Med Journal April 2021 | Page 12

Table 1 . Definitions used in Pediatric Sepsis . Adapted from Goldstein , et al . WBC = white blood cell count , ARDS = acute respiratory distress syndrome
Condition
Systemic Inflammatory Response Syndrome ( SIRS )
Sepsis
within one hour of recognition , and 3 ) administration of a 20 mL / kg fluid bolus . 6 A resuscitation algorithm for children has been developed by the SSC that emphasizes immediately establishing intravenous ( IV ) or intraosseous ( IO ) access , obtaining blood cultures , and administering empiric broad-spectrum antibiotics within the first hour of sepsis recognition ( See Figure 1 ). 7
Given the dynamic nature of sepsis , the initial resuscitation phase is characterized by frequent patient reassessment and careful attention to fluid management to both optimize resuscitation and minimize potential fluid overload . The updated guidelines recommend timely broad-spectrum antibiotics : within one hour for septic shock and within three hours of initial suspicion of sepsis ( See Figure 1 ). It is recommended that isotonic crystalloids be used in 10-20 mL / kg bolus doses until volume resuscitation is attained , or there is clinical evidence of fluid overload . Up to 40-60 mL / kg of fluid resuscitation should occur within the first hour of septic shock or sepsis-associated organ dysfunction , although some pediatric patients with severe shock require much more volume resuscitation . Adequate volume resuscitation is characterized by good perfusion , improved
Presence of ≥ 2 of the following : Core temperature ≥38.5 ° C or < 36 ° C Increased heart rate for age Tachypnea for age Increased or decreased WBC , or > 10 % bands
SIRS in presence of suspected or proven infection .
Severe Sepsis Sepsis + one of following : cardiovascular dysfunction , ARDS , or ≥ 2 other organ systems dysfunctions
Septic Shock
Sepsis and cardiovascular organ dysfunction .
capillary refill time , and strong pulses on examination , not by what the cardiopulmonary monitor demonstrates . Oftentimes , good urine output and improved mental status can be used as reassuring signs of adequate end-organ perfusion .
Starting an epinephrine infusion is prudent if concerns for myocardial dysfunction exist . Epinephrine and / or norepinephrine infusion may be necessary if shock persists after 40-60 mL / kg of fluid resuscitation , or sooner if fluid overload is evident ( See Figure 2 ).
Norepinephrine is the vasoactive medication of choice in children with signs of “ warm shock .” Epinephrine and norepinephrine can be administered through an IO , or an IV in diluted concentrations , while awaiting placement of central venous access . Lack of central access should not dissuade providers from early administration of inotropes .
Care should also be taken to closely monitor serum electrolytes in children with sepsis or shock . Hypocalcemia and hypoglycemia are frequently seen in sepsis and should be replenished once identified .
Conclusion
Recognizing pediatric sepsis and shock is challenging , but imperative . Establishing IV / IO access , obtaining blood cultures , and starting broad-spectrum antibiotics within the first hour of recognition , along with judicious fluid resuscitation with frequent patient-reassessment is the key to successful management . Developing a sepsis bundle that is designed based upon local resources is essential and will lead to improved outcomes .
References
1 . Weiss SL , Peters MJ , Alhazzani W . Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children . Pediatric Crit Care Med , 2020 ( February ); 21 : e52-e106
2 . Kochanek KD , Murphy SL , Xu J and Arias E : Deaths : Final data for 2017 . Natl Vital Stat Rep , 2017 ; 68 ( 9 ): 1-77
3 . Ruth A , McCracken CE , Fortenberry JD , et al . Pediatric severe sepsis : Current trends and outcomes from the Pediatric Health Information Systems database . Pediatric Crit Care Med , 2014 ; 15 ( 9 ): 828-838
4 . Goldstein B , Giroir B , Randolph A ; International Consensus Conference on Pediatric Sepsis : International pediatric consensus conference : Definitions for sepsis and organ dysfunction in pediatrics . Pediatric Crit Care Med , 2005 ; 6:2-8
5 . Schlapbach LJ , MacLaren G , Festa M , et al . Australian & New Zealand Intensive Care Society ( ANZICs ) Centre for Outcomes and Resource Evaluation ( CORE ) and Australian & New Zealand Intensive Care Society ( ANZICs ) Paediatric Study Group : Prediction of pediatric sepsis mortality within 1 h of intensive care admission . Intensive Care Med , 2017 ; 43:1085-1096
6 . Evans IVR , Philips GS , Alpern ER , et al : Association between the New York sepsis care mandate and in-hospital mortality for pediatric sepsis . JAMA , 2018 ; 320:358-367 .
7 . www . sccm . org / SurvivingSepsisCampaign / Guidelines / Pediatric-Patients
228 • The Journal of the Arkansas Medical Society www . ArkMed . org