23/09/13911

Dr Mostafavi N Departement of Pediatric infectious Disease Isfahan University of Medical Sciences 23/09/13912

Case 1 An 8 month old boy brought to your clinic with complain of high fever, poor intake, and. On examination the child has Ta= 39.5⁰С, RR= 35/min, HR= 130/min, cold extremities, NL blood pressure. Other wise the child is Ok. CBC revealed WBC= 18,000; PMN= 80%, PLT= 225,000. What's your diagnosis? what do you do? 23/09/13913

Case 2 An 8 month old boy brought to your clinic with complain of high fever and lethargy. On examination the child has RR= 65/min, grunting, HR= 180/min, weak pulses, cold extremities, and hypotension( not detectable). What's your diagnosis? what do you do? 23/09/13914

Sepsis characteristics Acute Fulminate course Distributive shock( first tachycardia, tachypnea then hypotension) Bacteremia of focal infection 23/09/13915

Shock= ↓cardiac output Hypovolemic: ↓ preload Distributive: ↓ afterload Cardiogenic: ↓ inotropy, ↓ chronotropy Obstructive: ↑ afterload Septic : ↓ preload, ↓ afterload, ↓ inotropy 23/09/13916

Sepsis = systemic inflammatory response syndrom due to infection Core T> 38.3 or <36 Unexplained tachycardia or in < 1 yr bradycardia Unexplained tachypnea or need to MV WBC> or 10%  At least first or last criteria & at least 2 out of 4 criteria 23/09/13917

Tachycardia 180/min 2-12 mo: 160/min 1-2 yr: 120/min 2-8 yr: 110/min > 8 yr: 100/min  Each ⁰C increase in temperature increase heart rate by 10-12/min 23/09/13918

Tachypnea 60/min 2-12 mo: > 50/min 1-5 yr: > 40/min 6-8 yr: > 30/min > 8 yr: > 20/min  Each ⁰C increase in temperature increase respiratory rate by 4-10/min 23/09/13919

Hypotension( SBP in mmHg) Neonate< mo< yr < age( yr) > 10 yr < 90 23/09/139110

Definitions Sepsis: pre-shock due to infection Severe sepsis: infection+ Reversible shock Organ hypo-perfusion( acidosis, oliguria, ↑ CRT) Organ dysfunction( coma, ARDS, ARF, DIC, cytopenia, coagulopathy, hepatic failure( Septic shock: irreversible shock due to infection 23/09/139111

Case 1 An 8 month old boy brought to your clinic with complain of high fever, poor intake, and. On examination the child has Ta= 39.5⁰С, RR= 35/min, HR= 130/min, cold extremities, NL blood pressure. Other wise the child is Ok. CBC revealed WBC= 18,000; PMN= 80%, PLT= 225,000. What's your diagnosis? what do you do? 23/09/139112

Case 1 DiagnosisPlan Fever without source in 3-36 mo old with WBC> 15,000 B/C and U/C then Intravenous ceftriaxone, F/U 23/09/139113

Case 2 An 8 month old boy brought to your clinic with complain of high fever and lethargy. On examination the child has RR= 65/min, grunting, HR= 180/min, weak pulses, cold extremities, and hypotension( not detectable). What's your diagnosis? what do you do? 23/09/139114

Case 2 DiagnosisPlan Severe sepsis, or septic shock Treatment of sepsis 23/09/139115

Steps in the treatment of sepsis 1. Maintenance of efficient respiratory function 2. Restoration of adequate tissue perfusion 3. Control of the infectious agent 4. Laboratory evaluation 5. Supportive care for organ dysfunction 23/09/139116

1. Efficient respiratory function High flow oxygen ( O2 sat> 92%) Periodic suctioning Ambu ventilation Intubation and MV if impending to respiratory failure 23/09/139117

2. Restoration of adequate tissue perfusion IV or IO access 20 mL/kg N/S up to mL/kg in 1 st hour sometimes as much as 200 mL/kg unless cardiogenic shock Coloid if needed( ↓ alb., ↑ PT & PTT, ↓ Hb) Dopamine after 40cc/kg via peripheral IV lines, with close monitoring Central IV line( fluid up to CVP< 10-15, then dopamine) Epinephrine in cold shock and norepinephrine in warm shock via central IV lines Dobutamine, hydrocortisone, … in special circumstances To normalize HR, U/O, CRT, MS 23/09/139118

Cardiogenic shock Smaller boluses of fluid (5-10 mL/kg) Early initiation of myocardial support with dopamine or epinephrine Administering an inodilator, such as milrinone, early in the process. 23/09/139119

3. Control of the infectious agent Predisposin g factor MicroorganismsBest antibiotics NeonatesGBS, enteric g-s, L. monocytogen Ampicillin+ cefotaxime and/or gentamicin Infants and children N. meningitidis, H.influenza type b, S. pneumonia Cefotaxime+ vancomycin Abdominal source enteric g-s, anaerobes, enterococci Clindamycin+ gentamicin+ ampicillin Urinary source enteric g-sCefotaxime+/- gentamicin Immunodefi ciency enteric g-s, P. aueroginosa, S. aureous, fungi Cefepime/ imipnem+ vancomycin+/- amphotericin Hospital acquired Resistant enteric g-s, P. aueroginosa, S. aureous Cefepime/ imipnem+ vancomycin 23/09/139120

4.Laboratory evaluation CBC diff: ↑ or ↓ WBC, ↓ plt, ↓ Hb ESR> 30, ↑ CRP, ↑ procalcitonin Peripheral smear: howel- jolly bodies, fragmented RBC ↑ PT, ↑ PTT, ↑ D-dimer, ↑ FDP ABG: Res. Alkalosis, Res. Alkalosis +Met. Acidosis, Mixed Acidosis, hypoxemia LFT: ↑ AST, ↑ ALT, ↓ Alb, ↑ Bil 23/09/139121

4. Laboratory evaluation ↑ or ↓ BS, ↓ Ca, ↓ Na, ↑ TG ↑ BUN, ↑ Cr CXR: ARDS Gram stain of buffy coat & petechia/purpura B/C, U/C, CSF/C U/A, CSF analysis 23/09/139122

5. Supportive care for organ dysfunction DisorderGoals ( prevent/treat)Therapies ARDSHypoxia, respiratory acidosis O2O2 Respiratory muscle fatigue BarotrumaEarly intubation and MV Central apneaDecrease work of breathingMV Renal failureHypovo/hypervolemia, hyperkalemia, acidosis, hypo/hypernatremia, hypertension Judicious fluid therapy Low dose dopamine, establish NL U/O and BP Lasix, dialysis Coagulopathy( DIC) BleedingVit.K, FFP, PLT ThrombosisAbnormal clottingHeparin, activated pr C 23/09/139123

Supportive care for organ dysfunction DisorderGoals (prevent/treat) Therapies Stress ulcerGastric bleeding, aspiration, distension H 2 blocker, PPI, Fix NG tube Ileus, bacterial translocation Mucosal athrophyEarly enteral feeding Adrenal insufficiency Adrenal crisisStress dose, physiologic dose Metabolic acidosis Correct etiology, normal PH Treatment of hypovolemia, cardiac dysfunction, renal excretion, bicarbonate if PH< 7.1 and adequate ventilation 23/09/139124

0-5 min High flow O 2 Suctioning, ventilation if needed Establish IV/IO access 23/09/139125

5-15 min Push 20 cc/kg NS and over 60 cc/kg until Perfusion improved( HR, CRT, U/O, MS) Rales Hepatomegaly Check BS and correct hypoglycemia Send lab exams, CXR Start antibiotic ( ceftriaxon, vancomycin) Start dopamine after 2 nd dose( 6BW/100cc DW5%, micro-drop 3-10 drop/min) 23/09/139126

15-40 min Establish CVC, ITT Titrate dopamine after 2 nd dose( 6BW/100cc DW5%, micro-drop 3-10 drop/min) Start and titrate epinephrine ( 0.6BW/100cc DW5%, micro-drop drop/min) for cold shock Start and titrate norepinephrine ( 0.6BW/100cc DW5%, micro-drop drop/min) for warm shock 23/09/139127

40-60 Start hydrocortisone mg/m 2 if catecholamine-resistant shock and at risk of adrenal insufficiency Transfer to PICU 23/09/139128

Conclusion Unexplained ↑ RR and HR as early signs of shock and sepsis Early oxygen and ventilation therapy Aggressive fluid and inotropic therapy Coloid therapy in suspected cases Early antibiotic therapy before sending to PICU Early check of BS 23/09/139129

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