1 / 19

Peds moment Sepsis

Peds moment Sepsis. Raphael Paquin, PGY-4 PEM fellow Aug 20, 2009. Recognising sepsis. Definition:. SIRS + Suspected or proven infection SIRS Criteria: 2 of: Fever (>38.5) or hypothermia (<36) Tachypnea Tachycardia or bradycardia Leucocytosis or leucopenia. &%!#$ Pediatrics!!.

bikita
Télécharger la présentation

Peds moment Sepsis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Peds momentSepsis Raphael Paquin, PGY-4 PEM fellow Aug 20, 2009

  2. Recognising sepsis

  3. Definition: SIRS + Suspected or proven infection SIRS Criteria: 2 of: • Fever (>38.5) or hypothermia (<36) • Tachypnea • Tachycardia or bradycardia • Leucocytosis or leucopenia

  4. &%!#$ Pediatrics!! Goldstein et al, Ped Crit Care Med, 2005

  5. 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.

  6. L E G S H I N Age and bugs, roughly… 0-1 mo 1-3 mos >3mos

  7. Listeria E. coli GBS Streptpneumo Haemophilus Influenzae Neis.mening. Age and bugs, roughly… 0-1 mo 1-3 mos >3mos L E G & S H I N

  8. 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

  9. SURVIVING SEPSIS EARLY GOAL-DIRECTED THERAPY… with a pediatric twist…

  10. 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

  11. 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

  12. 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

  13. 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%

  14. 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)

  15. 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.

  16. 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

  17. The curious case of immunosuppression • Pip/tazo + vanco (or antistaph pen) + aminoside • +/- antifungal Tx: ampho B +/- fluco, etc. • +/- antiviral Tx: aciclovir, ribavirine, etc.

  18. 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) Okay, we’re done…PICU admission criteria

  19. Surviving (talk on) sepsis: Congrats!!!

More Related