Diagnosis and management of sepsis Flashcards
Sepsis is a major cause of hospital admission, morbidity, and mortality in children. Sepsis is a systemic inflammatory response to the presence of suspected or proven infection. While tachycardia, tachypnea, and hyperthermia are classic features of sepsis, does the absence of fever in a young infant rule out sepsis as a possible diagnosis?
No - the absence of fever in an infant less than 60 days old does not eliminate the possibility of sepsis
Case 1: A 7-week-old infant presents with a history of decreased feeding and lethargy. On physical exam, he is irritable and his vital signs are: heart rate 185,respiratory rate 55, rectal temperature 35.8°C, blood pressure 100/62 (when crying). He appears mildly dehydrated and has slightly mottled extremities.
What empiric antimicrobials should be considered in this patient?
Empiric antibiotic therapy would include ceftriaxone or cefotaxime, and vancomycin (prescribed at appropriate meningitis doses)
Note: both bacterial and viral etiologies should be considered because their presentations can be similar in the young infant
Case 1: A 7-week-old infant presents with a history of decreased feeding and lethargy. On physical exam, he is irritable and his vital signs are: heart rate 185,respiratory rate 55, rectal temperature 35.8°C, blood pressure 100/62 (when crying). He appears mildly dehydrated and has slightly mottled extremities. This infant should undergo cultures of blood, urine, and cerebrospinal fluid (CSF) in addition to a complete blood count with differential (CBCD). What are indications for deferring a lumbar puncture (LP) in this case?
i) Clinical signs of respiratory or hemodynamic instability
ii) Other contraindications (e.g., coagulopathy, cutaneous lesions at the proposed puncture site, or signs of impending cerebral herniation)
Case 2: A 2-year-old child presents with a history of cough, fever of 39°C, and breathing difficulty. On examination, she appears unwell. Vital signs are: heart rate160, respiratory rate 35, blood pressure of 100/60 and a capillary refill time (CRT) of 3 seconds, with cool extremities. Oxygen saturation by pulse oximetry in room air is 89%. There is decreased air entry on the right side and chest X-ray reveals a right lower lobe infiltrate and pleural effusion. She is fatigued but responds appropriately during the physical exam. Is this patient considered septic? Why?
Yes - This patient’s fever, tachycardia, tachypnea, and her abnormal chest radiograph consistent with pneumonia and possible empyema, together fulfill the definition of sepsis
New definitions for adults recognize sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection”. In Pediatrics, sepsis-associated organ dysfunction in children is described as “severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction”. How is sepsis differentiated from septic shock?
According to the adult definition, both hypotension requiring vasopressors to maintain mean arterial pressure, and an elevated serum lactate despite adequate volume resuscitation must be present
In newly-published paediatric guidelines by Weiss et al, septic shock is defined as “severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication, or impaired perfusion)”
Many centres have developed sepsis “trigger tools” to aid in the rapid identification of patients with suspected sepsis and expedite access to medical evaluation and treatment. Examples of such tools include the TREKK PedsPacsSepsis Triage Poster and a tool developed by the American Academy of Pediatrics Pediatric Septic Shock Collaborative.
Most such tools incorporate what information as part of their scoring system?
i) vital signs abnormalities (in heart or respiratory rate, blood pressure, perfusion indicators such as CRT, pulse pressure, skin colour and temperature)
ii) mental status
iii) consideration of underlying medical conditions which entail higher risk for sepsis, such as age, malignancy, asplenia, immunodeficiency, or immunosuppression
Case 2: A 2-year-old child presents with a history of cough, fever of 39°C, and breathing difficulty. On examination, she appears unwell. Vital signs are: heart rate160, respiratory rate 35, blood pressure of 100/60 and a capillary refill time (CRT) of 3 seconds, with cool extremities. Oxygen saturation by pulse oximetry in room air is 89%. There is decreased air entry on the right side and chest X-ray reveals a right lower lobe infiltrate and pleural effusion. She is fatigued but responds appropriately during the physical exam. From an airway/breathing perspective, how should this patient be managed?
She should receive oxygen by face mask, or if her work of breathing is markedly increased, non-invasive ventilation may be considered
Case 2: A 2-year-old child presents with a history of cough, fever of 39°C, and breathing difficulty. On examination, she appears unwell. Vital signs are: heart rate160, respiratory rate 35, blood pressure of 100/60 and a capillary refill time (CRT) of 3 seconds, with cool extremities. Oxygen saturation by pulse oximetry in room air is 89%. There is decreased air entry on the right side and chest X-ray reveals a right lower lobe infiltrate and pleural effusion. She is fatigued but responds appropriately during the physical exam. From a circulation/fluids perspective, how should this patient be managed?
Peripheral intravenous (IV) access should be obtained, with consideration of intra-osseous needle insertion if peripheral venous access is not achieved rapidly. Fluid resuscitation should begin with a bolus of 10-20 mL/kg of balanced/buffered crystalloid solution (such as Ringer’s lactate, Plasma-Lyte/Normosol orisotonic saline), given over 5 to 20 minutes. Vital signs and peripheral perfusion should be monitored closely to evaluate the response to treatment, including potential fluid overload. Hepatomegaly or crackles on auscultation may suggest fluid overload. The bolus may be repeated depending on patient response, with frequent re-assessment
In a septic patient receiving supplemental fluids, clinical deterioration after bolus fluid administration, particularly in the presence of signs of volume overload, suggests the presence of what kind of shock? Other useful parameters to monitor in septic patients include: urine output, blood gases to assess presence of metabolic acidosis, serum lactate, bedside glucose, serum electrolytes, urea, and creatinine.
Cardiogenic shock
Case 2: A 2-year-old child presents with a history of cough, fever of 39°C, and breathing difficulty. On examination, she appears unwell. Vital signs are: heart rate160, respiratory rate 35, blood pressure of 100/60 and a capillary refill time (CRT) of 3 seconds, with cool extremities. Oxygen saturation by pulse oximetry in room air is 89%. There is decreased air entry on the right side and chest X-ray reveals a right lower lobe infiltrate and pleural effusion. She is fatigued but responds appropriately during the physical exam. Drainage of the pleural effusion may be considered for both diagnostic and therapeutic purposes. Blood cultures should be obtained before administration of antibiotics, but awaiting results should not delay initiation of antimicrobial therapy. Within what window of time should antibiotics be given? What would be appropriate empiric antimicrobial therapy in this case?
Antibiotics should be given ideally within 1 hour of diagnosing severe sepsis. Intramuscular or intraosseous injections can be used until IV access is obtained. The agents chosen should reflect the patient’s age and clinical presentation. In this case, a cephalosporin such as cefotaxime or ceftriaxone (in addition to vancomycin if methicillin-resistant Staphyloccus aureus (MRSA) is suspected, and depending on local epidemiology) would be appropriate in the presence of pneumonia and empyema
Case 3: A 15-year-old adolescent female is admitted for fever and weakness. She began her most recent menstrual period 3 days ago, and regularly uses tampons. On physical examination she is confused. Vital signs are: temperature 39.4°C, heart rate 150, respiratory rate 24, blood pressure of 80/24. She has diffuse erythroderma and her distal extremities are warm with bounding pulses and rapid CRT. She remains hypotensive despite 60 mL/kg of fluid boluses and initiation of appropriate antibiotics (cloxacillin and clindamycin). What is the underlying diagnosis? Which organism(s) is/are most likely to cause this presentation?
This patient shows signs of vasodilated septic shock: despite her warm extremities and bounding pulses, she is hypotensive and likely to have some degree of multi-organ dysfunction. The working diagnosis would be staphylococcal toxic shock syndrome.
Toxin-mediated sepsis can be caused by strains of S. aureus or Streptococcus pyogenes, which produce a superantigen toxin that causes over-activation of cytokines and inflammatory cells and leads to a characteristic pattern of multi-organ involvement.
Case 3: A 15-year-old adolescent female is admitted for fever and weakness. She began her most recent menstrual period 3 days ago, and regularly uses tampons. On physical examination she is confused. Vital signs are: temperature 39.4°C, heart rate 150, respiratory rate 24, blood pressure of 80/24. She has diffuse erythroderma and her distal extremities are warm with bounding pulses and rapid CRT. She remains hypotensive despite 60 mL/kg of fluid boluses and initiation of appropriate antibiotics (cloxacillin and clindamycin). When administering large volume fluid resuscitation in septic shock or sepsis-associated organ dysfunction, what types of fluids are recommended?
Balanced/buffered crystalloids have been associated with lower mortality and may be preferable to large volumes of isotonic saline. There is no clear benefit to using colloids such as albumin, and there is potential harm in using starches and gelatins (thus, they are not recommended)
Case 3: A 15-year-old adolescent female is admitted for fever and weakness. She began her most recent menstrual period 3 days ago, and regularly uses tampons. On physical examination she is confused. Vital signs are: temperature 39.4°C, heart rate 150, respiratory rate 24, blood pressure of 80/24. She has diffuse erythroderma and her distal extremities are warm with bounding pulses and rapid CRT. She remains hypotensive despite 60 mL/kg of fluid boluses and initiation of appropriate antibiotics (cloxacillin and clindamycin). Since this patient remains in shock unresponsive to fluid resuscitation, what class of medications should be started? Which specific agent would be best in this example? How does this impact her disposition?
Vasopressor therapy should be started (the choice of agent is driven by the patient’s clinical condition), ideally through a central venous line, though a peripheral IV line may be used initially. Central venous access would allow for measurement of central venous pressure and saturation to guide fluid resuscitation and adjustment of vasoactive medication.
While dopamine has often been used as the initial vasoactive agent for hypotension in paediatric patients, it is no longer the first choice. In this case, norepinephrine, with its pure alpha-adrenergic vasoconstrictor effect, would be most efficacious.
This patient requires continuous monitoring and close assessment of organ function. Transfer to a tertiary care centre is recommended.
Case 4: An 8-year-old boy with nephrotic syndrome who is currently receiving daily corticosteroids presents with a one-day history of being generally unwell, diffuse abdominal pain, and multiple episodes of vomiting. On initial assessment he appears Cushingoid, and his vital signs are: heart rate 140, respiratory rate 30, temperature 37.5°C, blood pressure 88/32. CRT is less than 2 seconds and peripheral pulses are easily palpated. The patient is confused and somewhat uncooperative. His abdomen is distended and diffusely sensitive to palpation, with mild involuntary guarding. You suspect that this patient may have primary peritonitis, likely due to Streptococcus pneumoniae and a well-described infectious complication of nephrotic syndome. Treatment with a third-generation cephalosporin such as ceftriaxone or cefotaxime should be initiated, as well as vancomycin. Is this patient likely to have adrenal insufficiency? While clinical signs of adrenal insufficiency are difficult to distinguish from other causes of vasodilated shock, what are some potential clues in screening bloodwork?
Chronic corticosteroid administration in this patient has caused suppression of the hypothalamic-adrenal axis, which can lead to adrenal insufficiency when stressed.
Serum biochemistry may show relative hyponatremia, hyperkalemia, and hypoglycaemia.
The diagnosis and role of adrenal insufficiency and its treatment in paediatric sepsis remain controversial. What are some examples of patient populations at risk for adrenal insufficiency in the setting of septic shock? Note: for other patients, it is suggested that hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability. However, no gold standard exists for the diagnosis of acute adrenal insufficiency in the context of critical illness, and abstention from hydrocortisone therapy would also be acceptable, pending results of on-going research on this topic.
i) individuals with purpura fulminans or Waterhouse-Friderichsen syndrome (characterized by the abrupt onset of fever, petechiae, septic shock, and DIC followed by acute hemorrhagic necrosis of the adrenal glands and severe cardiovascular dysfunction)
ii) those who have received steroid therapies for chronic illness
iii) patients with pituitary or adrenal abnormalities
Outline the normal heart rate values according to age for both awake and sleeping.
(see attached image)
Outline the normal respiratory rate values according to age.
(see attached image)
Outline the systolic blood pressure cut offs for what constitutes hypotension based on age.
(see attached image)
The choice of vasocactive medications following 60mL/kg of IV bolus of crystalloid and/or colloid depends on the clinical context. What are some clinical features that would lead to the selection of epinephrine (low vs high dose) vs norepinephrine?
(see attached image)
