFA) score of 2 points or more Associated with a mortality of 10%! M. Singer, C.S. Deutschman, C. W. Seymour, Third International Consensus Definition for Sepsis and septic shock JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

Sepsis Organ Failure Assessment

Poor outcome more likely if qSOFA was 2: Respiratory rate of 22/min or greater, Altered mentation Systolic BP: 100 mm Hg or less M. Singer, C.S. Deutschman, C. W. Seymour, Third International Consensus Definition for Sepsis and septic shock JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

Septic shock Vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater Serum lactate level > 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. Associated with a mortality of 40% M. Singer, C.S. Deutschman, C. W. Seymour, Third International Consensus Definition for Sepsis and septic shock JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

How do we recognize sepsis in busy OPDs where fever is the commonest cause for hospital visits?

Is it infection or sepsis? Sepsis: Dysregulated host response + organ dysfunction

Applicability Lab investigations in OPDs for suspected sepsis: Blood collection not easy in sick kids Often unavailable in OPD settings Take time Cost

How we recognize sepsis in our setting… Triage questions for all children who present with fever/foci Busy OPDs! 1) History of incessant cry, lethargy, more sleepy than usual, ‘not as usual’. If yes, anticipate shock 2) History of breathlessness? (not episodic or since birth) If yes, anticipate pulmonary oedema due to ALI or cardiac dysfunction. Pediatric Emergency Medicine Course-2013

Clinical criteria to recognize sepsis Modified Rapid cardio-pulmonary cerebral assessment and modified PAT Pediatric Emergency Medicine Course-2013

Concurrently resuscitate using the same tool Pediatric Emergency Medicine Course-2013

Management of septic shock based on a prospective randomized controlled trial since 2004!

Mortality due to septic shock 2005 and 2014 Septic shock: Mortality :55.9% 2005 vs 5.2% in 2014: OR 23.13 ( 95 CI 15.74-33.99: P<0.000 ) Data from MRD,ICH&HC, Chennai

Ideal clinical criteria Triage questions Modified rapid cardiopulmonary cerebral assessment Modified PAT aid in early recognition Concurrent management Identify all the elements of sepsis (infection, host response, and organ dysfunction) Simple to obtain Prompt availability Reasonable cost or burden.

Summary The criteria for recognizing sepsis in our centre needs validation