Sepsis Flashcards
Signs of sepsis in a neonate (COMPENSATED)
- Plan for next 5 min
- plan for next few hours
“warm shock”
Hx of poor feeding, vomiting / diarrhea, fever
Tachycardic Sunken fontanelle Lethargic Bounding pulses increased WOB = subcostal retractions, nasal flaring, head bobbing
1) 2 large bore IV ==> 20mL/kg NS over 5 min x3 as needed.
2) place on CRM, pulse O2, q5min BP
3) non-rebreather O2 (HFNC +/- CPAP)
4) Labs - STAT glucose, BMP, CBC, coags, VBG, iCa/Mg/Phos, Blood/urine Cx
5) start empiric Abx with ceftriaxone
6) dose of rectal acetaminophen (NO NSAIDS for 5mo)
7) Prep for intubation / central acess
8) lumbar puncture (when heme stable)
9) PICU == ionotropes
what is the best fluid for resuscitation
NS
What is the age cutoff for NSAIDS
none for kids <6mo.
Define: shock
Insufficient oxygen perfusion to tissues +/- end-tissue damage.
O2 delivery < metabolic demands
Define delivery of oxygen
DO2 = CO * O2 carrying capacity
CO = SV*HR
SV = preload, contractility, afterload
O2 carrying capacity = bound to Hgb (1.36HgbSpO2) + unbound to Hgb (0.003*PaO2)
MAP = CO*SVR
difference between compensated v. uncompensated shock
compensated ==> might just look dehydrated & volume down
uncompensated ==> CRASHING
Define SIRS
presence of 2+
- temp instability
- tachycardia/bradycardia
- tachypnea
- leukocytosis/leukopenia
define sepsis
SIRS + infection
define septic shock
Sepsis + CV dysfunction not responsive to 40mL/kg fluids
Sepsis / MODS
at least 2 organ system failures
Define: severe sepsis
sepsis + organ dysfunction
what kind of shock do you get when your heart gives out first , and then the peripheral system is holding it together
COLD
~cardiogenic shock = COLD shock = uncompensated
how do kids experience sepsis differently compared to adults
sxs = head bobbing
1) different erelative head size == different upper airway anatomy (smaller distal & medium airways)
2) softer, more compliant chest walls
heart gives out first , and then the peripheral system is holding it together (low CO, high SVR) ==> ~ cardiogenic
v. adults = high CO, low SVR
what is the relationship between neonate and severe sepsis?
what is the importance of this?
neonates == 1/3 of all cases of sepsis
kids <1yo == 1/2 of all cases
==> neuro, cardiac, pulm & immune comorbidities greately increase risk of sepsis and death
tx = SPEED
1) isotonic fluids
2) abx
what kinds of bugs cause sepsis?
- staph aureus, CoNS
- Strep pneumo
- strep pyogenes
- GBS (Neonates)
- pseudomonas
- E coli (younger kids)
- enterococcus
- klebsiella
in what popualation is GBS more likely to cause sepsis?
neonates
in what popualation is E. coli more likely to cause sepsis?
younger kids
how do you manage fluid refractory shock
1) ionotrope IV/IO (dopamine or Epi)
2) atropine/ketamine
what is the one most important thing that has lead to the survival of more neonates with sepsis
RAPID and AGGRESSIVE resuscitation and IV Abx
how to reverse cold shock
titrate central dopamine
or if resistant- titrate central epinephrine
how to reverse warm shock
titrate central NorE
define: warm shock
tx
hypovolemic
compensated
tx = norE
define: cold shock
tx
cardiogenic
uncompensated
tx = Epi
for a patient that we are trying to resuscitate, what are the end goals that we are monitoring?
- Cap refill <2 secs
- Warm extremities, -central pulses=peripheral
- Urine output >1 ml/kg/hr
- Normal mental status
- Normal blood pressure for age
- Cardiac Index > 3.3, venous sat >70%
Signs of sepsis in a neonate (UNCOMPENSATED)
- plan
Sxs
- lethargic, moans to painful stimiulation
- increased WOB
- pulses weak, cool to thighs
tx
- Continue with fluid resuscitation -Start dopamine 5 mcg/kg/min through PIV
- Proceed with intubation – cautious sedation with fentanyl/rocuronium
- Obtain central access and arterial line
- Start epinephrine infusion at 0.1-1 mcg/kg/min
- Obtain SvO2 to determine tissue perfusion
when should you start vasopressors and what should you use for each situation?
==> once 2nd line access is obtained
#1 == dopamine warm shock == norE col dshock = Epi
Mgmt:
15 y/o male, “not acting right”
Family on vacation, got a bug bite at camp, not it’s gotten worse.
Family now at home, mom calls and says he’s “lethargic”
What questions do you want to ask?
Just returned from camp, no known sick contacts
Previously healthy, unimmunized
No diarrhea
Complaining of headache, pain with bright lights
Mom thinks he is difficult to wake up, when he does wake up he just groans and goes back to sleep
What is your recommendation?
T 39.8 HR 145 RR 6 Sat 97% (RA) BP 90/60
Gen: Ill-appearing, listless. Eyes closed, groans but no full sentences
HEENT: NCAT. Dry mucous membranes. OP clear. Scattered petechiae across nasal bridge, conjunctival hemorrhage
CV: Tachycardic, no murmur. Distal CR ~5 s.
Resp: Lungs CTAB, no increased WOB
Abdomen: Soft, NTND, NABS, no HSM
Leg: red, indurated, cratered lesion in the leg with surrounding redness
Extremities: Cool to touch, scattered petechiae throughout
Neuro: Somnolent, moves extremities weakly when asked, not cooperative with CN exam. Reflexes 2+ and equal bilaterally. GCS…?
Major concern: SEPSIS
==> inadequate perfusion - not enough oxygen to tissue; signs of end organ dysfunction
- classic for MRSA infection
Immediate = FLUIDS, ABx (3-4 boluses)
physical findings of sepsis due to bug bite
Fever Tachycardia or Bradycardia Decreased peripheral pulses OR bounding pulses Mottled or cool extremities Delayed cap refill Dry mucous membranes, sunken eyes, decreased UOP Tachypnea, bradypnea, apnea Hypotension Hypothermia (neonates) Altered mental status
lab findings of sepsis due to bug bite
Acidosis Elevated Lactate == GI ischemia Hyperglycemia Hypocalcemia Coag derangements Elevated LFTs == liver ischemia Elevated BUN and Creatinine == kidney ischemia Leukocytosis Elevated inflammatory markers
