1. Pediatric Sepsis Dr. S. Veroukis Pediatric Critical Care
Winnipeg Children’s Hospital
Winnipeg, MB CANADA

2. Objective
Review of the 2007 Clinical Practice Guidelines on Pediatric and Neonatal Septic Shock

3. Guidelines
Aim to standardize care of the septic patient to decrease mortality
Expected mortality if guidelines adhered to are expected to be very low:
0-5% for previously healthy children
10% for children with chronic illness

4. Recognizing Sepsis
Clinical triad: fever, tachycardia, vasodilation plus change in level of consciousness and urine output is the most common presentation of sepsis
Our hospital has a screening tool
Used for the febrile patient who also has changes in vital signs or level of consciousness

5. SIRS SIRS = Systemic Inflammatory Response Syndrome
2 out of the 4 must be met, and 1 out of the two must be either a) or b)
a) core temperature >38.5 degC or <36degC
b) leukocyte count elevated or depressed or > 10% immature neutrophils
c) tachycardia, or bradycardia (<1yr old)
d) tachypnea or need for mechanical ventilation

6. Sepsis Definition
Sepsis is defined as a condition meeting the SIRS definition in the presence of suspected or proven infection.
Septic shock is Sepsis with cardiovascular dysfunction (hypotension, poor perfusion, elevated lactate)

7. Recommendations for Pediatric Septic Shock

9. Clinical Diagnosis Suspected or proven infection
Hypothermia or hyperthermia
Signs of inadequate tissue perfusion:
Decreased mental status
Prolonged capillary refill >2sec, diminished pulses, narrow pulse pressure (cold shock)
Brisk capillary refill, bounding pulses, wide pulse pressure (warm shock)
Decreased urine output <1ml/kg/hr

10. The First Hour of Resuscitation (Emergency Room)
Push 20cc/kg of Crystalloid or Colloid up to 60cc/kg IV or Intraosseous
Start antibiotics (eg. Vancomycin, Cefotaxime)
Correct hypoglycemia and hypocalcemia
Need to give fluids until capillary refill and peripheral pulses are normalized or until hepatomegaly and/or rales develop

11. Airway and Ventilation
During the first hour, the work of breathing may increase, oxygen saturation may decrease
May need to intubate
40% of cardiac output is used for work of breathing
Recommended medications: atropine and ketamine( mg/kg IV or IO)

12. Fluid Refractory Septic Shock
Dopamine IV or IO
May need to start second inotrope
Cold shock: (low CO, high SVR) choose epinephrine IV or IO
If warm shock (high CO, low SVR) choose norepinephrine
Need to establish central venous access soon in order to run inotropes at central concentrations

13. Cold Shock Characterized by Tachycardia Cold extremities
Weak pulses, prolonged capillary refill
Elevated blood pressure with narrow pulse pressure
Usually Cardiac Output is low but Systemic Vascular Resistance (SVR) is high

14. Warm Shock Characterized by Tachycardia
Low BP especially diastolic blood pressure
Warm extremities, brisk capillary refill
Bounding pulses
Wide pulse pressure (from low Diastolic BP)
Usually a state of high Cardiac Output but low SVR

15. Further Therapy Maintenance fluids should be started :
D10WNS solution to run at maintenance
Ng if intubated
Foley to accurately measure urine output
Frequent vitals (hourly)
Treat temperature
If intubated needs sedation: most frequent fentanyl and midazolam infusions

16. Fluid and Catecholamine Resistant Shock
When fluid boluses and inotropes have not corrected poor perfusion, decreased LOC and urine output
Consider hydrocortisone therapy especially for those patients at risk:
Adrenal or pituitary insufficiency
Purpura fulminans
History of steroid treatment
Dosing: 2-50mg/kg/day (if possible take random cortisol level first) (should be >496nmol/L or >18mcg/dL)

17. Intensive Care
Patient can be transferred to Intensive Care at any point
Central venous access to be established
Obtain central venous oxygen saturation (ScvO2)
Surrogate for cardiac output and tissue oxygenation

18. Central Venous Saturation
If ScvO2 <70% then cardiac output is not sufficient to keep up with the body’s demands
Need to improve oxygen delivery by:
improving fluid status (fluid boluses)
Increasing oxygen carrying capacity (packed RBC transfusion)
Improving cardiac contractility (inotropes/vasopressors)
Improving cardiac output by afterload reduction (milrinone, dobutamine, nitroprusside)

19. Cold Shock with Normal Blood Pressure
Titrate fluid and epinephrine to have ScvO2 >70%
Maintain Hb>100g/L
If ScvO2 <70%, add an afterload reducer like milrinone, nitroprusside, nitroglycerin

20. Cold Shock with Low BP
Titrate fluid and epinephrine, to meet ScvO2 >70%
Maintain Hb >100g/L
If still hypotensive consider norepinephrine
If ScvO2 <70% despite fluids, blood transfusion and increased epinephrine infusion, then consider afterload reduction (milrinone, dobutamine)

21. Warm Shock with Low Blood Pressure
Titrate fluid and norephinephrine to ScvO2>70%
If still hypotensive, consider vasopressin or low dose epinephrine

22. Persistant Catecholamine Resistant Shock
Rule out pericardial effusion, pneumothorax, congenital cardiac lesion (duct dependent lesion) in a neonate
Consider thyroid replacement, IVIG
More fluids, packed RBC, FFP, addition of other inotropes, pressors, or afterload reduction
If not reversed by any of these measures, consider ECMO (extracorporeal membrane oxygenation)

23. Fluid Removal
Patients will get lots of fluid, even up to 200cc/kg in 24hr period
Capillary leak from SIRS  edematous skin, pulmonary edema, ascites and risk of abdominal compartment syndrome
If kidneys can not produce enough urine, and patient is 10% fluid overloaded, may use diuretics, peritoneal dialysis, CRRT to remove fluid

24. Outcomes
Early initiated, goal directed therapy has made great improvement in pediatric sepsis survival
Oliveira et al showed that by following the recommendations, mortality in pediatric sepsis was reduced from 39% to 12%

25. Summary Recognizing Sepsis early is important in decreasing mortality
Consider sepsis in the patient with fever, tachycardia, and altered mental status
Fluid boluses to begin within 5 minutes of suspecting sepsis
Bolus 20cc/kg up to 60cc/kg in 15-20mins
Start antibiotics as soon as possible

26. Summary Start peripheral or central dopamine if fluid refractory shock
IV or IO; establish central venous access if possible
Titrate fluids, norepinephrine, epinephrine, packed red blood cells to ensure
Tachycardia, capillary refill, pulses and BP normalize
Lactate within normal, ScvO2>70%
Urine output >1mg/kg/hr

27. Summary For persistent severe septic shock consider the following:
Hydrocortisone
Thyroid replacement
ECMO
IVIG

28. Thank-you!