Kids aren't little adults.  Pediatric sepsis and septic shock normally presents as 'cold daze' where as adult septic daze commonly presents as 'warm shock', for example.  In this episode, a continuation of our discussion on Fever from with Ottawa PEM experts, Sarah Reid and Gina Neto, nosotros discuss the pearls and pitfalls in the recognition and direction of pediatric sepsis and septic shock. We review the subtle clinical findings that will help you pick upward septic shock before it's too late as well as key maneuvers and algorithms to stabilize these patients. We cover tips for using IO in children, induction agents of selection, timing of intubation, ionotropes of choice, the indications for steroids in septic stupor, and much more…..

Written Summary & Blog post Prepared by Michael Kilian & Niran Argintaru, edited by Anton Helman, Baronial 2014

Cite this podcast as: Helman, A, Reid, S, Neto, G. Recognition and Management of Pediatric Sepsis and Septic Shock. Emergency Medicine Cases. Baronial, 2014. https://emergencymedicinecases.com/episode-50-recognition-management-pediatric-sepsis-septic-shock/. Accessed [date].

Pediatric Sepsis

Sepsis in children is a relatively rare emergency department presentation. Although simply nigh 0.35% of pediatric emergency department visits are for sepsis, the bloodshed charge per unit is equally high equally 2 to x% (1,2). Having a sepsis guidelines protocol in the emergency department can decrease bloodshed from 5% to equally low as 1% (2)

Cherry-red Flags in the Recognition of Pediatric Sepsis

  1. Age:
  2. Of the children <1yr, almost will be
  • Unexplained tachycardia (later on correcting for fever – see below)
  • Clinical signs:
    1. Poor perfusion (long cap refill, lethargy, irritability)
  • Conditions that predispose to sepsis: neuromuscular disease, immunocompromised, respiratory atmospheric condition, cardiac disease
  • Contempo surgery

Temperature Corrected Centre Rate and Respiratory Charge per unit

**Recall from podcast 48, rule of thumb – Centre Rate increases by approximately 10 beats/min and Respiratory Rate by five breaths/min for every Celsius degree (1.8 caste of Fahrenheit) of fever >38°C

Normal Pediatric Vital Signs

Age Middle Rate (beats/min) Claret Force per unit area (mm Hg) Respiratory Rate (breaths/min)
Premie 120-170 55-75/35-45 40-seventy
0-3 mo 100-150 65-85/45-55 35-55
3-six mo ninety-120 seventy-90/50-65 30-45
six-12 mo lxxx-120 80-100/55-65 25-40
1-3 yr 70-110 90-105/55-lxx 20-30
iii-6 yr 65-110 95-110/threescore-75 20-25
half-dozen-12 twelvemonth lx-95 100-120/60/75 14/22
12 > twelvemonth 55-85 110-135/65/85 12-18

Hypotension is a Belatedly Sign of Pediatric Septic Daze

  • Be very cautious in setting of tachycardia and Practice Non WAIT for hypotension to make diagnosis of septic shock.
  • A pediatric patient with hypotension and sepsis is a pre-arrest patient.

Investigations in Sepsis

Blood work should include CBC, electrolytes, glucose, kidney function, blood gas, blood cultures, LFTs, and lactate. Urine cultures are commonly washed to identify a possible source. Clinical history guides imaging such as breast x-ray.

ABC – DEFG = ABC, DON'T EVER FORGET GLUCOSE

Up to 25% of children with septic shock will have adrenal insufficiency, so always bank check glucose in septic children. Extremes in claret glucose in sepsis are associated with higher mortality in children (2). Arterial lactate 2 times upper limit of normal indicates organ dysfunction.

Acute Management of Pediatric Sepsis

Fluid Resuscitation in Pediatric Sever Sepsis and Septic Daze

Circulation is of paramount importance in this patient and COMES Before AIRWAY and all other concerns. Thus the approach should exist CAB:

1) Apportionment, two) Airway, 3) Breathing.

Establishing Iv access in a septic child can be very difficult, especially in the setting of hypotension. If, after 1MINUITE of trying, you cannot establish 4 access, motility to IO (ideally x2).

Initial fluid goal: 60cc/kg of NS in first hour (3)(2)

  1. Older children: level 1 infuser

Claret pressure should not be a deciding factor in giving fluids. All septic patients should receive the initial boluses.

Intraosseous Access (IO)

IO access tin can be used in all ages, even in awake patients. Studies show that the pain from the IO comes more from the actual infusion than the insertion (5). In social club to decrease pain, consider infiltrating lidocaine into the os prior to infusion of fluids. The possibility of pain should not cause hesitation in establishing IO admission. (2)

Sites (in this order of preference):

  1. Proximal tibia
  2. Distal femur
  3. Proximal humerus

You tin can administer the aforementioned agents through an IO equally an IV (fluids, antibiotics, vasopressors etc.)(ii)

Initial Antibiotic Choice: Ceftriaxone 100mg/kg IV push(2)

When to intubate in Pediatric Sepsis and Septic Shock?

Consider early on intubation in fluid refractory septic daze (after 3 boluses of 20ml/kg Four NS) or in any compromised airway.

Infants or neonates with severe sepsis may require early intubation. Intubation and mechanical ventilation increases intrathoracic pressure which reduce venous render and lead to worsening stupor. Therefore, fluid resuscitation must be done first. emergency management of pediatric seizures

Choice of medications in intubation

There is no strong data supporting any particular induction agents or paralytic agents in the intubation of a septic kid.

Ketamine Drug of choice as it is relatively rubber in hypotension and tachycardia. However, catecholamine depletion can cause refractory hypotension and result in worsening shock.
Propofol Should not be used for long-term sedation in children younger than 3 years old because of an clan with fatal metabolic acidosis.
Etomidate Should exist discouraged or used carefully in septic shock as information technology inhibits the adrenal axis and sympathetic nervous organization affecting hemodynamic stability. Etomidate is associated with increased bloodshed in children with meningococcal sepsis because of adrenal suppression effect.

Succinylcholine ane mg/kg (or 2mg/kg in infants) 4 or Rocuronium 0.45-0.6 mg/kg Iv are both reasonable choices for paralytic agents.

Fluid Refractory Shock

If there are no signs of improvement within 1 60 minutes of aggressive fluid resuscitation (recall goal of 60cc/kg), the initiation of ionotropes is indicated. Consider which amanuensis yous volition employ early (during second bolus of 20cc/kg) then that it can exist ready to administer at 60min marking without filibuster if necessary. (2)

Cold vs. Warm shock

Most children have COLD shock, which is characterized past high SVR and depression cardiac output (this differs from adults who usually have low SVR and present with warm shock). Thus, children are poorly perfused, accept delayed cap refill with cold extremities and have a temperature differential between their core and their extremities. (5)

pediatric septic shock

Ionotropic Choices in Pediatric Septic Stupor

  1. Cold Shock: Epinephrine 0.05-0.3 mcg/kg/min and titrate to effect
  2. Warm Shock: Norepinephrine .05-0.3 mcg/kg/min and titrate to effect.

You tin safely start these inonotropes through a peripheral IV or IO. The lack of a central line should not delay the initiation of inonotropes at the 60min mark . (2)(5)

Adjunct Treatments in the Direction of Pediatric Sepsis and Septic Stupor

  • Glucose: Remember to cheque the glucose in all children and treat as necessary. Both hypo and hyperglycemia are associated with worse outcomes. For glucose <6mmol, start D10W 5cc/kg (avert higher concentration). (two)
  • Corticosteroids: The use of hydrocortisone in pediatric septic shock is currently beingness investigated and its role is unclear. Consider using hydrocortisone 2mg/kg in whatever kid that has fluid and inotropic resistant septic shock or proven adrenal insufficiency (one).

Goals of Resuscitation in Pediatric Septic Shock

Normalization of vital signs is a main goal. Aim for a normal blood pressure, pulse (without differences between fundamental and peripheral pulses).

Clinically, the child should have a normal capillary refill, warm extremities and urine output >1ml/kg/hour indicating improved perfusion. Lactate and mental condition should be normalized every bit well.

Cerebral Determination Aids in The Direction of Pediatric Sepsis and Septic Shock

ESTABLISHED PROTOCOLS for pediatric sepsis accept been shown to DECREASE Mortality. (5)(2) It is helpful to have your room equipped with PALS algorithms (6), broslow tapes, GCS and normal vital sign tables to facilitate timely and accurate decisions. See below for The Children's Hospital of Eastern Ontario pediatric sepsis algorithm.

Extra-Corporeal Membrane Oxygenation (ECMO)

If all else fails, ECMO can be used in the kid who is in cardio-respiratory failure and refractory to all treatment. (2) However, in Canada, this treatment is well-nigh exclusive to the ICU setting given all the resource involved.

 Children's Infirmary of Eastern Ontario Algorithm for Septic Stupor

PEds Sepsis Algorithm

Peds Sepsis Algorithm 2

PEM sepsis algorithm 5

PEM sepsis algorithm 8

Key Accept Home Points

  1. Hypotension is a late sign – do non expect for it to diagnose and aggressively care for pediatric sepsis.
  2. CAB, not ABCs – fluid 20ml/kg is the first priority even if normal BP. Aim for 3 boluses over the first hour. Don't filibuster using an IO!
  3. Early on goal directed therapy – early antibiotics! (ceftriaxone twenty 100mg/kg 4)
  4. Don't forget glucose –a large proportion of septic children take adrenal insufficiency, which is associated with increased mortality.

Now Test Your Knowledge

Answer: A history of recent surgery, neuromuscular illness, respiratory or cardiac desease or immunocompromised land should all increase your suspicion for sepsis in a child presenting to the ED with fever. Infants under 1 month of historic period are specially high take chances, and early on adolescents are also at chance.
Respond: Hypotension is almost universal in adults, where as unexplained tachycardia without hypotension signifies septic shock in children. Hypotension is a belatedly sign of septic shock in children. Whereas adults unremarkably present in 'warm shock', children normally nowadays in 'cold shock'. Finally, the incidence of adrenal insufficiency in septic shock is much college than in adults, and then hypoglycemia should be assessed and treated early in the direction of children in septic shock, and consideration of steroid therapy should be given in fluid refractory shock.
Respond: In improver to signs of poor perfusion (prolonged capillary refill, lethargy and irritability), a sometimes disregarded clue to the presence of septic daze is tachycardia that is out of proportion to fever (Hour increases by about 10bpm and RR past v breaths/min for every Celsius degree top of temperature to a higher place 38).
Answer: Aggressive fluid administration (60ml/kg NS) before attempts at intubation, unless a respiratory abort is imminent. The priorities of management in septic stupor is CAB (Circulation, Airway, Breathing) rather than ABC.
Respond: Ketamine, although not supported past any vigorous information, is usually the drug of selection as it is relatively safe in patients with hypotension.  Propofol is associated with fatal metabolic acidosis in children.
Answer: The goals of resuscitation in pediatric septic shock are the normalization of vital signs, normal mental condition, normal capillary refill, warm extremities, a urine output of >1ml/kg/hr and a normal lactate.

For more Pediatric EM learning visit ane of EM Cases newest collaborators trekk.ca – Translating Emergency Knowledge for Kids (TREKK) is a growing network of researchers, clinicians, health consumers and national organizations who want to accelerate the speed at which the latest knowledge in children'due south emergency care is put into practice in general EDs – rural, remote or urban.

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For more than information on paediatric shock on EM Cases:
Best Instance Ever 27: Pediatric Stupor

For more than EM Cases content on Paediatric Emergencies visit EM Cases Digest Vol. 2 Pediatric Emergencies hither.

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Dr. Helman, Dr. Neto and Dr. Reid have no conflicts of involvement to declare.

Fundamental References

1) Singhal S, Allen MW, Mcannally JR, Smith KS, Donnelly JP, Wang HE. National estimates of emergency department visits for pediatric severe sepsis in the United States. PeerJ. 2013;1:e79. Full Text

2) Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Intendance Med. 2013;41(2):580-637. Total text

3) Kleinman ME, Chameides L, Schexnayder SM, et al. Pediatric advanced life back up: 2010 American Eye Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010;126(five):e1361-99. Full Text

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