peds moment sepsis raphael paquin, pgy-4 pem fellow aug 20, 2009
TRANSCRIPT
Peds momentPeds momentSepsisSepsis
Raphael Paquin, PGY-4Raphael Paquin, PGY-4
PEM fellowPEM fellow
Aug 20, 2009Aug 20, 2009
Definition:
SIRS + Suspected or proven infection
SIRS Criteria: 2 of:• Fever (>38.5) or hypothermia (<36)• Tachypnea• Tachycardia or bradycardia• Leucocytosis or leucopenia
&%!#$ Pediatrics!!
Age Tachy-pnea
Brady-cardia
Tachy-cardia
WBC BPsyst
0-7d >50 <100 >180 >34 <59
7d-1m >40 <100 >180 >19.5, <5 <79
1m-1y >34 <90 >180 >17.5, <5 <75
2-5y >22 NA >140 >15.5, <6 <74
6-12y >18 NA >130 >13.5,<4.5 <83
13-17y >14 NA >110 >11, <4.5 <90
Goldstein et al, Ped Crit Care Med, 2005
Classification of sepsis• Sepsis: SIRS + susp/proven infection• Severe sepsis: sepsis + one of:
• ARDS• Cardiovascular dysfunction• 2 end-organ dysfunctions (neuro, hem, renal, hepatic)
• Septic shock: sepsis + cardiovasc dysfct• HypoTN (despite 40cc/kg of IVF)• Use of pressors• > 2 signs of hypoperfusion
– Lactate 2x > N values– Diuresis < 0.5cc/kg/hr– Capillary refill > 5 sec– Central temp - peripheral temp > 3 deg C.
Age and bugs, roughly…
Listeria
E. coli
GBS
Strept pneumoHaemophilusInfluenzaeNeis. mening.
0-1 mo 1-3 mos >3mos
LEG&SHIN
Bugs & Immunodeficiencies
• Usual bugs as well as:• Staph aureus, staph viridans, CoNS
(incresed risk if central catheter)• Gram -ve: pseudomonas, Klebsiella,
enterococcus.• Fungi: aspergillus, candida,
pneumocystis• Protozoan: toxoplasma,
cryptosporidium
SURVIVING SEPSIS
EARLY GOAL-DIRECTED THERAPY… with a pediatric twist…
• Central line for Central/Mixted Venous O2 sat rarely available in the resuscitation room
• BP drops much later in peds than in adult patients
– Therefore, even though the theoretical cvO2 sat goal >70%, authors suggest using indirect measurement-related objectives:
» Cap refill <2 sec» Normal LOC» Decreasing lactate level
Surviving sepsisThis hour has 60 minutes…• A-B
– Goal: O2 sats > 95% w FiO2 0.4-1.0.– Early intubation/ventilation
• Decreased LOC• Severe hypoxemia
– PaO2 <60 mmHg or O2sat <88-90% w FiO2 0.6-0.8
• Persistent hypercapnea – PaCO2 >50-55mmHg
• Severe hyperventilation• Hypotension refractory to initial management
Surviving sepsisThis hour has 60 minutes…
• C– 1-2 large bore PIV +/- CVL– Rapid infusion of crystalloids (20cc/kg bolus ad 60-
80cc/kg) regardless of BP– Then consider colloids (alb 5% or synthetic)
• 5-10cc/kg boluses– Arterial line– Foley catheter to monitor urine output.– Critical blood samples when starting PIV:
• CBC, gas, lytes, urea/creat, glycemia, lactate, BC
Surviving sepsis (cont’d)
• C targets– cvO2 >70%, mvO2 >65%– MAP:
• <1mo: > 45• 1mo-10y: >60• >10y: >65
– CVP: >8 mmHg– Urine output: > 0.5cc/kg/hr– Hematocrit: >30%
Surviving sepsis (cont’d)
• Refractory shock @ 30 minutes– Start pressor (dopamine, norepi, epi)– Susp. myocardial dysf: add dobutamine– Eventually add vasodilator (nitroprussiate,
milrinone) if refractory cold shock
• Refractory shock at 60min:– Hydrocortisone 1mg/kg q6h (Parker et al, Crit
Care Med, 2004)
Oh yeah, how about treating the cause?!?
• Start empiric therapy ASAP (if possible, after having collected blood, urine, CSF, ETT cultures)
• DO NOT DELAY TX!!!• Of course, empiric treatment depends on
age(!), suspected focus of infection and immunodeficiency status.
Empiric antibiotic treatment• No or occult focus:
– 0-1mo: amp + aminoside (or cefotax)– 1-3mos: amp + cefot +/- vanco– >3mos: 3GC + vanco +/- aminoside
• Resp focus: 3GC + antistaph pen +/- vanco• Meningitis
– 0-1mo: amp + cefotax + aminoside– >1 mo: 3GC + vanco
• Urinary focus: amp + aminoside• Purpura fulminans: 3GC• CVL: 3GC + vanco + gent• Cutaneous
– Strept susp: amp or penG + clinda if toxin-related Sx– Non MRSA staph: Clox or vanco + clinda if toxin-related Sx
The curious case of immunosuppression
• Pip/tazo + vanco (or antistaph pen) + aminoside
• +/- antifungal Tx: ampho B +/- fluco, etc.
• +/- antiviral Tx: aciclovir, ribavirine, etc.
Okay, we’re done…PICU admission criteria
• Absolute criteria:– Mechanical ventilation– Vasopressor infusion– Respiratory failure
(FiO2 >0.5 for O2 sats >95%), heart fail, renal failure, decreased level of consciousness.
– Purpura fulminans
• Relative indications:– Stabilized patient still
requiring aggressive fluid management
– 2 mild end-organ dysf.– Elevated lactate– Suspected
meningococcemia (fever and petechiae)