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Pediatric Sepsis PowerPoint Presentation

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Description : Check out this medical presentation on Pediatrics, which is titled "Pediatric Sepsis", to know about Pediatric and Neonatal Septic Shock.

Tags : Pediatrics, Pediatric Sepsis, Neonatal, Septic Shock

Published on : Aug 03, 2021 | Views : 2971 | Downloads : 3

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Slide 1-

Pediatric Sepsis Dr. S. Veroukis Pediatric Critical Care Winnipeg Children’s Hospital Winnipeg, MB CANADA
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Objective Review of the 2007 Clinical Practice Guidelines on Pediatric and Neonatal Septic Shock
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Guidelines Aim to standardize care of the septic patient to decrease mortality Expected mortality if guidelines adhered to are expected to be very low: 0-5% for previously healthy children 10% for children with chronic illness
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Recognizing Sepsis Clinical triad: fever, tachycardia, vasodilation plus change in level of consciousness and urine output is the most common presentation of sepsis Our hospital has a screening tool Used for the febrile patient who also has changes in vital signs or level of consciousness
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SIRS SIRS = Systemic Inflammatory Response Syndrome 2 out of the 4 must be met, and 1 out of the two must be either a) or b) a) core temperature >38.5 degC or <36degC b) leukocyte count elevated or depressed or > 10% immature neutrophils c) tachycardia, or bradycardia (<1yr old) d) tachypnea or need for mechanical ventilation
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Sepsis Definition Sepsis is defined as a condition meeting the SIRS definition in the presence of suspected or proven infection. Septic shock is Sepsis with cardiovascular dysfunction (hypotension, poor perfusion, elevated lactate)
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Recommendations for Pediatric Septic Shock
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Clinical Diagnosis Suspected or proven infection Hypothermia or hyperthermia Signs of inadequate tissue perfusion: Decreased mental status Prolonged capillary refill >2sec, diminished pulses, narrow pulse pressure (cold shock) Brisk capillary refill, bounding pulses, wide pulse pressure (warm shock) Decreased urine output <1ml/kg/hr
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The First Hour of Resuscitation (Emergency Room) Push 20cc/kg of Crystalloid or Colloid up to 60cc/kg IV or Intraosseous Start antibiotics (eg. Vancomycin, Cefotaxime) Correct hypoglycemia and hypocalcemia Need to give fluids until capillary refill and peripheral pulses are normalized or until hepatomegaly and/or rales develop
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Airway and Ventilation During the first hour, the work of breathing may increase, oxygen saturation may decrease May need to intubate 40% of cardiac output is used for work of breathing Recommended medications: atropine and ketamine(0.5-1.5mg/kg IV or IO)
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Fluid Refractory Septic Shock Dopamine IV or IO May need to start second inotrope Cold shock: (low CO, high SVR) choose epinephrine IV or IO If warm shock (high CO, low SVR) choose norepinephrine Need to establish central venous access soon in order to run inotropes at central concentrations
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Cold Shock Characterized by Tachycardia Cold extremities Weak pulses, prolonged capillary refill Elevated blood pressure with narrow pulse pressure Usually Cardiac Output is low but Systemic Vascular Resistance (SVR) is high
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Warm Shock Characterized by Tachycardia Low BP especially diastolic blood pressure Warm extremities, brisk capillary refill Bounding pulses Wide pulse pressure (from low Diastolic BP) Usually a state of high Cardiac Output but low SVR
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Further Therapy Maintenance fluids should be started : D10WNS solution to run at maintenance Ng if intubated Foley to accurately measure urine output Frequent vitals (hourly) Treat temperature If intubated needs sedation: most frequent fentanyl and midazolam infusions
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Fluid and Catecholamine Resistant Shock When fluid boluses and inotropes have not corrected poor perfusion, decreased LOC and urine output Consider hydrocortisone therapy especially for those patients at risk: Adrenal or pituitary insufficiency Purpura fulminans History of steroid treatment Dosing: 2-50mg/kg/day (if possible take random cortisol level first) (should be >496nmol/L or >18mcg/dL)
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Intensive Care Patient can be transferred to Intensive Care at any point Central venous access to be established Obtain central venous oxygen saturation (ScvO2) Surrogate for cardiac output and tissue oxygenation
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Central Venous Saturation If ScvO2 <70% then cardiac output is not sufficient to keep up with the body’s demands Need to improve oxygen delivery by: improving fluid status (fluid boluses) Increasing oxygen carrying capacity (packed RBC transfusion) Improving cardiac contractility (inotropes/vasopressors) Improving cardiac output by afterload reduction (milrinone, dobutamine, nitroprusside)
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Cold Shock with Normal Blood Pressure Titrate fluid and epinephrine to have ScvO2 >70% Maintain Hb>100g/L If ScvO2 <70%, add an afterload reducer like milrinone, nitroprusside, nitroglycerin
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Cold Shock with Low BP Titrate fluid and epinephrine, to meet ScvO2 >70% Maintain Hb >100g/L If still hypotensive consider norepinephrine If ScvO2 <70% despite fluids, blood transfusion and increased epinephrine infusion, then consider afterload reduction (milrinone, dobutamine)
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Warm Shock with Low Blood Pressure Titrate fluid and norephinephrine to ScvO2>70% If still hypotensive, consider vasopressin or low dose epinephrine
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Persistant Catecholamine Resistant Shock Rule out pericardial effusion, pneumothorax, congenital cardiac lesion (duct dependent lesion) in a neonate Consider thyroid replacement, IVIG More fluids, packed RBC, FFP, addition of other inotropes, pressors, or afterload reduction If not reversed by any of these measures, consider ECMO (extracorporeal membrane oxygenation)
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Fluid Removal Patients will get lots of fluid, even up to 200cc/kg in 24hr period Capillary leak from SIRS  edematous skin, pulmonary edema, ascites and risk of abdominal compartment syndrome If kidneys can not produce enough urine, and patient is 10% fluid overloaded, may use diuretics, peritoneal dialysis, CRRT to remove fluid
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Outcomes Early initiated, goal directed therapy has made great improvement in pediatric sepsis survival Oliveira et al showed that by following the recommendations, mortality in pediatric sepsis was reduced from 39% to 12%
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Summary Recognizing Sepsis early is important in decreasing mortality Consider sepsis in the patient with fever, tachycardia, and altered mental status Fluid boluses to begin within 5 minutes of suspecting sepsis Bolus 20cc/kg up to 60cc/kg in 15-20mins Start antibiotics as soon as possible
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Summary Start peripheral or central dopamine if fluid refractory shock IV or IO; establish central venous access if possible Titrate fluids, norepinephrine, epinephrine, packed red blood cells to ensure Tachycardia, capillary refill, pulses and BP normalize Lactate within normal, ScvO2>70% Urine output >1mg/kg/hr
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Summary For persistent severe septic shock consider the following: Hydrocortisone Thyroid replacement ECMO IVIG
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Thank-you!