Sepsis (peds): Difference between revisions
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===[[Vasopressors]]===
===[[Vasopressors]]===
*If vasopressors needed for septic shock, follow recommendations:
*Traditional teaching:
**Normotensive shock with impaired perfusion: [[dopamine]]
**Normotensive shock with impaired perfusion: [[dopamine]]
**Warm shock (vasodilated with poor perfusion or low BP): [[norepinephrine]]
**Warm shock (vasodilated with poor perfusion or low BP): [[norepinephrine]]
**Cold shock (vasoconstricted with poor perfusion or low BP): [[epinephrine]]
**Cold shock (vasoconstricted with poor perfusion or low BP): [[epinephrine]]
*Consider epinephrine and perhaps norepinephrine over [[dopamine]] as a 1st line vasopressor<ref>Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus [[Epinephrine]]as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302. </ref>
*Newer evidence argues to consider [[epinephrine]] and perhaps [[norepinephrine]] over [[dopamine]] as a 1st line vasopressor<ref>Ventura AM, Shieh HH, Bousso A, Goes PF, Fernandes IC, de Souza DC, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus [[Epinephrine]]as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015;43:2292-302. </ref>
**Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well<ref>Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.</ref>
**Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well<ref>Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.</ref>
**RTC trial in 2015 from Brazil, without other larger RTCs or multi-center trials to corroborate information


==Disposition==
==Disposition==

Revision as of 17:01, 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 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
  • Breathing
    • CPAP can buy time for fluid resuscitation 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

Peds

Treatment will differ by local protocols

OR

OR

Vasopressors

  • 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[4]
    • Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[5]

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. ↑ 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.
  5. ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.
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