2. 8 year old female arrives at ED with HR 180, RR 35, looks
toxic. Has had URTI symptoms for past couple of days.
Paeds Reg called by ED doctor saying can you come and
have a look.
You make your first assessment
HR 180
T 39.9f
RR-32br/min
BP 70/50mmhg
SPO2 90% on RA
Quiet, tired, opens eyes
Cap refill 4 seconds
Worry??????
3. Why are we worried about it?
Still remains significant cause of morbidity and mortality
19 milln. Cases worldwide / year( adhikari et al)
30% of paediatric patients with sepsis will develop septic
shock.
Mortality rates in septic shock are 20-30% (up to 50% in
some countries).
4. Risk factors for Sepsis in Children
< 1 year of age
Very low birthweight infants
Prematurity
Presence of underlying illness
Co-morbidities
Boys
Genetic factors
5. So
What is SEPSIS ….. ..????????????
Sepsis is a life threatening response to infection.
It represents a continuum through SIRS, sepsis, and septic shock
6. How do we define it
Systemic Inflammatory Response Syndrome
Infection
Sepsis
Severe Sepsis
Septic Shock
7. SIRS…in peds
Core Temp >38.5 or < 36 degrees
Mean HR > 2SD for age or persitant elevation over 0.5-4hrs
If < 1yr old: bradycardia HR < 10th centile for age
Mean RR > 2 SD above normal for age
Leucocyte abnormality.
≥2 criteria should be present
≥ 2 SIRS criteria but no infection : SIRS
≥ 2 SIRS criteria + sign of acute organ failure : severe SIRS
8. Sepsis
SIRS + suspected or proven infection
Severe Sepsis
Sepsis + sepsis induced organ dysfunction, / tissue hypo
perfusion
Septic Shock
Sepsis + Hypotnsn /CV organ dysfunction
9. Cardiovascular dysfunction
Despite >40ml/kg Isotonic fluid bolus in 1 hour:
Decrease in BP <5th centile for age
Need for vasoactive drug to maintain BP
2 of the following:
Unexplained metabolic acidosis
Increase lactate
Oliguria
Prolonged cap refill > 5 seconds
Core-peripheral temp gap >3 degrees
13. Blood Pressure in Children
This is main difference with adults.
Blood pressure does not fall in septic shock until very
late.
CO= HR x SV
HR in children much higher therefore BP falling is late.
Hypotension formula :
70+(age× 2)
14. Etio+ pathophysiology
Pneumonia < Intraabdominal < UTI
Cultures are positive in only 1/3rd cases
Staph aureus and Streptococcus pneumoniae(gr +)
E coli, klebsiella species,Pseudomonas aeruginosa(gr -)
15. PATHOPHYSIOLOGY
Infectious organism/ endotoxin activates immune system
Their interaction c infectioning organism stimulates Cytokines
Cytokines
produce vasodilation & damage endothelium of vessles
↑cap.permiablity→cap.leakage
Inhibits anticoag.properties + ↑ Antifibrinolysis → microvascular
thrombosis →MOD & DIC
Specific inflam.mediator→ impaired cardiac contractility & myocard. d/f
Adrenal gland are prone to microvascular thrombosis & hemorrhage in
septic shock
↓
↓ SVR & myocardial d/f
16. Management….
Recognise early
Resuscitation must be done in a proactive time-sensitive
manner.
Every minute counts – “golden hour”
Every hour without appropriate resuscitation increases
mortality risk by 40%
17. Coming back to our patient….
HR 180
Initial management
T 39.9f
BP 70/50mmhg
SPO2 90% on RA
Quiet, tired, opens eyes
Mod respiratory distress
Cap refill 4 seconds
+
Symptoms of URTI
WHAT NEXT????
EGDT ???????????
Blood & Imaging
Source control
Disposition ?????????
20. GOAL: SEPSIS INDUCED HYPOPERFUSION
IN FIRST 6 HOURS
Central venous pressure 8-12 mm Hg
Mean arterial pressure (MAP) ≥ 65 mm Hg
Urine output ≥ 0.5 ml/kg/hr
Scvo2 or Smvo2 ≥ 70% or ≥ 65%, respectively
Decreased lactate
Source control
Better perfusion
Improvement in Mental status
21. 0-5min:
Recognise Sign of poor perfusion
Maintain airway and establish IV/IOaccess
5-15 min:
20mls/kg isotonic saline boluses up to and
over 60mls/kg
Correct hypoglycemia
0.5-1gm/kg
Dx25:-2-4ml/kg
Dx10:-5-10ml/kg
Our pt.
BP- 76/50
HR-170
CRT -≥4sec.
Repeat bolus upto
60ml/kg
or
Sign of overload
22. Fluid Refractory Shock
Inotrops /vasopressor
to maintain
Map->65
Cvp- 8-12
Svo2->70%
Central line
Arterial line
First dose of Antibiotic
Catecholamine Resistant shock
Stress dose of Hydrocort
15-60 min….
23. O -5min
5-15m
Recognise Sign of poor perfusion
Maintain airway and establish access
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Correct hypoglycemia
Antimicrobials, Correct hypoglycemia
15 -60m
fluid Responsiveness
Observe in PICU
Fluid Refractory shock
24. 15min
Fluid Refractory Shock
Begin dopamine / Norad/ Epineph.
Establish central venous access
Establish arterial access
Titrate Adrenaline for cold shock and noradrenaline for warm
shock to normal MAP-CVP and SVC sats>70%
60 min
Catecholamine resistant shock
25. Catecholamine Resistant Shock
At Risk of adrenal insufficency – give hydrocortisone-draw a baseline cortisole
Evaluate Scvo2 >70%
Normal BP ,poor perfusion
SVC < 70%
Transfuse PRBC Hb>10
Add Dopamine/NPS
Milrinone
Low BP,poor perfusion
Cold Shock
SVC < 70%
Transfuse PRBC,Hb>10
Adrenaline
Dobutamine+Norad.
ECMO
Low BP
Scvo2 >70
Warm Shock
Additional volume
& Noradrenaline
±
Vasopressin
26. Therapeutic endpoints
Clinical
Heart Rate normalized for age
Capillary refill < 2sec
Normal pulse quality
No difference in central and peripheral pulses
Warm extremities
Blood pressure normal for age
Urine output >1 mL/kg/h
Normal mental status
CVP >8 mmHg
27. During the first 6 hrs, if the venous O2 saturation target not
achieved with fluid resuscitation:
Packed RBC transfusion to achieve a hematocrit of ≥ 30%
Active source control
28. SOURCE CONTROL
Specific anatomic site of infection should be established as rapidly as
possible and within the first 6 hours of presentation
Formally evaluate patient for a focus of infection amenable to source
control measures (eg: abscess drainage, tissue debridement)
Implement source control measures as soon as possible following
successful initial resuscitation
(Exception: infected pancreatic necrosis, where surgical intervention best
delayed.)
Choose source control measure with maximum efficacy and
minimal physiologic upset.
Remove intravascular access devices /cathetor if potentially infected.
29. Investigations
Sepsis Work up
Lactate , ABG , CBC
PCT , CRP
Metabolic Panel /Electrolyte
Coagulation Profile
Urine, blood, sputum ,stool, throat swab cultures
Viral cultures
Never do CSF in shocked patient.
Imaging:
CXR, CT, MRI, PET scan, ECHO, Ultrasound
30. Other treatment
Maintain Glucose control
Nutrition
Maintain Hb > 10g/dL
No stress ulcer protection /no DVT protection before
puberty age
Early CVVH
31. Drug
Dose
Comments
Dopamine
2-20mcg/kg/min
Historically 1st choice in kids
Alpha, beta and dopamine receptor
activation
Can be given peripherally
Dobutamine
5-10mcg/kg/min
Chronotropic as well as inotropic
Afterload reduction
Adrenaline
0.05- 1mcg/kg/min
Initially increases contractility/heart rate
High doses increase PVR
Noradrenaline
0.05 – 1 mcg/kg/min
Vasopressor
Increases PVR
Milrinone
0.25-0.75mcg/kg/min
Phosphodiesterase inhibitor
Afterload reduction
32. Take home points….
Early Recognition
Early goal directed therapy
Remember golden hour
Early and Emperic antimicrobials
Early source control and aggressive therapy
