UMEM Educational Pearls

Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.

Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).

The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.

A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.

Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

Additional Information

For respiratory distress and hypoxia: Infants have a lower FRC and can desaturate very quickly!

Supplemental O₂ should be delivered via face mask or nasal cannula or other devices such as high flow nasal cannula or nasopharyngeal CPAP, even if O₂ saturation levels appear normal with peripheral monitoring devices

For improved circulation: utilize peripheral IO early

Peripheral IV or IO access can be used for fluid resuscitation, inotrope infusion, and antibiotic delivery when central access is not readily available or obtainable

Initial therapeutic resuscitative end points: hypotension and poor capillary refill may portend imminent cardiovascular collapse!

• Capillary refill of < or = 2s
• Normalization of heart rate for age
• Normalization of blood pressure for age
• Lack of difference between central and peripheral pulses
• Warm extremities
• Urine output >1mL/kg/hr
• Normal level of consciousness

Antibiotics and source control: Early and aggressive source control is key, just as in adults!

• In up to 75% of pediatric sepsis cases, the underlying pathogen(s) remain unknown,
• A child’s immune system is incompletely formed, and they are markedly more susceptible to viruses and encapsulated bacteria
• Empiric antibiotics should be administered within 1 hour
• Blood cultures prior to antibiotics is preferred, but should not delay starting antibiotics
• Tailor antimicrobials to epidemic and endemic ecologies and consider resistant organisms
• Clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension
• C. diff. colitis should be treated with enteral antibiotics if possible, with vancomycin preferred in severe cases

Fluid resuscitation: Support the pump, and fill, but don’t overload the tank!

• Bolus 20 mL/kg fluid (isotonic crystalloid) IV/IO over 5-20min or faster if needed
• Repeat 20 mL/kg bolus of fluid (up to 60 mL/kg) until clinical symptoms improve or patient develops respiratory distress/rales/ hepatomegaly
• Titrate to reversing hypotension, increasing urine output, and attaining normal capillary refill, peripheral pulses, and level of consciousness
• If hepatomegaly or rales are present, consider early inotropic support and carefully titrated fluids
• Use diuretics to reverse fluid overload when shock has resolved, and if unsuccessful then CVVH or intermittent dialysis to prevent >10% total body weight fluid overload
• In non-hypotensive children with severe hemolytic anemia (i.e. severe malaria or sickle cell crisis) blood transfusion is considered superior to crystalloids
• Consider adrenal insufficiency in refractory shock and give hydrocortisone accordingly

Inotropes and vasopressors: not just Levo for all!

• Normotensive shock (impaired perfusion but normal blood pressure): Dopamine 2-20 mcg/kg/min IV/IO, titrate to desired effect; if continued poor perfusion, consider dobutamine infusion 2-20 mcg/kg/min IV/IO, titrate to desired effect (may cause hypotension, tachycardia)
• Warm shock (warm extremities, flash capillary refill): Norepinephrine 0.1-2 mcg/kg/min IV/IO infusion, titrate to desired effect
• Cold shock (cool extremities, delayed capillary refill): Epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrate to desired effect

Extracorporeal Membrane Oxygenation (ECMO)

Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

Blood products

• In hemodynamically unstable children in shock on pressors, hgb levels of ≥10 g/dL are targeted
• In stable critically ill children, a lower hgb target of ≥7.0 g/dL is recommended
• Similar platelet transfusion targets in children as in adults
• Consider plasma therapies in children to correct sepsis-induced thrombotic disorders
• IV immunoglobulin may also be considered

Mechanical ventilation

• If mechanical ventilation is required, then cardiovascular instability during intubation may be less likely after appropriate cardiovascular resuscitation
• Use lung-protective strategies during mechanical ventilation
• Sedation/analgesia is recommended in critically ill mechanically ventilated kids with sepsis

Glycemic control

• Watch for hypoglycemia (neonates < 45 mg/dL, infants/children < 60 mg/dL)
• Control hyperglycemia using similar targets as in adults < or = 180 mg/dL

References

Randolph AG & McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014: 1;5(1):179-89. doi: 10.4161/viru.27045.

Wheeler DS, Wong HR, Zingarelli B. Pediatric Sepsis - Part I: "Children are not small adults!" Open Inflamm J. 2011: 7;4:4-15. doi: 10.2174/1875041901104010004.