Paediatric Sepsis and Shock

Red Flags in the Recognition of Pediatric Sepsis

Age:
- Of the children <1yr
  - In children < 3 months
    - rate of serious bacterial infection ~10%
      - 8% UTI
      - 2% bacteraemia
Unexplained tachycardia (after correcting for fever)
- Heart Rate increases by approximately 10 beats/min
- Respiratory Rate by 5 breaths/min for every Celsius degree (1.8 degree of Fahrenheit) of fever >38°C
Clinical signs:
- Poor perfusion (long cap refill, lethargy, irritability)
Conditions that predispose to sepsis:
- neuromuscular disease
- immunocompromised
- respiratory conditions
- cardiac disease
Recent surgery

Systemic inflammatory response syndrome (SIRS)

Severe sepsis/Shock

associated with hypotension
- < 65 mmHg in infants
- < 75 mmHg in children
- < 90 mmHg in adolescents
Hypotension is a Late Sign of Pediatric Septic Shock
Be very cautious in setting of tachycardia and DO NOT WAIT for hypotension to make diagnosis of septic shock.
A pediatric patient with hypotension and sepsis is a pre-arrest patient

Cold vs. Warm shock

COLD shock, which is characterized by high SVR and low cardiac output more common in infants and neonates
Thus, children are poorly perfused, have delayed cap refill with cold extremities and have a temperature differential between their core and their extremities
WARM Shock, characterised by a wide pulse pressure and rapid capillary refill. The underlying haemodynamic abnormality is vasoplegia, which is more common in older children and adolescents.

Acute Management of Pediatric Sepsis

Fluid Resuscitation in Pediatric Sever Sepsis and Septic Shock
Circulation is of paramount importance in this patient and COMES BEFORE AIRWAY and all other concerns.
- Thus the approach should be CAB:
- 1) Circulation, 2) Airway, 3) Breathing.
Establishing IV access in a septic child can be very difficult, especially in the setting of hypotension.
If, after 1MINUITE of trying, you cannot establish IV access, move to IO (ideally x2).

IO access can be used in all ages, even in awake patients
Studies show that the pain from the IO comes more from the actual infusion than the insertion.
In order to decrease pain, consider infiltrating lidocaine into the bone prior to infusion of fluids.
Sites (in this order of preference):
- Proximal tibia
- Distal femur
- Proximal humerus
- Blood pressure should not be a deciding factor in giving fluids.
- All septic patients should receive the initial boluses
- IV Fluids
  - Default is 0.9% Normal Saline
    - Can cause hyperchloraemic metabolic acidosis in large volumes
  - Alternatives: Plasmalytes, Hartmans, Ringers Lactate
  - Initial Bolus of 20ml/kg crystalloid as a push

Then: sampling for blood culture,FBC, CRP, and venous blood gas
- If lactate >4, repeat gas in 2 hours

early administration of Empirical IV Antibiotics (RCH guidelines)
- Age < 1month
  - Cefotaxime 50mg/kg and BenPen 60mg/kg IC
- Age > 1 month
  - Ceftriaxone or Cefotaxime 50mg/kg (max 2g) + Flucloxacillin 50kg/kg (max 2 g) IV (assuming meningitis cannot be excluded)
- For Onc Patients
  - Pip/Taz – 100mg/kg – max 4g
  - Add Amikacin 25mg/kg(max 1.5g) + Vancomycin 15mg/kg(max 500mg) if severely unwell

Inotropes
- If there are no signs of improvement within 1 hour of aggressive fluid resuscitation (after 3 boluses of 20ml/kg IV NS), the initiation of ionotropes is indicated.
- While there is no good evidence to support specific pressor selection in pediatric sepsis, dopamine 10mcg/kg/min is considered the first line choice in USA
  - First line: Dopamine 10mcg/kg/min,
  - Cold Shock: Epinephrine 0.05-0.3 mcg/kg/min and titrate to effect
  - Warm Shock: Norepinephrine .05-0.3 mcg/kg/min and titrate to effect.
- RCH Guidelines
  - Adrenaline/Noradrenaline 0.15mg/kg in 500ml 0.9% NaCL (5% Dextrose for Neonates)
- You can safely start these inotropes through a peripheral IV or IO. The lack of a central line should not delay the initiation of inotropes at the 60min mark

Respiratory Support
- Normal conscious stat::: Consider NIV – HFNC, CPAP, BiPAP
- Altered level of consciousness(compromised airway) or fluid refractory septic shock::: Consider intubation
  - Infants or neonates with severe sepsis may require early intubation
  - Intubation and mechanical ventilation increases intrathoracic pressure which reduce venous return and lead to worsening shock. Therefore, fluid resuscitation must be done first.
  - Drugs
    - Ketamine: relatively safe in hypotension and tachycardia. However, catecholamine depletion can cause refractory hypotension and result in worsening shock.
    - Propofol: Should not be used for long-term sedation in children younger than 3 years old because of an association with fatal metabolic acidosis.
    - Etomidate: Should be discouraged or used carefully in septic shock as it inhibits the adrenal axis and sympathetic nervous system affecting hemodynamic stability. Etomidate is associated with increased mortality in children with meningococcal sepsis because of adrenal suppression effect.
    - Paralytic agents: Succinylcholine 1 mg/kg (or 2mg/kg in infants) IV or Rocuronium 0.45-0.6 mg/kg IV

Adjunct Treatments
- Treating Adrenal insufficiency ?
  - The initial inflammatory response to sepsis activates the endogenous release of cortisol 🡪 which in turn modulates the synthesis and release of both pro- and anti-inflammatory mediators to restrict inflammation in infected tissues.
  - Due to
    - vascular or ischemic damage
    - inflammation and apoptosis within the hypothalamic-pituitary adrenal axis
    - use of drugs that alter cortisol metabolism
    - may lead to adrenal insufficiency
  - Corticosteroids: The use of hydrocortisone in pediatric septic shock is currently being investigated and its role is unclear.
  - Consider using hydrocortisone 2mg/kg in any child that has fluid and inotropic resistant septic shock or proven adrenal insufficiency
- Hypoglycemia
  - Both hypo and hyperglycemia are associated with worse outcomes
  - For glucose <6mmol, start D10W 5cc/kg (avoid higher concentration)

Further Investigations
- FBE
- CRP
- Procalcitonin
  - serum procalcitonin > 0.3ng/mL as a predictor for serious bacterial infection in children 7days-3 months of age
  - -sensitivity 90%
  - -specificity 78%
- Urine Analysis
- CSF