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Dr Mostafavi NDepartement of Pediatric infectious Disease

Isfahan University of Medical Sciences

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Case 1An 8 month old boy brought to your

clinic with complain of high fever, poor intake, and . On examination the child has Ta= 39.5⁰С, RR= 35/min , HR= 130/min, cold extremities, NL blood pressure. Other wise the child is Ok. CBC revealed WBC= 18,000; PMN= 80%, PLT= 225,000.

What's your diagnosis?what do you do?23/09/1391 3

Case 2An 8 month old boy brought to your

clinic with complain of high fever and lethargy. On examination the child has RR= 65/min , grunting, HR= 180/min, weak pulses, cold extremities, and hypotension( not detectable).

What's your diagnosis?what do you do?

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Sepsis characteristicsAcute Fulminate courseDistributive shock( first tachycardia, tachypnea then hypotension)

Bacteremia of focal infection

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Shock= ↓cardiac output Hypovolemic: ↓ preload Distributive: ↓

afterload Cardiogenic: ↓

inotropy, ↓ chronotropyObstructive: ↑

afterloadSeptic : ↓ preload, ↓

afterload, ↓ inotropy

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Sepsis = systemic inflammatory response syndrom due to infection

Core T> 38.3 or <36Unexplained tachycardia or in < 1 yr

bradycardiaUnexplained tachypnea or need to MVWBC> 15000 or < 4000 or band cell>

10%At least first or last criteria & at least

2 out of 4 criteria23/09/1391 7

Tachycardia < 2 mo: > 180/min2-12 mo: 160/min1-2 yr: 120/min2-8 yr: 110/min> 8 yr: 100/min Each ⁰C increase in temperature

increase heart rate by 10-12/min

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Tachypnea< 2mo: > 60/min2-12 mo: > 50/min1-5 yr: > 40/min6-8 yr: > 30/min> 8 yr: > 20/minEach ⁰C increase in temperature

increase respiratory rate by 4-10/min

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Hypotension( SBP in mmHg) Neonate< 60 1-12 mo< 701-10 yr < 70 + 2 age( yr)> 10 yr < 90

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DefinitionsSepsis: pre-shock due to infection Severe sepsis: infection+

Reversible shock Organ hypo-perfusion( acidosis,

oliguria, ↑CRT) Organ dysfunction( coma, ARDS, ARF,

DIC, cytopenia, coagulopathy, hepatic failure(

Septic shock: irreversible shock due to infection

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Case 1An 8 month old boy brought to your

clinic with complain of high fever, poor intake, and . On examination the child has Ta= 39.5⁰С, RR= 35/min , HR= 130/min, cold extremities, NL blood pressure. Other wise the child is Ok. CBC revealed WBC= 18,000; PMN= 80%, PLT= 225,000.

What's your diagnosis?what do you do?23/09/1391 12

Case 1Diagnosis Plan Fever without source in 3-36 mo old with WBC> 15,000

B/C and U/C then Intravenous ceftriaxone, F/U

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Case 2An 8 month old boy brought to your

clinic with complain of high fever and lethargy. On examination the child has RR= 65/min , grunting, HR= 180/min, weak pulses, cold extremities, and hypotension( not detectable).

What's your diagnosis?what do you do?

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Case 2Diagnosis Plan

Severe sepsis, or septic shock

Treatment of sepsis

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Steps in the treatment of sepsis1. Maintenance of efficient respiratory

function2. Restoration of adequate tissue

perfusion 3. Control of the infectious agent4. Laboratory evaluation 5. Supportive care for organ

dysfunction23/09/1391 16

1. Efficient respiratory functionHigh flow oxygen ( O2 sat> 92%)

Periodic suctioningAmbu ventilationIntubation and MV if impending to respiratory failure

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2. Restoration of adequate tissue perfusionIV or IO access20 mL/kg N/S up to 60-80 mL/kg in 1st hour sometimes

as much as 200 mL/kg unless cardiogenic shock Coloid if needed( ↓alb., ↑PT & PTT, ↓Hb)Dopamine after 40cc/kg via peripheral IV lines, with

close monitoringCentral IV line( fluid up to CVP< 10-15, then

dopamine)Epinephrine in cold shock and norepinephrine in

warm shock via central IV linesDobutamine, hydrocortisone, … in special

circumstancesTo normalize HR, U/O, CRT, MS 23/09/1391 18

Cardiogenic shockSmaller boluses of fluid (5-10 mL/kg)Early initiation of myocardial

support with dopamine or epinephrine

Administering an inodilator, such as milrinone, early in the process.

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3. Control of the infectious agentPredisposing factor

Microorganisms Best antibiotics

Neonates GBS, enteric g-s, L. monocytogen

Ampicillin+ cefotaxime and/or gentamicin

Infants and children

N. meningitidis, H.influenza type b, S. pneumonia

Cefotaxime+ vancomycin

Abdominal source

enteric g-s, anaerobes, enterococci

Clindamycin+ gentamicin+ ampicillin

Urinary source

enteric g-s Cefotaxime+/- gentamicin

Immunodeficiency

enteric g-s, P. aueroginosa, S. aureous, fungi

Cefepime/ imipnem+ vancomycin+/- amphotericin

Hospital acquired

Resistant enteric g-s, P. aueroginosa, S. aureous

Cefepime/ imipnem+ vancomycin23/09/1391 20

4.Laboratory evaluation CBC diff: ↑ or ↓ WBC, ↓plt, ↓HbESR> 30, ↑CRP, ↑procalcitoninPeripheral smear: howel- jolly bodies,

fragmented RBC↑PT, ↑PTT, ↑D-dimer, ↑FDPABG: Res. Alkalosis, Res. Alkalosis +Met.

Acidosis, Mixed Acidosis, hypoxemiaLFT: ↑AST, ↑ALT, ↓Alb, ↑Bil

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4. Laboratory evaluation ↑ or ↓ BS, ↓Ca, ↓Na , ↑TG↑BUN, ↑CrCXR: ARDSGram stain of buffy coat &

petechia/purpuraB/C, U/C, CSF/CU/A, CSF analysis

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5. Supportive care for organ dysfunctionDisorder Goals (

prevent/treat)Therapies

ARDS Hypoxia, respiratory acidosis

O2

Respiratory muscle fatigue

Barotruma Early intubation and MV

Central apnea

Decrease work of breathing

MV

Renal failure Hypovo/hypervolemia, hyperkalemia, acidosis, hypo/hypernatremia, hypertension

Judicious fluid therapyLow dose dopamine, establish NL U/O and BPLasix, dialysis

Coagulopathy( DIC)

Bleeding Vit.K, FFP, PLT

Thrombosis Abnormal clotting Heparin, activated pr C

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Supportive care for organ dysfunctionDisorder Goals (prevent/treat)

Therapies

Stress ulcer

Gastric bleeding, aspiration, distension

H2 blocker, PPI, Fix NG tube

Ileus, bacterial translocation

Mucosal athrophy

Early enteral feeding

Adrenal insufficiency

Adrenal crisis Stress dose, physiologic dose

Metabolic acidosis

Correct etiology, normal PH

Treatment of hypovolemia, cardiac dysfunction, renal excretion, bicarbonate if PH< 7.1 and adequate ventilation

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0-5 minHigh flow O2

Suctioning, ventilation if neededEstablish IV/IO access

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5-15 minPush 20 cc/kg NS and over 60 cc/kg until

Perfusion improved( HR, CRT, U/O, MS) Rales Hepatomegaly

Check BS and correct hypoglycemiaSend lab exams, CXRStart antibiotic ( ceftriaxon, vancomycin)Start dopamine after 2nd dose( 6BW/100cc

DW5%, micro-drop 3-10 drop/min)

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15-40 minEstablish CVC, ITTTitrate dopamine after 2nd dose( 6BW/100cc

DW5%, micro-drop 3-10 drop/min) Start and titrate epinephrine (

0.6BW/100cc DW5%, micro-drop 0.5-30 drop/min) for cold shock

Start and titrate norepinephrine ( 0.6BW/100cc DW5%, micro-drop 0.5-15 drop/min) for warm shock

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40-60 Start hydrocortisone 50-100 mg/m2 if catecholamine-resistant shock and at risk of adrenal insufficiency

Transfer to PICU

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Conclusion Unexplained ↑ RR and HR as early signs of

shock and sepsisEarly oxygen and ventilation therapyAggressive fluid and inotropic therapyColoid therapy in suspected cases Early antibiotic therapy before sending to

PICUEarly check of BS23/09/1391 29

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