Med Journal Jan 2021 Final - Page 15

Darren O ’ Quinn
Table 2 . Physical Findings in Children With Sepsis
Physical Exam Findings in Pediatric Severe Sepsis and Shock
Agitation Apnea Tachycardia Cold / pale extremities Delayed capillary refill time ( CRT ) ( > 3 seconds ) - “ cold ” shock Flash CRT - “ warm ” shock Bounding or weak pulses Mottled skin Decreased urine output Dry mucous membranes Tachypnea Grunting Nasal flaring Hypotension ( late symptom ) Hypoxia Lethargy
Clinical Presentation
The insidious presentation of sepsis varies with the age of the patient . In neonates , any change from the patient ’ s baseline behavior raises suspicion for sepsis , whether a fever is present or not . In older children , tachycardia may be the only presenting sign . Children with intact cardiovascular systems can misleadingly maintain a normal blood pressure for a relatively long period despite having sepsis or severe sepsis . 5 If compensated shock remains unrecognized and untreated , the child will deteriorate quickly .
It is crucial to assess the state and activity of the child , whether a fever is present or not , and understand the features that vary with age . It is essential to ask about the patient ’ s vaccination status , current medical conditions , and any recent illnesses or procedures that may increase the likelihood of sepsis . Any risk factor , if present , that can increase the likelihood of infection or decrease the body ’ s ability to fight an infection should raise the suspicion for sepsis .
A child may present with signs ranging from slightly elevated heart rate to overt signs such as respiratory failure or altered mental status . Always consider sepsis in children with persistently abnormal vital signs and be aware that persistent tachycardia often is missed . Common physical exam findings for severe sepsis and shock include : tachycardia , cold / pale extremities , delayed capillary refill time ( CRT ) > 3 seconds or flash CRT , bounding or weak pulses , mottled skin , decreased urine output , dry mucous membranes , tachypnea , apnea , grunting , nasal flaring , hypoxia , lethargy , agitation , and hypotension as a late symptom ( Table 2 ). 6
First and foremost , sepsis is a clinical diagnosis . Labs are not necessary for the diagnosis , and there should be no delay in treatment , as early recognition of sepsis and septic shock is crucial to improving outcomes . However , numerous labs and studies can assist in diagnosing abnormalities found in sepsis . A one-hour delay in the initiation of appropriate resuscitation measures has been associated with increased mortality . 7 Blood cultures should be obtained before initiating antibiotic therapy but should not delay antibiotics in a critically ill child . Electrolyte abnormalities , including hypoglycemia and hypocalcemia , should be corrected . 8 A two-fold increase in creatinine can reflect kidney injury . A blood gas can assist in the evaluation of oxygenation , ventilation , and acid-base disturbances ; especially when noninvasive methods become unreliable due to cold extremities , weak pulses , or other factors . If there are concerns for disseminated , intravascular coagulation , complete the workup to confirm its presence with a decrease in fibrinogen and / or an elevation in prothrombin time , partial thromboplastin time , INR , and / or D-dimer .
Once severe sepsis or septic shock is identified , there should be a rapid assessment of the child followed by the initiation of time-sensitive , goal-directed management and support . 8
In the first five minutes , the goal is to initiate intravenous ( IV ) access with two large-bore IV catheters , depending on the age and size of the child . If IV access is unable to be acquired , then intraosseous ( IO ) access should be obtained . Supplemental oxygen should be provided . If the child is in respiratory distress , consider high-flow nasal cannula or noninvasive , positive-pressure ventilation . 9
Treatment goals in the first 15 minutes should include obtaining laboratory tests , preparing IV antibiotics , and fluid resuscitation . An initial volume of 20 mL / kg of an isotonic solution should be administered . Crystalloid fluids , such as normal saline and Ringer ’ s lactate , are equally effective as colloids . These fluids should be rapidly pushed via 60 mL syringes or a rapid infuser should be used . IV infusion pumps may be too slow . It is crucial to frequently reassess the patient ’ s response to IV fluids to monitor for fluid overload . Signs of fluid overload include crackles in the lungs , hepatomegaly , and / or deleterious heart rate response . The total goal for fluid resuscitation is 60 mL / kg within the first 60 minutes . When a child remains in a state of shock after 60 mL / kg of rapid fluid resuscitation , the patient is diagnosed with fluid-refractory shock ( i . e ., septic shock ). Neonates and children with renal or cardiac disease with septic shock should receive less aggressive fluid therapy . These children require closer attention and evaluation after boluses to assess for fluid overload .
The Surviving Sepsis Guidelines emphasize the importance of antibiotic administration within one hour of sepsis recognition [ 9 ]. Mortality increases with every one-hour delay in the administration of antibiotics ; this reaches statistical significance once a three-hour delay in the initial dose occurs . 10 If obtaining IV access is difficult , many antibiotics can be given intramuscularly . Start with broad-spectrum antibiotics . Empiric treatment with ceftriaxone and vancomycin provides considerable gram-negative and gram-positive coverage . Additionally , these antibiotics are
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Darren O ’ Quinn
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Volume 117 • Number 7 JANUARY 2021 • 159