17.8 Resuscitation Flashcards
You are called to the emergency department to see a 2-year-old child who presents with a four-hour
history of high temperature and drowsiness. On examination, there is prolonged capillary refill time and a non-blanching rash.
A presumptive diagnosis of meningococcal septicaemia is made.
a) What are the normal weight, pulse rate, mean arterial blood pressure and capillary refill time for a
child of this age? (4 marks)
Weight
12–17 kg.
Traditionally, 2 (age in years + 4),
but as this tends to underestimate
weight, a newer calculation is
3 (age in years) + 7
Pulse rate
95–140 bpm.
Mean arterial blood pressure
58 mm Hg.
(1.5 × age in years) + 55.
Capillary refill time
Less than two seconds
b) Define appropriate resuscitation goals for this child (2 marks) and
Resuscitation goals:
» Capillary refill time less than 2 seconds.
> > Mean arterial pressure 58 mm Hg.
> > Normal pulses with no differential
between central and peripheral.
> > Warm extremities.
> > Urine output greater than 1 ml/kg/h.
> > Normal mental status.
outline the management in the
first 15 minutes after presentation. (7 marks)
Meningococcal septicaemia is a medical emergency and so I would assess and manage the patient simultaneously following an ABCDE approach.
Request senior help and give ceftriaxone 80 mg/kg intravenously without delay.
Initiate communication with paediatric retrieval service and download guidance to assist with drug dosing.
A: Assess airway patency – consider need for immediate intubation for either
respiratory compromise or moribund state.
B: Assess respiratory rate, oxygen saturations, give 100% oxygen.
C: Intravenous access, ideally two cannulae. Obtain intraosseous access if intravenous access not immediately feasible.
Assess for signs of shock:
» Capillary refill time greater than 2 seconds.
» Unusual skin colour.
» Tachycardia and/or hypotension.
» Cold hands/feet.
» Toxic/moribund state.
» Altered mental state/decreased conscious level.
» Poor urine output.
Treat shock with up to three boluses of
20 ml/kg 4.5% human albumin solution *
or 0.9% sodium chloride each over 5–10 minutes.
c) After 15 minutes, the child remains shocked and is unresponsive to fluid. What is the most likely
pathophysiological derangement in this child’s circulation (2 marks) and
The child has developed septic shock:
in addition to the organ dysfunction
occurring as a result of the child’s physiological response to infection,
shock has developed due to circulatory,
cellular and metabolic dysfunction.
Consequences include vasodilatation,
activation of inflammatory and coagulation cascades, capillary leak and dysfunctional oxygen utilisation at
cellular level.
what are the important further
treatment options? (5 marks)
Intubation at third bolus
Retrieval team
Further fluid boluses may be required: consider using blood.
Consider contributing causes to shock: acidosis, extravasation of fluids.
Initiate vasoactive support as per retrieval team guidance.
D: Continue to monitor the child’s mental state (GCS or AVPU scoring) and need for intubation.
Assess for signs of meningism.
E: Examine child, look for rash, check capillary blood glucose.
BJA extras Sepsis in Paeds
Key points
1 • Early signs of septic shock include tachycardia and derangements in temperature, mental status and peripheral perfusion.
2• In younger children, intraosseous (i.o.) access is often easier and achieved more quickly than i. v. access.
3 • Broad-spectrum antibiotics should be given within 1 h of presentation.
4 • Children in septic shock are often extremely dehydrated and respond favourably to initial resuscitation with fluids.
5• Infusions of inotropic drugs can be started through either the peripheral i.v. or i.o. routes.
Mortality can be over 10%, and influenced by the child’s age and comorbidities, source of infection, causative organism and management.
Definitions
why difficult - general concept
Third international consensus defn for sepsis + shock 2016
Definitions
The pathophysiology of sepsis is complex, involving an altered inflammatory response to infection, paired with derangements in coagulation, cardiovascular, immune, metabolic, hormonal and neuronal responses.
Life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock, is associated with higher mortality and can be defined as sepsis accompanied by significant circulatory, cellular and metabolic abnormalities
Pending updated definitions
In the meantime, paediatric sepsis continues to be discussed in terms of the systemic inflammatory response syndrome (SIRS) criteria, defined as the presence of at least two of the following four criteria, one of which must be abnormal temperature or leucocyte count
Definitions
why difficult - general concept
Third international consensus defn for sepsis + shock 2016
Definitions
The pathophysiology of sepsis is complex, involving an altered inflammatory response to infection, paired with derangements in coagulation, cardiovascular, immune, metabolic, hormonal and neuronal responses.
Life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock, is associated with higher mortality and can be defined as sepsis accompanied by significant circulatory, cellular and metabolic abnormalities
Pending updated definitions
In the meantime, paediatric sepsis continues to be discussed in terms of the systemic inflammatory response syndrome (SIRS) criteria, defined as the presence of at least two of the following four criteria,
one of which must be abnormal temperature or leucocyte count
Sirs
septic shock
(i)
Core temperature of >38.5°C or <36°C
(ii)
Tachycardia, defined as a mean HR >2 standard deviations (sd) above normal for age in the absence of external stimulus, chronic drugs or painful stimuli; or otherwise unexplained persistent increase in HR over a 0.5–4 h time period; or for children <1 yr old: bradycardia, defined as a mean HR <10th percentile for age in the absence of external vagal stimulus, beta-blocker drugs or congenital heart disease; or otherwise unexplained persistent decrease in HR over a 0.5 h time period
(iii)
Mean ventilatory frequency >2 sd above normal for age or mechanical ventilation for an acute process not related to underlying neuromuscular disease or the receipt of general anaesthesia
(iv)
Leucocyte count increased or decreased for age (not secondary to chemotherapy-induced leucopenia) or >10% immature neutrophils
Systemic inflammatory response syndrome in the presence of a known or suspected infection is considered diagnostic of sepsis.6 When cardiovascular organ dysfunction exists in the presence of sepsis, the child is considered to be in septic shock.6
The consensus criteria define cardiovascular organ dysfunction as despite giving isotonic i. v. fluid bolus ≥40 ml kg
(i) Decrease in BP (hypotension) <5th percentile for age or systolic BP <2 sd below normal for age, or
(ii) Need for vasoactive drug to maintain BP in normal range (dopamine >5 kg−1 min−1, or dobutamine, adrenaline [epinephrine] or noradrenaline [norepinephrine] at any dose), or
(iii) Two of the following:
(a) Unexplained metabolic acidosis: base deficit >5.0
(b) Increased arterial lactate >2 times upper limit of normal
(c) Oliguria: urine output <0.5 ml kg−1 min−1
(d) Prolonged capillary refill: >5 s
(e) Core to peripheral temperature gap >3°C
Recognition
Resus Bundles
Shock
American College of Critical Care Medicine
Warm Shock
Norad first
0.05-3mcg / kg / Min
then vaso
.002-0.2 u / kg min
Cold Shock
Adrenaline 1st
0.05 - 3 mcg kg min
then norad
then milrinone
catechol resistant
Rule out
PTX Tamponadte
IAH
Adrenal supression - streoids
Thyroid repalcement
It is advisable to dilute peripheral adrenaline by a factor of 10 to that given centrally.9 The limb, in which adrenaline is infusing, should be monitored closely for signs of infiltration and ischaemia.
Antibiotics
Broad-spectrum antibiotics should be given to the child with sepsis within 1 h of presentation.10 Ideally, blood cultures should be sent before giving antibiotics. However, attaining i.v. access can be difficult in children and should not delay antibiotics that can be given by i.m. injection
The initial antibiotics should be broad spectrum and cover endemic and suspected Gram-negative and Gram-positive organisms, based on source and suspected site of infection.13 Combination therapy of at least two antibiotics should be used in septic shock.
Source control
Although an obvious source of infection is often not apparent in up to 50% of children with sepsis, in those children with an identifiable source, early and aggressive source control is fundamental to their management.10 Once intravascular or i.o. access has been attained, indwelling lines, if present, should be removed.10,13 Debridement and drainage of wounds should occur expediently, and intraperitoneal sources, such as a perforated viscus, should be repaired with peritoneal washout as soon as medically and logistically possible.1
Anasthesia paeds algoritihm - see saved images
Saved image - key pts
IV access x 2 / Central
IO inarporp for surger
cosnider cvc under sedation prior to induction
Review sepsis panel
Transfuse hb >10
correct coagulopathy (Plt ffp / cryo
Correct hypogylcaemia
correct a/b abnorm
abx approp
Induction
preo2
consider bolus
infusion prep/ commenced before inductionn
consider invasive monitor
prioritise HD over risk of aspiration
Intraop
titrate anaesthetic
achieve adequate depth
lac <2
Repeat abc every 2 half lives
LV vent
Postop
? remain I+V
Pain octnrol
picu
intensivist and ID specialist
