sepsis and child mortality Flashcards
how common is infection in paediatrics
- common in children
- avg pre-school child will have 8-12 resp infections p/a
- likely to spend 3-5mths p/a w/ viral infection
- majority due to viruses
- majority self limiting and last 8-14 days
infections and admissions to hospital
39% of all acute paeds admissions
25% of GP OOH - 60% of these are 1-4y/o
UK child mortality (<5y/o)
- 27 per 1000 live births
- 4% or 1/ 234 children
problems with child mortality in UK
- mortality outcomes are considerably worse than comparable HICs
- UK ranks in bottom 3 countries in the EU15+ for mortality from common infectious in both sexes and across all age groups
- mortality from treatable infection in UK - almost 2x that of best performing European neighbours
failure to recognise serious illness at the 1st point of healthcare contact is an important avoidable factor in child death
how many deaths does infection account for
16.2% deaths 1-4y/o
8% deaths 5-9y/o
causes of child death
infectious disease ~½ of all deaths
- pneumonia, diarrhoea diseases, meningitis, malaria, measles
neonatal disorders
injuries and accidents
non-communicable diseases
how common is sepsis
severe sepsis is one of the leading causes of death in all children
>½ of all sepsis cases worldwide occurred in children
when is the peak incidence of sepsis
early childhood
- infants <1y: 1 in 200
- children 1-4: 1 in 2000
- children 5-15: 1 in 5000
fatality from sepsis
10%
how to improve survival in sepsis
early recognition and appropriate treatment
- UK: only 38% compliance w/ recommended treatment guidelines
what is sepsis
sepsis = systemic inflammatory response syndrome (SIRS) + suspected/proven infection
what is severe sepsis
severe sepsis = sepsis + organ dysfunction
what is septic shock
septic shock = sepsis = CVS dysfuntion
what is SIRS
≥ 2 of:
- temp >38 or <36
- WCC >15x 10^9/L or <5x 10^9/L
- tachycardia >2SD above normal for age
- tachypnoea >2SD above normal for age
paediatric normal values
- faster HR as baby, slows gradually w/ age
- faster RR as baby, slow gradually w/ age
traffic light system for fever <5y/o
- helps identify high risk children
- remember to take CRT centrally e.g. sternum
changes in HR w/ temp
10bpm increase for every 1C is normal
paeds sepsis signs
temp <36 or >38
inappropriate tachycardia
poor peripheral perfusion/CRT >2s/mottles
altered mental state - sleepiness, irritability, lethargy, floppiness
inappropriate tachypnoea
hypotension - very late sign in children
when would we have a lower threshold for treating sepsis
- infants <3mths
- immunosuppresed/immunocompromised/chemotherapy/long term steroids
- recent surgery
- indwelling devices/lines
- complex neuro-disability/long term conditions - observations may vary from their baseline
- high index of clinical suspicion - tachypnoea, rash, leg pain, biphasic illness, poor feeding
- significant parental concern
sepsis 6 for paeds
- high flow oxygen
- IV/IO access and take blood test - blood cultures, blood glucose, blood lactate
- IV/IO abx: broad spectrum as per local policy
IF SHOCKED:
- consider fluid resuscitation
- consider inotropic support early - adrenaline
- senior/specialist involvement early
why do we have a lower treatment threshold for infants <3mths
- increased risk of bacterial infection
- increased risk of sepsis
- increased risk meningitis
- may have minimal signs and symptoms
- presentation often non-specific
- may not mount a febrile response (~50%)
- deteriorate quickly
what are the risk factors for infection in infants <3mths
- prematurity (<37/40)
- prolonged rupture of membranes
- maternal pyrexia/chorioamnionitis
- maternal group B strep (this pregnancy)
- previous child w/ group B strep
- maternal STI - chlamydia, gonorrhoea, syphilis, HSV
management of sepsis in children
Airway
Breathing
Circulation - fluid bolus (20ml/kg 0.9% NaCl)
DEFG - 2ml/kg 10% dextrose
abx - 3rd gen cephalosporin (e.g. cefotaxime/ceftriaxone), add IV amoxicillin if <1m/o
investigations for sepsis in children
bloods - FBC (leucocytosis, thrombocytopaenia), CRP, coagulation screen (DIC), blood gas (metabolic acidosis, raised lactate), glucose, blood culture
cultures - blood, urine, CSF (incl to send to virology), +/- stool (micro + virology)
imaging - CXR (can be helpful to exclude focal pneumonia)
causative organisms of sepsis in neonates (<1mth)
group B strep
Escherichia coli
listeria monocytogenes
causative organisms of sepsis in older infants and children
streptococcus pnuemonia
Neisseria meningitidis
Group A streptococcus
Staphylococcus aureus
pathogenesis of sepsis
- overwhelming response to infection
- bacterial infection triggers cytokine responses from endothelium and chemotaxis
- LPS produced by bacteria also trigger complement activation and coagulation cascade activation
- release of anti-inflammatory cytokines, disruption of coagulation cascade and activation of complement → impaired vascular permeability
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