Sepsis (peds): Difference between revisions
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**Consider [[steroids]] if not fluid responsive | **Consider [[steroids]] if not fluid responsive | ||
*Airway | *Airway | ||
**Consider | **Consider [[intubation]], especially in fluid refractory [[pediatric shock|shock]] | ||
**[[ | **Consider use of [[ketamine]] for sedation (less hypotension) | ||
** | **Be prepared for cardiovascular collapse | ||
**Typical [[neuromuscular blocking agents|paralytic agents]] | **Typical [[neuromuscular blocking agents|paralytic agents]] | ||
*Breathing | *Breathing | ||
**[[CPAP]] can buy time for fluid | **[[CPAP]] can buy time for fluid resusitation prior intubation | ||
*Glucose | *Glucose | ||
**Ensure euglycemia | **Ensure euglycemia | ||
Revision as of 16:57, 12 June 2024
This page is for adult patients. For pediatric patients, see: Sepsis.
Background
- Tachycardia is typically most predominant, hypotension is a late and ominous sign
- Neonatal Sepsis
- Early onset
- First few days of life
- Fulminant, associated with maternal or perinatal risk factors
- Septic shock and neutropenia are more common
- Late onset
- Occurs after 1wk of age
- Gradual
- Meningitis more likely
- Consider if feeding disturbance, rash, lethargy, irritability, seizure, apnea, tachypnea, grunting, vomiting, poor PO, gastric distention, diarrhea
- Early onset
Clinical Features
Shock: Warm vs Cold Shock
| Warm Shock | Cold Shock | |
|---|---|---|
| Peripheries | Warm, Flushed | Mottled, Cold, Clammy |
| Cap Refill | <2 sec | >2 sec |
| Pulse | Bounding | Weak, Thready |
| BP | Compensated | Hypotension |
| HR | Tachy | Tachy or Brady |
| Pulse Pressure | Widen | Narrow |
Differential Diagnosis
Sick Neonate
THE MISFITS [1]
- Trauma
- Heart
- Congenital heart disease
- Hypovolemia
- Endocrine
- Metabolic
- Sodium
- Calcium
- Glucose
- Inborn errors of metabolism
- Seizure
- Formula / feeding problems
- Intestinal Disasters
- Toxin
- Sepsis
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Juvenile rheumatoid arthritis
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
Evaluation
Work-Up
- CBC, CMP
- Coags, D-dimer, fibrinogen
- Lactate, CRP
- Blood glucose
- Urinalysis/urine culture
- CXR
- Blood cultures
- Consider LP for CSF
Diagnosis
- Initial screening and decision to send studies is based on provider judgement
- Use the Phoenix Sepsis Score to calculate sepsis criteria, including septic shock.[2][3]
- Not indicated for adults, preterm (<37 weeks), or peri-birth hospitalizations
Management
Initial assessment
- Circulation
- 1 min to attain IV access
- If unable to get IV in 1 min, consider IO access
- 60ml/kg IVF over the first hour
- Consider vasopressors if not fluid responsive
- Consider steroids if not fluid responsive
- Airway
- Consider intubation, especially in fluid refractory shock
- Consider use of ketamine for sedation (less hypotension)
- Be prepared for cardiovascular collapse
- Typical paralytic agents
- Breathing
- CPAP can buy time for fluid resusitation prior intubation
- Glucose
- Ensure euglycemia
Golden Hour Goals of Resuscitation
- Cap refill <2 sec
- Normal BP
- Normal pulses, similar central and peripheral
- Warm extremities
- UOP >1 mL/kg/hr
- Normal mental status
Antibiotics
Neonatal
- Ampicillin 50mg/kg q8h + gentamicin 2.5mg/kg q24h + acyclovir
- If gram-negative strongly suspected replace gentamicin with cefotaxime or ceftazadine
- Have better CNS penetration
- If gram-negative strongly suspected replace gentamicin with cefotaxime or ceftazadine
Peds
Treatment will differ by local protocols
- Extended-spectrum penicillin (e.g. Ppiperacillin-tazobactam]]) ± aminoglycoside ± vancomycin
OR
- 3rd or 4th generation cephalosporin ± aminoglycoside ± vancomycin
OR
Vasopressors
- If vasopressors needed for septic shock, follow recommendations:
- Normotensive shock with impaired perfusion: dopamine
- Warm shock (vasodilated with poor perfusion or low BP): norepinephrine
- Cold shock (vasoconstricted with poor perfusion or low BP): epinephrine
- Consider epinephrine and perhaps norepinephrine over dopamine as a 1st line vasopressor[4]
- Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[5]
- RTC trial in 2015 from Brazil, without other larger RTCs or multi-center trials to corroborate information
Disposition
- Admit
See Also
External Links
References
- ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
- ↑ Schlapbach LJ, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):665-674. doi: 10.1001/jama.2024.0179.
- ↑ Sanchez-Pinto LN, et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):675-686. doi: 10.1001/jama.2024.0196.
- ↑ Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrineas First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302.
- ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.