FRCA Notes

Paediatric Sepsis

Resources

  • Sepsis and septic shock are a major cause of paediatric morbidity and mortality worldwide
  • The mortality of septic shock requiring PICU admission is up to 17%
  • Paediatric sepsis is sometimes still discussed in terms of SIRS criteria:
    1. Pyrexia >38.5°C (or hypothermia <36°C)
    2. Leukocyte count increased or decreases for age (or >10% immature neutrophils)
    3. Tachycardia (mean HR >2SD above mean for that age over 4hr period) or bradycardia (HR <10th centile for age)
    4. Tachypnoea (mean RR >2SD above mean for that age), or requiring mechanical ventilation

  • According to various sepsis screening tools one needs SIRS criteria + 1 of:
    • Altered mental status e.g. sleepy, lethargic, floppy, irritable
    • Mottled skin OR prolonged capillary refill time OR ‘flash’ capillary refill time OR limb pain
    • Confirmed or suspected infection
    • Clinical concern regarding sepsis
  • Other features may include a lactate >2mmol/L or a low diastolic blood pressure (low systolic pressure is a late sign)

  • Septic shock is when cardiovascular organ dysfunction exists despite 40ml/kg fluid resuscitation


Monitoring

  • Continuous (or 5 minutely if not continuous)
    • Saturations
    • Respiratory rate
    • NIBP
    • Heart rate using 3-lead ECG
  • Temperature monitoring
  • Capillary refill time
  • Urine output
  • Point-of-care glucose
  • Level of consciousness

Respiratory

  • Apply 100% oxygen via high-flow device
  • May need escalation of respiratory support in worsening or fluid-refractory shock
  • Reduced conscious level, inadequate respiratory drive or persistently refractory shock should prompt I&V

  • At high risk of pulmonary oedema from a combination of:
    • Iatrogenic fluid overload
    • SIRS-induced capillary leak
    • Sepsis-related myocardial depression

Cardiovascular

  • IV or IO access x 2 within 5mins of sepsis recognition
    • IV access may be difficult and should avoid persevering with difficult IV access and move quickly to IO access
    • Exception is those <3kg (IO contra-indicated)
    • Onset of action of IO medications is similar

  • Take bloods for:
    • VBG
    • FBC
    • U&E
    • CRP
    • LFT
    • Coagulation profile
    • Group & save

  • Fluid resuscitation with 5-20ml/kg isotonic (balanced) crystalloid
  • Targets:
    • Age-appropriate HR, RR and BP
    • Normal peripheral perfusion
    • Palpable peripheral pulses
    • Lactate <2mmol/L

  • Treat hypocalcaemia if present

  • Treat hypo- or hyper-glycaemia if present, targetting a plasma glucose <10mmol/L

Antibiotics

  • Broad spectrum antibiotics within 1hr of presentation
    • IM injection if IV access not possible
    • E.g. ceftriaxone 80mg/kg [Max 4g]

  • Source control with removal of indwelling lines/catheters and debridement & drainage of wounds

Fluid-refractory shock

  • If within 15mins of the first 20ml/kg of boluses there is still ongoing shock, give up to another 40ml/kg in boluses to acheive targets
  • If after a total of 40-60ml/kg, or if signs of fluid overload at any point (hepatomegaly, crackles on auscultation) move to manage as fluid-refractory shock

  • Management includes:
    • Discussion with regional tertiary centre/PICU ± retrieval
    • Peripheral adrenaline 0.1μg/kg/min as a temporising strategy
    • Invasive ventilation to gain control and facilitate central access
    • Addition of further vasoactive drugs once central access is obtained depending on type of shock:
      • 'Warm shock' i.e. vasoplegic, warm, flash capillary refill, wide pulse pressure i.e. low SVR/high CO state → noradrenaline ± vasopressin
      • 'Cold shock' i.e. shut down, narrow pulse pressure, prolonged capillary refill i.e. low CO/high SVR state → adrenaline ± milrinone ± dopamine

Catecholamine-refractory shock

  • Consider:
    • Addition of hydrocortisone
    • Exclude other causes of shock e.g. hypothyroidism, haemorrhage, adrenal insufficiency, pneumothorax
    • Clindamycin and IVIg for toxic shock syndrome
    • Addition of antibiotics to cover anaerobic (metronidazole) or meningitic sources
    • ECMO

Anaesthetics considerations for the septic child undergoing surgery


  • 25% of children with sepsis will undergo surgery as part of their management

Altered pharmacokinetics

  • Give drugs IV as altered skin, muscle and gut blood flow will lead to unpredictable absorption
  • Altered protein binding, body water, pH and tissue permeability will affect drug distribution
  • Metabolism is reduced due to hepatic dysfunction from:
    • Reduced hepatocyte intrinsic activity (especially affects clearance of drugs with low hepatic extraction ratios)
    • Reduced hepatic blood flow (especially affects clearance of drugs with high hepatic extraction ratios)
    • Renal injury affects excretion of drugs and their metabolites

Drug Dose alterations Notes
Ketamine ↓ dose 0.25 - 0.5mg/kg Direct myocardial depression, with exaggerated effect in sepsis
Impaired hepatic metabolism prolongs the effects
Propofol ↓ dose 0.5 - 1mg/kg May cause profound cardiovascular depression
May take longer for induction to occur due to sepsis-induced cardiomyopathy
Higher risk of PRIS; maintain infusion <4mg/kg/hr
Benzodiazepines ↓ dose e.g. midazolam 0.05 - 0.1mg/kg Prolonged effect from hepatic and renal dysfunction
Enhanced effect from reduced serum albumin concentrations
Opioids ↓ dose e.g.
fentanyl 0.5 - 1μg/kg
morphine 0.025 - 0.05mg/kg		 Consider using alongside another agent e.g. benzodiazepine
Volume of distribution decreased therefore effects prolonged
Reduced clearance from hepatic hypoperfusion (except remifentanil)
Rocuronium Prolonged effects from hepatic dysfunction, ↓ albumin, acidosis, hypothermia & electrolyte abnormalities
Use NMBA monitoring
Suxamethonium Avoid in sepsis as increased risk of hyperkalaemia from concurrent AKI, rhabdomyolysis or prolonged immobility
Sepsis-induced, acquired pseudocholinesterase deficiency prolongs action