Peds momentPeds momentSepsisSepsis

Raphael Paquin, PGY-4Raphael Paquin, PGY-4

PEM fellowPEM fellow

Aug 20, 2009Aug 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!!

Age Tachy-pnea

Brady-cardia

Tachy-cardia

WBC BPsyst

0-7d >50 <100 >180 >34 <59

7d-1m >40 <100 >180 >19.5, <5 <79

1m-1y >34 <90 >180 >17.5, <5 <75

2-5y >22 NA >140 >15.5, <6 <74

6-12y >18 NA >130 >13.5,<4.5 <83

13-17y >14 NA >110 >11, <4.5 <90

Goldstein et al, Ped Crit Care Med, 2005

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.

Age and bugs, roughly…

L

E

G

S

H

I

N

0-1 mo 1-3 mos >3mos

Age and bugs, roughly…

Listeria

E. coli

GBS

Strept pneumoHaemophilusInfluenzaeNeis. mening.

0-1 mo 1-3 mos >3mos

LEG&SHIN

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

SURVIVING SEPSIS

EARLY GOAL-DIRECTED THERAPY… with a pediatric twist…

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

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

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

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%

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)

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.

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

The curious case of immunosuppression

• Pip/tazo + vanco (or antistaph pen) + aminoside

• +/- antifungal Tx: ampho B +/- fluco, etc.

• +/- antiviral Tx: aciclovir, ribavirine, etc.

Okay, we’re done…PICU admission criteria

• 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)

Surviving (talk on) sepsis:

Congrats!!!