Sepsis (peds): Difference between revisions
Line 94: Line 94:


===[[Vasopressors]]===
===[[Vasopressors]]===
*For children that have:
**Myocardial dysfunction
**Shock in the setting of fluid overload
**Continue to have abnormal perfusion after 40 to 60 mL/kg of fluid resuscitation
*[[Epinephrine]] and [[norepinephrine]] (i.e., ''not'' dopamine) are the preferred as the initial catecholaminergic agents
*Traditional teaching:
*Traditional teaching:
**Normotensive shock with impaired perfusion: [[dopamine]]
**Normotensive shock with impaired perfusion: [[dopamine]]

Revision as of 20:16, 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

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]

Pediatric fever

Evaluation

Work-Up

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 Resuscitation Focus

  1. Treat hypoxemia with supplemental oxygen (goal SpO2 92-98%)[4]
  2. Obtain intravenous/intraosseous access
    • Rapidly transition to IO access, if difficulties with starting IV
  3. Collect diagnostic tests (including blood culture, lactate, ionized calcium; see workup above)
  4. Early empiric broad-spectrum antibiotics (see below)
  5. Administer bolus intravenous fluid therapy administration (see below), if shock is present
  6. Start vasoactive agents, if shock persists
  7. Airway
    • Consider CPAP (may buy time for fluid resuscitation prior intubation)
    • Consider intubation, especially in fluid refractory shock
      • Consider use of ketamine for sedation (less hypotension)
      • Be prepared for cardiovascular collapse
  8. Consider corticosteroids and other metabolic resuscitation options[5]
  9. Continue to reassess (see below)

Empiric Broad-Spectrum Antibiotics

If in shock, administer as soon as possible. If not, it is reasonable to perform expedited diagnostics before administration.[6]

Neonatal

Peds

Treatment will differ by local protocols

OR

OR

Fluid Resuscitation

  • For shock, 20 mL/kg boluses of isotonic crystalloid fluid titrated to clinical markers of cardiac output[7]
    • Frequently ≥40 mL/kg in the first hour of resuscitation
  • In low-resource settings (e.g., low income countries), fluid bolus therapy should be avoided unless the child exhibits hypotension[8]

Vasopressors

  • For children that have:
    • Myocardial dysfunction
    • Shock in the setting of fluid overload
    • Continue to have abnormal perfusion after 40 to 60 mL/kg of fluid resuscitation
  • Epinephrine and norepinephrine (i.e., not dopamine) are the preferred as the initial catecholaminergic agents


  • Traditional teaching:
    • 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
  • Newer evidence argues to consider epinephrine and perhaps norepinephrine over dopamine as a 1st line vasopressor[9]
    • Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[10]

Reevaluation

  • Patients should be continuously reassessed for signs of:
    • Ongoing or worsening shock
    • Iatrogenic fluid overload (e.g., pulmonary rales, hepatomegaly, peripheral edema, and echocardiographic findings that may suggest fluid overload)
  • Golden Hour Goals
    • Cap refill <2 sec
    • Normal BP
    • Normal pulses, similar central and peripheral
    • Warm extremities
    • UOP >1 mL/kg/hr
    • Normal mental status

Disposition

  • Admit

See Also

External Links

References

  1. ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  5. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  6. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  7. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  8. ↑ Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967
  9. ↑ 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.
  10. ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.
Retrieved from "https://www.wikem.org/w/index.php?title=Sepsis_(peds)&oldid=373857"