Sepsis (peds): Difference between revisions

(Text replacement - "*CXR" to "*CXR")
 
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***First few days of life
***First few days of life
***Fulminant, associated with maternal or perinatal risk factors
***Fulminant, associated with maternal or perinatal risk factors
***Septic shock and neutropenia are more common
***[[Septic shock]] and [[neutropenia]] are more common
**Late onset
**Late onset
***Occurs after 1wk of age
***Occurs after 1wk of age
***Gradual
***Gradual
***Meningitis more likely
***[[Meningitis (Peds)|Meningitis]] more likely
**Consider if feeding disturbance, rash, lethargy, irritability, seizure, apnea, tachypnea, grunting, vomiting, poor PO, gastric distention, diarrhea
**Consider if feeding disturbance, rash, lethargy, irritability, seizure, apnea, tachypnea, grunting, vomiting, poor PO, gastric distention, diarrhea


==Clinical Features==
==Clinical Features==
Warm Shock vs Cold Shock
[[Pediatric shock|Shock]]: Warm vs Cold Shock


{| class="wikitable"
{| class="wikitable"
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*CBC, CMP, arterial lactate, CRP
*CBC, CMP, arterial lactate, CRP
*Blood glucose
*Blood glucose
*UA/urine culture
*[[Urinalysis]]/urine culture
*[[CXR]]
*[[CXR]]
*CSF
*[[CSF]]
*Blood cultures
*Blood cultures


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*Cardiovascular organ dysfunction
*Cardiovascular organ dysfunction
*Respiratory distress
*Respiratory distress
OR
'''OR'''
*CNS dysfunction - GCS <11 or >3 loss from baseline  
*CNS dysfunction - GCS <11 or >3 loss from baseline  
*Platelets <80 or >50% decrease from baseline
*Platelets <80 or >50% decrease from baseline
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*Total bilirubin >4 or ALT >2x normal
*Total bilirubin >4 or ALT >2x normal


===Septic Shock===
===Septic [[Pediatric shock|Shock]]===
*Hypotension <5th % for age, or SBP <2 SD below normal for age
*[[Hypotension]]<5th % for age, or SBP <2 SD below normal for age
OR
'''OR'''
*Need for vasoactive drugs to maintain BP
*Need for vasoactive drugs to maintain BP
OR
'''OR'''
*Metabolic acidosis base deficit >5
*Metabolic acidosis base deficit >5
*Arterial lactate >2x normal
*Arterial lactate >2x normal
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*Circulation
*Circulation
**1 min to attain IV access
**1 min to attain IV access
**Afer 1 min attain [[IO access]]
**If unable to get IV in 1 min, consider [[IO access]]
**60ml/kg IVF over the first hour
**60ml/kg IVF over the first hour
**Consider vasopressors if not fluid responsive
**Consider [[vasopressors]] if not fluid responsive
**Consider steroids if not fluid responsive
**Consider [[steroids]] if not fluid responsive
*Airway
*Airway
**Consider early intubation, especially in fluid refractory shock
**Consider early [[intubation]], especially in fluid refractory [[pediatric shock|shock]]
**[[Ketamine]] for sedation is drug of choice
**[[Ketamine]] for sedation is drug of choice
***Hypotension can still occur in septic patients
***[[Hypotension]]can still occur in septic patients
**Typical paralytic agents
**Typical [[neuromuscular blocking agents|paralytic agents]]
*Breathing
*Breathing
**CPAP can buy time for fluid rescuss prior intubation
**[[CPAP]] can buy time for fluid resus prior intubation
*Glucose
*Glucose
**Ensure euglycemia
**Ensure euglycemia
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*Normal mental status
*Normal mental status


===Lactate===
===[[Lactate]]===
*Compared to adults, peds more often has normal lactate levels
*Compared to adults, pediatric sepsis patients have normal lactate ore often
*Controversial but surviving sepsis campaign no longer recommends trending lactate in pediatric patients<ref>Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Med 2013; 39: 165-228.</ref>
*Controversial but surviving sepsis campaign no longer recommends trending lactate in pediatric patients<ref>Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Med 2013; 39: 165-228.</ref>


===Antibiotics===
===Antibiotics===
====Neonatal====
====Neonatal====
*Ampicillin 50mg/kg + [[gentamicin]] 2.5mg/kg + acyclovir
*[[Ampicillin]] 50mg/kg q8h + [[gentamicin]] 2.5mg/kg q24h + [[acyclovir]]
**If gram-negative strongly suspected replace [[gentamicin]] with cefotaxime or ceftaz
**If gram-negative strongly suspected replace [[gentamicin]] with [[cefotaxime]] or [[ceftazadine]]
***Have better CNS penetration
***Have better CNS penetration
====Peds====
====Peds====
''Treatment will differ by local protocols''
''Treatment will differ by local protocols''
*Extended-spectrum penicillin ± aminoglycoside ± vancomycin  
*Extended-spectrum penicillin (e.g. Ppiperacillin-tazobactam]]) ± [[aminoglycoside]] ± [[vancomycin]]
OR
'''OR'''
*3rd or 4th generation cephalosporin ± aminoglycoside ± vancomycin  
*3rd or 4th generation [[cephalosporin]] ± [[aminoglycoside]] ± [[vancomycin]]
OR
'''OR'''
*Carbapenem ± aminoglycosidea ± vancomycin
*[[Carbapenem]] ± [[aminoglycoside]] ± [[vancomycin]]


===Vasopressors===
===[[Vasopressors]]===
*If vasopressors needed for septic shock, follow recommendations:
*If vasopressors needed for septic shock, follow recommendations:
**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>
**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==
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[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Critical Care]]
[[Category:ID]]

Latest revision as of 04:25, 16 May 2020

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

  • CBC, CMP, arterial lactate, CRP
  • Blood glucose
  • Urinalysis/urine culture
  • CXR
  • CSF
  • Blood cultures

SIRS Criteria in Peds

Requires > or equal to 2 of 4 requirements, with abnormal temperature or WBC required

  • Temperature >100.4 or <96.8
  • Age specific tachycardia or bradycardia <10th % for age <1 year
  • RR >2 SD above the norm
  • WBC elevated or depressed, based on age, or >10% bands

Severe Sepsis

  • Cardiovascular organ dysfunction
  • Respiratory distress

OR

  • CNS dysfunction - GCS <11 or >3 loss from baseline
  • Platelets <80 or >50% decrease from baseline
  • Creatinine >2x upper limit of normal/baseline
  • Total bilirubin >4 or ALT >2x normal

Septic Shock

  • Hypotension<5th % for age, or SBP <2 SD below normal for age

OR

  • Need for vasoactive drugs to maintain BP

OR

  • Metabolic acidosis base deficit >5
  • Arterial lactate >2x normal
  • UOP <0.5 mL/kg/hr
  • Capillary refill >5 sec
  • Core to peripheral temperature gap >3 degrees C
  • DESPITE IVF resuscitation >40mL/kg in 1 hour

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 resus 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

Lactate

  • Compared to adults, pediatric sepsis patients have normal lactate ore often
  • Controversial but surviving sepsis campaign no longer recommends trending lactate in pediatric patients[2]

Antibiotics

Neonatal

Peds

Treatment will differ by local protocols

OR

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[3]
    • Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well[4]
    • RTC trial in 2015 from Brazil, without other larger RTCs or multi-center trials to corroborate information

Disposition

  • Admit

See Also

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. ↑ Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Med 2013; 39: 165-228.
  3. ↑ 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.
  4. ↑ Marik PE. Dopamine increases mortality in pediatric septic shock. Journal of Pediatrics. January 2016, Volume 168, Pages 253–256.

Tintinalli "Pediatric Sepsis" published in EM Resident 2013 40(4) , adapted from Goldstein, et al. Pediatr Crit Care Med 2005; 6:2-8.

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