23/09/13911. dr mostafavi n departement of pediatric infectious disease isfahan university of...
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Dr Mostafavi NDepartement of Pediatric infectious Disease
Isfahan University of Medical Sciences
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Case 1An 8 month old boy brought to your
clinic with complain of high fever, poor intake, and . On examination the child has Ta= 39.5⁰С, RR= 35/min , HR= 130/min, cold extremities, NL blood pressure. Other wise the child is Ok. CBC revealed WBC= 18,000; PMN= 80%, PLT= 225,000.
What's your diagnosis?what do you do?23/09/1391 3
Case 2An 8 month old boy brought to your
clinic with complain of high fever and lethargy. On examination the child has RR= 65/min , grunting, HR= 180/min, weak pulses, cold extremities, and hypotension( not detectable).
What's your diagnosis?what do you do?
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Sepsis characteristicsAcute Fulminate courseDistributive shock( first tachycardia, tachypnea then hypotension)
Bacteremia of focal infection
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Shock= ↓cardiac output Hypovolemic: ↓ preload Distributive: ↓
afterload Cardiogenic: ↓
inotropy, ↓ chronotropyObstructive: ↑
afterloadSeptic : ↓ preload, ↓
afterload, ↓ inotropy
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Sepsis = systemic inflammatory response syndrom due to infection
Core T> 38.3 or <36Unexplained tachycardia or in < 1 yr
bradycardiaUnexplained tachypnea or need to MVWBC> 15000 or < 4000 or band cell>
10%At least first or last criteria & at least
2 out of 4 criteria23/09/1391 7
Tachycardia < 2 mo: > 180/min2-12 mo: 160/min1-2 yr: 120/min2-8 yr: 110/min> 8 yr: 100/min Each ⁰C increase in temperature
increase heart rate by 10-12/min
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Tachypnea< 2mo: > 60/min2-12 mo: > 50/min1-5 yr: > 40/min6-8 yr: > 30/min> 8 yr: > 20/minEach ⁰C increase in temperature
increase respiratory rate by 4-10/min
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Hypotension( SBP in mmHg) Neonate< 60 1-12 mo< 701-10 yr < 70 + 2 age( yr)> 10 yr < 90
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DefinitionsSepsis: pre-shock due to infection Severe sepsis: infection+
Reversible shock Organ hypo-perfusion( acidosis,
oliguria, ↑CRT) Organ dysfunction( coma, ARDS, ARF,
DIC, cytopenia, coagulopathy, hepatic failure(
Septic shock: irreversible shock due to infection
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Case 1An 8 month old boy brought to your
clinic with complain of high fever, poor intake, and . On examination the child has Ta= 39.5⁰С, RR= 35/min , HR= 130/min, cold extremities, NL blood pressure. Other wise the child is Ok. CBC revealed WBC= 18,000; PMN= 80%, PLT= 225,000.
What's your diagnosis?what do you do?23/09/1391 12
Case 1Diagnosis Plan Fever without source in 3-36 mo old with WBC> 15,000
B/C and U/C then Intravenous ceftriaxone, F/U
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Case 2An 8 month old boy brought to your
clinic with complain of high fever and lethargy. On examination the child has RR= 65/min , grunting, HR= 180/min, weak pulses, cold extremities, and hypotension( not detectable).
What's your diagnosis?what do you do?
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Case 2Diagnosis Plan
Severe sepsis, or septic shock
Treatment of sepsis
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Steps in the treatment of sepsis1. Maintenance of efficient respiratory
function2. Restoration of adequate tissue
perfusion 3. Control of the infectious agent4. Laboratory evaluation 5. Supportive care for organ
dysfunction23/09/1391 16
1. Efficient respiratory functionHigh flow oxygen ( O2 sat> 92%)
Periodic suctioningAmbu ventilationIntubation and MV if impending to respiratory failure
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2. Restoration of adequate tissue perfusionIV or IO access20 mL/kg N/S up to 60-80 mL/kg in 1st hour sometimes
as much as 200 mL/kg unless cardiogenic shock Coloid if needed( ↓alb., ↑PT & PTT, ↓Hb)Dopamine after 40cc/kg via peripheral IV lines, with
close monitoringCentral IV line( fluid up to CVP< 10-15, then
dopamine)Epinephrine in cold shock and norepinephrine in
warm shock via central IV linesDobutamine, hydrocortisone, … in special
circumstancesTo normalize HR, U/O, CRT, MS 23/09/1391 18
Cardiogenic shockSmaller boluses of fluid (5-10 mL/kg)Early initiation of myocardial
support with dopamine or epinephrine
Administering an inodilator, such as milrinone, early in the process.
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3. Control of the infectious agentPredisposing factor
Microorganisms Best antibiotics
Neonates GBS, enteric g-s, L. monocytogen
Ampicillin+ cefotaxime and/or gentamicin
Infants and children
N. meningitidis, H.influenza type b, S. pneumonia
Cefotaxime+ vancomycin
Abdominal source
enteric g-s, anaerobes, enterococci
Clindamycin+ gentamicin+ ampicillin
Urinary source
enteric g-s Cefotaxime+/- gentamicin
Immunodeficiency
enteric g-s, P. aueroginosa, S. aureous, fungi
Cefepime/ imipnem+ vancomycin+/- amphotericin
Hospital acquired
Resistant enteric g-s, P. aueroginosa, S. aureous
Cefepime/ imipnem+ vancomycin23/09/1391 20
4.Laboratory evaluation CBC diff: ↑ or ↓ WBC, ↓plt, ↓HbESR> 30, ↑CRP, ↑procalcitoninPeripheral smear: howel- jolly bodies,
fragmented RBC↑PT, ↑PTT, ↑D-dimer, ↑FDPABG: Res. Alkalosis, Res. Alkalosis +Met.
Acidosis, Mixed Acidosis, hypoxemiaLFT: ↑AST, ↑ALT, ↓Alb, ↑Bil
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4. Laboratory evaluation ↑ or ↓ BS, ↓Ca, ↓Na , ↑TG↑BUN, ↑CrCXR: ARDSGram stain of buffy coat &
petechia/purpuraB/C, U/C, CSF/CU/A, CSF analysis
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5. Supportive care for organ dysfunctionDisorder Goals (
prevent/treat)Therapies
ARDS Hypoxia, respiratory acidosis
O2
Respiratory muscle fatigue
Barotruma Early intubation and MV
Central apnea
Decrease work of breathing
MV
Renal failure Hypovo/hypervolemia, hyperkalemia, acidosis, hypo/hypernatremia, hypertension
Judicious fluid therapyLow dose dopamine, establish NL U/O and BPLasix, dialysis
Coagulopathy( DIC)
Bleeding Vit.K, FFP, PLT
Thrombosis Abnormal clotting Heparin, activated pr C
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Supportive care for organ dysfunctionDisorder Goals (prevent/treat)
Therapies
Stress ulcer
Gastric bleeding, aspiration, distension
H2 blocker, PPI, Fix NG tube
Ileus, bacterial translocation
Mucosal athrophy
Early enteral feeding
Adrenal insufficiency
Adrenal crisis Stress dose, physiologic dose
Metabolic acidosis
Correct etiology, normal PH
Treatment of hypovolemia, cardiac dysfunction, renal excretion, bicarbonate if PH< 7.1 and adequate ventilation
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0-5 minHigh flow O2
Suctioning, ventilation if neededEstablish IV/IO access
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5-15 minPush 20 cc/kg NS and over 60 cc/kg until
Perfusion improved( HR, CRT, U/O, MS) Rales Hepatomegaly
Check BS and correct hypoglycemiaSend lab exams, CXRStart antibiotic ( ceftriaxon, vancomycin)Start dopamine after 2nd dose( 6BW/100cc
DW5%, micro-drop 3-10 drop/min)
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15-40 minEstablish CVC, ITTTitrate dopamine after 2nd dose( 6BW/100cc
DW5%, micro-drop 3-10 drop/min) Start and titrate epinephrine (
0.6BW/100cc DW5%, micro-drop 0.5-30 drop/min) for cold shock
Start and titrate norepinephrine ( 0.6BW/100cc DW5%, micro-drop 0.5-15 drop/min) for warm shock
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40-60 Start hydrocortisone 50-100 mg/m2 if catecholamine-resistant shock and at risk of adrenal insufficiency
Transfer to PICU
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Conclusion Unexplained ↑ RR and HR as early signs of
shock and sepsisEarly oxygen and ventilation therapyAggressive fluid and inotropic therapyColoid therapy in suspected cases Early antibiotic therapy before sending to
PICUEarly check of BS23/09/1391 29
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