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 In the bloodLocalized Sepsis

–infection + Two or more of the following: –temperature >38  C or <36  C –tachycardia (>2 SD above nl) –tachypnea (>2 SD above nl) –WBC >12.000, 10% band forms Sepsis - definitions -

Infectious agent In the bloodLocalized Sepsis Sepsis syndrome / severe sepsis

- sepsis + at least one of the following: - acute CNS changes - hypoxemia - elevated lactate in plasma - oliguria Sepsis - skilgreiningar -

Sepsis - definitions - Infectious agent In the bloodLocalized Sepsis Sepsis syndrome Septic shock

sepsis syndrome / severe sepsis + progressive hypotension / hypoperfusion Sepsis - definitions -  Multiorgan dysfunction syndrome (MODS) DIC, ARDS, renal failure, hepatic failure, CNS dysfunction, myocardial dysfunction

Sepsis - definitions - Infectious agent In the bloodLocalized Sepsis Sepsis syndrome Septic shock Death

Sepsis - pathophysiology - Infectious agents or parts of... HormonesCytokinesEnzymes Immune systemCoagulation systemEndothelium damage Sepsis/Sepsis syndrome

Age <3 months - non-specific, sometimes afebrile, NB fever !!!! - mottled skin, irritability Sepsis - clinical symptoms - Age >3 months - fever, tachypnea, tachycardia - poor perfusion - petechial rash - irritability

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 - epidemiology -

0-1 mo. gram neg. bacteria gr. B streptococci enterococci Listeria staph. aureus Herpes simplex Sepsis - treatment - Consider: Age, circumstances, origin of infection Ampicillin and aminoglycosides or 3rd gen. cephalosporins ?? Acyclovir

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 Sepsis - treatment - Children at hospitals staph. aureus, gram neg. bacteria, fungi Immune deficiency gram neg. bacteria, staph. aureus, fungi Foreign bodies staphylococci

Sepsis - immunomodulating treatment - Infection Parts of microorganism TNF, IL-1, IFN Activation of endothelial cells and WBC. Secondary mediators IL, PAF o. fl ACTH / endorphins Increased coagulation Kallikrein - kinin stimulation endothelial damage vasodilation complement activation Stimulation of PMN´s endothelial damage capillary leak SHOCK Death

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 - immunomodulating treatment -

- fluids - vasopressors - oxygen - acid-base - respirator - platelets - plasma - plasma exchange ?? - nutrition Sepsis - treatment -

How can outcome be improved ? Outcome not improved for several years ? Improve diagnosis –clinical –laboratory Preventive measures –vaccinations