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Peds moment Sepsis

Peds moment Sepsis. Raphael Paquin, PGY-4 PEM fellow Aug 20, 2009. Recognising sepsis. Definition:. SIRS + Suspected or proven infection SIRS Criteria: 2 of: Fever (>38.5) or hypothermia (<36) Tachypnea Tachycardia or bradycardia Leucocytosis or leucopenia. &%!#$ Pediatrics!!.

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Peds moment Sepsis

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  1. Peds momentSepsis Raphael Paquin, PGY-4 PEM fellow Aug 20, 2009

  2. Recognising sepsis

  3. Definition: SIRS + Suspected or proven infection SIRS Criteria: 2 of: • Fever (>38.5) or hypothermia (<36) • Tachypnea • Tachycardia or bradycardia • Leucocytosis or leucopenia

  4. &%!#$ Pediatrics!! Goldstein et al, Ped Crit Care Med, 2005

  5. Classification of sepsis • Sepsis: SIRS + susp/proven infection • Severe sepsis: sepsis + one of: • ARDS • Cardiovascular dysfunction • 2 end-organ dysfunctions (neuro, hem, renal, hepatic) • Septic shock: sepsis + cardiovasc dysfct • HypoTN (despite 40cc/kg of IVF) • Use of pressors • > 2 signs of hypoperfusion • Lactate 2x > N values • Diuresis < 0.5cc/kg/hr • Capillary refill > 5 sec • Central temp - peripheral temp > 3 deg C.

  6. L E G S H I N Age and bugs, roughly… 0-1 mo 1-3 mos >3mos

  7. Listeria E. coli GBS Streptpneumo Haemophilus Influenzae Neis.mening. Age and bugs, roughly… 0-1 mo 1-3 mos >3mos L E G & S H I N

  8. Bugs & Immunodeficiencies • Usual bugs as well as: • Staph aureus, staph viridans, CoNS (incresed risk if central catheter) • Gram -ve: pseudomonas, Klebsiella, enterococcus. • Fungi: aspergillus, candida, pneumocystis • Protozoan: toxoplasma, cryptosporidium

  9. SURVIVING SEPSIS EARLY GOAL-DIRECTED THERAPY… with a pediatric twist…

  10. SURVIVING SEPSIS EARLY GOAL-DIRECTED THERAPY… with a pediatric twist… • Central line for Central/Mixted Venous O2 sat rarely available in the resuscitation room • BP drops much later in peds than in adult patients • Therefore, even though the theoretical cvO2 sat goal >70%, authors suggest using indirect measurement-related objectives: • Cap refill <2 sec • Normal LOC • Decreasing lactate level

  11. Surviving sepsisThis hour has 60 minutes… • A-B • Goal: O2 sats > 95% w FiO2 0.4-1.0. • Early intubation/ventilation • Decreased LOC • Severe hypoxemia • PaO2 <60 mmHg or O2sat <88-90% w FiO2 0.6-0.8 • Persistent hypercapnea • PaCO2 >50-55mmHg • Severe hyperventilation • Hypotension refractory to initial management

  12. Surviving sepsisThis hour has 60 minutes… • C • 1-2 large bore PIV +/- CVL • Rapid infusion of crystalloids (20cc/kg bolus ad 60-80cc/kg) regardless of BP • Then consider colloids (alb 5% or synthetic) • 5-10cc/kg boluses • Arterial line • Foley catheter to monitor urine output. • Critical blood samples when starting PIV: • CBC, gas, lytes, urea/creat, glycemia, lactate, BC

  13. Surviving sepsis (cont’d) • C targets • cvO2 >70%, mvO2 >65% • MAP: • <1mo: > 45 • 1mo-10y: >60 • >10y: >65 • CVP: >8 mmHg • Urine output: > 0.5cc/kg/hr • Hematocrit: >30%

  14. Surviving sepsis (cont’d) • Refractory shock @ 30 minutes • Start pressor (dopamine, norepi, epi) • Susp. myocardial dysf: add dobutamine • Eventually add vasodilator (nitroprussiate, milrinone) if refractory cold shock • Refractory shock at 60min: • Hydrocortisone 1mg/kg q6h (Parker et al, Crit Care Med, 2004)

  15. Oh yeah, how about treating the cause?!? • Start empiric therapy ASAP (if possible, after having collected blood, urine, CSF, ETT cultures) • DO NOT DELAY TX!!! • Of course, empiric treatment depends on age(!), suspected focus of infection and immunodeficiency status.

  16. Empiric antibiotic treatment • No or occult focus: • 0-1mo: amp + aminoside (or cefotax) • 1-3mos: amp + cefot +/- vanco • >3mos: 3GC + vanco +/- aminoside • Resp focus: 3GC + antistaph pen +/- vanco • Meningitis • 0-1mo: amp + cefotax + aminoside • >1 mo: 3GC + vanco • Urinary focus: amp + aminoside • Purpura fulminans: 3GC • CVL: 3GC + vanco + gent • Cutaneous • Strept susp: amp or penG + clinda if toxin-related Sx • Non MRSA staph: Clox or vanco + clinda if toxin-related Sx

  17. The curious case of immunosuppression • Pip/tazo + vanco (or antistaph pen) + aminoside • +/- antifungal Tx: ampho B +/- fluco, etc. • +/- antiviral Tx: aciclovir, ribavirine, etc.

  18. Absolute criteria: Mechanical ventilation Vasopressor infusion Respiratory failure (FiO2 >0.5 for O2 sats >95%), heart fail, renal failure, decreased level of consciousness. Purpura fulminans Relative indications: Stabilized patient still requiring aggressive fluid management 2 mild end-organ dysf. Elevated lactate Suspected meningococcemia (fever and petechiae) Okay, we’re done…PICU admission criteria

  19. Surviving (talk on) sepsis: Congrats!!!

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