Sepsis (peds): Difference between revisions
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==Management==
==Management==
===Initial assessment===
===Initial Resuscitation Focus===
*Circulation
#Treat hypoxemia with supplemental [[oxygen]] (goal SpO2 92-98%)<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
**1 min to attain IV access
#Obtain intravenous/[[intraosseous access]]
**If unable to get IV in 1 min, consider [[IO access]]
#*Rapidly transition to [[IO access]], if difficulties with starting IV
**60ml/kg IVF over the first hour
#Collect diagnostic tests (including [[blood culture]], [[lactate]], ionized calcium; see workup above)
**Consider [[vasopressors]] if not fluid responsive
#*Treat [[hypoglycemia]], if present
**Consider [[steroids]] if not fluid responsive
#Early empiric broad-spectrum [[antibiotics]] (see below)
*Airway
#Administer fluid bolus(es) (see below), if shock is present
**Consider [[intubation]], especially in fluid refractory [[pediatric shock|shock]]
#Start vasoactive agents, if shock persists
**Consider use of [[ketamine]] for sedation (less hypotension)
#Airway
**Be prepared for cardiovascular collapse
#*Consider [[CPAP]] (may buy time for fluid resuscitation prior intubation)
**Typical [[neuromuscular blocking agents|paralytic agents]]
#*Consider [[intubation]], especially in fluid refractory [[pediatric shock|shock]]
*Breathing
#**Consider use of [[ketamine]] for sedation (less hypotension)
**[[CPAP]] can buy time for fluid resuscitation prior intubation
#**Be prepared for cardiovascular collapse
*Glucose
#Consider corticosteroids and other metabolic resuscitation options<ref>Weiss SL, Fitzgerald  JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics (2024) 153 (1): e2023062967. https://doi.org/10.1542/peds.2023-062967</ref>
**Ensure euglycemia
#Constinue to reassess (see below)
 
===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===
===Antibiotics===
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====Peds====
====Peds====
''Treatment will differ by local protocols''
''Treatment will differ by local protocols''
*Extended-spectrum penicillin (e.g. Ppiperacillin-tazobactam]]) ± [[aminoglycoside]] ± [[vancomycin]]  
*Extended-spectrum penicillin (e.g. Piperacillin-tazobactam]]) ± [[aminoglycoside]] ± [[vancomycin]]  
'''OR'''
'''OR'''
*3rd or 4th generation [[cephalosporin]] ± [[aminoglycoside]] ± [[vancomycin]]  
*3rd or 4th generation [[cephalosporin]] ± [[aminoglycoside]] ± [[vancomycin]]  
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*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>
*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>
===Golden Hour Goals of Resuscitation===
  and reversal of hypoglycemia and ionized hypocalcemia are also important. Patients should be continuously reassessed for signs of ongoing shock, evolving fluid status (including pulmonary rales, hepatomegaly, peripheral edema, and echocardiographic findings that may suggest fluid overload), and response to each intervention while arranging for transfer to an appropriate intensive/critical care unit.
*Cap refill <2 sec
*Normal BP
*Normal pulses, similar central and peripheral
*Warm extremities
*UOP >1 mL/kg/hr
*Normal mental status


==Disposition==
==Disposition==

Revision as of 18:06, 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 fluid bolus(es) (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. Constinue to reassess (see below)

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[6]
    • Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[7]

Golden Hour Goals of Resuscitation

 and reversal of hypoglycemia and ionized hypocalcemia are also important. Patients should be continuously reassessed for signs of ongoing shock, evolving fluid status (including pulmonary rales, hepatomegaly, peripheral edema, and echocardiographic findings that may suggest fluid overload), and response to each intervention while arranging for transfer to an appropriate intensive/critical care unit.
  • 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. ↑ 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.
  7. ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.
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