Sepsis Flashcards
What are the intermediate risk signs on the traffic light system for identifying an unwell child?
(CHARCO) Circulation and Hydration: Tachycardia - >160 aged <12m >150 aged 12-24m >140 aged 2-5yrs CRT >3s Dry mucous membranes Poor feeding Reduced urine output
Activity - not responding normally to social cues, no smile, wakes only with prolonged stimulation, decreased activity
Respiratory: Nasal flaring RR >50 aged 6-12m RR >40 aged >12m O2 sats <95% OA Crackles in chest
Colour:
pallor reported by parent/caregiver
Other: Age 3-6m w/temp >39 Fever >5d Rigors Limb/joint swelling/not weight bearing or using extremity
What are the high risk signs on the traffic light system for identifying an unwell child?
Circulation and Hydration:
Reduced skin turgor
Activity:
No response to social cues, appears ill to healthcare professional, does not wake or stay awake when roused
Weak, high pitched or continuous cry
Respiratory:
Grunting
RR >60
Moderate/severe chest indrawing
Colour:
Pale/mottled/ashen blue
Other: Age <3m w/temp >38 Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neuro signs/seizures
Also 3Ts with White Sugar and Bufalo stuff needed
Common causes of sepsis in kids
Common emergency protocols
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What does a septic screen consist of?
Urine sample – anything cultured?
Bloods:
i) FBC – increased WCC
ii) CRP – increased
iii) U+E – any derangement indicating UTI
iv) Culture - MC+S
v) Glucose - may be raised
vi) Lactate – if 2-4+ mmol/L = raised
vii) Creatinine - high
viii) Clotting – any signs of thrombocytopaenia/increased APTT or INR
LP
i) Increased WCC (probs neutrophils), possible bacteria; high protein: very low glucose (bacterial meningitis)
CXR
What are some key risk factors for neonatal sepsis?
Premature rupture of membrane - >24hrs
Prematurity - <37wks
Maternal group B strep (carried by 10-30%)
Intrapartum fever
What is the formula for estimate weight?
(age + 4) x 2 = estimated kg
Standard weights (+ surface areas) also exist in BNF
What are the maintenance fluid calculations in children >1yr?
0.9% NaCl + 5% glucose +/- KCl
1st 10kg = 100ml/kg
2nd 10kg = 50ml/kg
Every kg after = 20ml/kg
/24 = hourly rate
e.g. a child weighing 25kg will have 1500ml + 100ml = 1600ml/24 = 66.6 = 67ml/hr
What is the additional fluid requirement if a child is 5% dehydrated? 10% dehydrated/shocked?
5% dehydrated:
Maintenance + 50ml/kg
10% dehydrated/shocked:
Maintenance + 100ml/kg + bolus(‘s) (20ml/kg of 0.9% NaCl)
What are the special cases for giving fluids?
DKA:
Special maintenance doses (see guidelines) + replace /48hrs (to avoid cerebral oedema) + 10ml/kg bolus in shocked
Trauma + shocked:
10ml/kg bolus (1st clot is the best clot)
When do you give oxygen in suspected sepsis?
If O2 drops below 92% OA (or working very hard to maintain levels) - give high flow
Given to maintain aerobic metabolism and prevent metabolic acidosis
When do you give antipyretics in suspected sepsis?
Paracetamol OR ibuprofen IF and only IF child is distressed
NOT solely for the purpose of bringing down temperature
What is a standard antibiotic regimen for suspected sepsis?
( Pre-cultures: IV Benzylpenicillin (25mg/kg/8-12hrs - depending on severity) + IV Gentamycin (5mg/kg stat and at 36hrs) - idk where this has come from)
Post cultures or precultures if clinical meningococcal sepsis:
Confirmed G-ve bacterial sepsis (e.g. N.meningidites - diplococci)
3rd generation cephalosporin – ceftriaxone or cefotaxime (as sensitive to G-ve)
Dose:
Ceftriaxone = 80-100mg/kg = 800-1000mg IV OD
Cefotaxime = 50mg/kg = 500mg IV OD (or first line if on IV Ca)
If under 3m:
Add amoxicillin - to cover for listeria
If neonate septic within first 72hrs:
Use Benpen + Gent
What causes the rash in meningococcal sepsis?
Bleeding under the skin, hence non-blanching
The endotoxin of N.meningitidis triggers an immune response – excess inflammatory mediator release (especially tissue factor/TF) leads to increased permeability of endothelium + dilatation of vessels – DIC (clotting + bleeding) + decrease in cardiac output
What other drug treatments may be necessary for managing meningococcal sepsis +/- meningitis?
(Sympathomimetic) Inotropes - e.g. adrenaline, dobutamine; vasoconstrictors e.g noradrenaline - all usually confined to ICU environments
Replacement of blood or blood products – platelets, blood transfusion, fresh frozen plasma, fibrinogen
Heparin – if VTE risk
Dexamethasone – reduce neuroinflammation/swelling and long-term complications e.g. deafness
What is the first line treatment recommended to close contacts of meningitis?
Chemoprophylaxis, given asap (ideally within 24hrs after Dx of index case)
Ciprofloxacin:
Adults – 500mg PO single dose
5-11yrs – 250mg PO single dose
Neonates-4yrs – 30mg/kg single dose (up to 125mg)
What are the contraindications and side effects to the chemophophylaxis of meningitis?
Tendon disorders related to quinolone use:
Quinolones may case direct tissue inflammation (tendinitis), injury or necrosis
Starts within 48hrs of treatment but to several months after stopping
Risk increased with concomitant corticosteroid use
Pregnancy:
If pregnant, use azithromycin 500mg PO single dose
If additional cases appear in close contacts within 4wks of prophylaxis, alternative agent:
Rifampicin – 600mg PO BD 2x days; (children 1-11) 100mg/kg BD 2x days; (under 12m) 5mg/kg BD 2x days
What is the definition of a close contact?
Anyone who has spent an increased amount of time in close proximity (6ft) to the affected individual, during a period where the individual was likely to be infective; such as close family members, work colleagues, school peers (sexual partners in older adults)
N.meningitides is also normally carried by 10% of people in their nasal passages – transmissible in saliva and respiratory secretions
What are some clinical contraindications of LP?
signs suggesting raised intracranial pressure or reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 points or more)
relative bradycardia and hypertension
focal neurological signs
abnormal posture or posturing
unequal, dilated or poorly responsive pupils
papilloedema
abnormal ‘doll’s eye’ movements
shock
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities or coagulation results outside the normal range or platelet count below 100x109/litre or receiving anticoagulant therapy
local superficial infection at the lumbar puncture site
respiratory insufficiency in children
