Description
Early recognition and prompt management are critical in pediatric sepsis and septic shock. Initial steps include rapid assessment of airway, breathing, and circulation, followed by immediate fluid resuscitation with isotonic crystalloids (20 mL/kg boluses), reassessing after each bolus. Early administration of broad-spectrum antibiotics, ideally within the first hour, is essential to improve outcomes. If shock persists after fluid resuscitation, vasoactive agents like epinephrine or norepinephrine are initiated to maintain adequate perfusion. Monitoring includes vital signs, urine output, lactate levels, and mental status. Source control—such as drainage of abscesses or removal of infected devices—is also vital. Supportive care includes oxygen, mechanical ventilation if needed, and correction of metabolic imbalances. Management should follow updated guidelines such as those from the Surviving Sepsis Campaign. Multidisciplinary care in a pediatric intensive care unit (PICU) setting significantly improves survival and reduces complications in children with sepsis and septic shock.
Summary Listen
- **Septic Shock: Definition and Importance**
- Septic shock, a subset of sepsis, involves circulatory, cellular, and metabolic dysfunction. Early recognition and prompt treatment are crucial to prevent irreversible tissue damage. Shock is defined as a state of tissue hypoperfusion due to inadequate oxygen delivery, increased oxygen consumption, or impaired tissue utilization.
- **Types of Shock and Focus on Septic Shock**
- Shock is categorized into hypovolemic, cardiogenic, distributive, and obstructive types. Septic shock falls under distributive shock. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, encompassing bacteria, viruses, or fungi.
- **Evolution of Sepsis Definition and Challenges**
- The previous SIRS (Systemic Inflammatory Response Syndrome) and severe sepsis classifications are replaced by quick SOFA (qSOFA). Limitations of the new definition include the exclusion of sepsis without organ dysfunction, questionable accuracy of qSOFA, the impracticality of lactate level checks in resource-limited settings, and a lack of representation from low and middle-income countries.
- **Importance of Biomarkers**
- Clinical signs have moderate sensitivity and specificity. Microcirculatory signs like serum lactate and base deficit have better sensitivity and specificity. Markers can be divided into clinical and investigation.
- **Recognition and Screening Tools**
- Recognizing compensated shock before hypotension is crucial. Symptoms include tachycardia, tachypnea, prolonged capillary refill, and cool extremities. Quick SOFA (qSOFA) is a simplified screening tool using respiratory rate, GCS, and systolic blood pressure.
- **Red Flags and Early Recognition Tools**
- Screening tools such as the qSOFA provide an easy tool with only 3 clinical criteria to assess, the Respiratory Rate, GCS and Systolic Blood Pressure. Additionally, there are red flags for sepsis management, including tools from the UK's sepsis trust for general practitioners, and pediatric sepsis six-point checklists for early recognition.
- **Initial Management: Oxygen, IV Access, and Antibiotics**
- Initial steps include administering 100% oxygen via non-rebreather mask, securing IV/IO access, obtaining blood cultures and blood glucose (and blood gas if available), and administering the first dose of broad-spectrum antibiotics promptly, prior to fluids.
- **Fluid Resuscitation Strategies**
- Fluid resuscitation involves crystalloids (avoiding colloids) like normal saline (though plasma-lyte is preferred due to lower chloride). Fluid volume depends on blood pressure and ICU availability. Bolus administration should be slower without ICU facilities, with close monitoring for fluid overload.
- **Initial Algorithm for Children from Surviving Sepsis**
- The initial algorithm is to get IV access, take blood cultures, administer the first dose of antibiotic and pressure lactate levels. Then, give fluid bolus if the child is in shock and if not, give maintenance. If after giving fluids, the shock continues, then consider Basioactivation.
- **Ten Commandments for Fluid Boluses**
- Fluid bolus can damage the glycocalyx leading to increased capillary lead. Static and dynamic tests have their own limitations. Restrictive fluid plus early vasoactive agents decreases the requirement of organ support when the cell is admitted to the ICU.
- **Vasoactive Medications: Choice and Rationale**
- Start vasoactive medications after 40-60 ml/kg of fluid bolus if perfusion remains poor. Epinephrine is preferred over dopamine as the first-line vasoactive agent. Vasopressin can be added for those requiring high doses of epinephrine or norepinephrine.
- **Antibiotic Therapy and Source Control**
- Initiate appropriate antibiotic therapy and source control within one hour of presentation in septic shock and within three hours for sepsis without shock. Choose a broad-spectrum antibiotic based on local practices and the patient's immune status. Source control should occur within six hours.
- **Steroids and Supportive Management**
- The role of steroids is limited in pediatric septic shock. They may be considered if hemodynamic stability isn't achieved with fluids and vasoactives. Supportive management includes early non-invasive ventilation, restrictive PRBC transfusion, and correction of metabolic abnormalities.
- **Additional Management Strategies**
- Early enteral nutrition should be initiated. Hemofiltration or peritoneal dialysis may be considered as a last option. Implement systematic screening, monitor lactate levels, obtain cultures, and start empirical broad-spectrum therapy.
- **Importance of Documentation and Communication**
- Documentation, including counseling, is crucial. Communication should occur between the team and the patient's family. Follow the tentips for Vasopresses, have goals for mean arterial pressure, individualized goals and reassess fluids.
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