SEPTIC SHOCK AND SEPSIS-

ASSOCIATED ORGAN
DYSFUNCTION IN
CHILDREN:
AN UPDATE
Dr A. KHALDI, PICU, KSH
December 2020
INTRODUCTION
q Leading cause of morbidity, mortality
q Under estimated Sequels outcome
q Healthcare utilization for children worldwide
q Family/Social impact
q Economic Impact
q Mortality for children with sepsis :4% -50%,
q illness severity
q risk factors
q geographic location
q Rapid and Efficient Recognition and Management
q Guidelines and Recommandations bundle management associated
with improved outcome
qEarly Recognition
qRapid Antibiotics
qTarget Fluid Resuscitation
qAgressive BP support
qImproved Intensive Care
A SPECTRUM OF ILLNESS
 DEFINITIONS

q First (and LAST!!) Formal definition 2005

q the International Pediatric Sepsis Consensus Conference
q Adult definition last update 2016
q Pediatric Upadte Coming soon …
SIRS and INFECTION
SEPSIS, SEVERE SEPSIS
ORGAN DYSFUNCTION DEFINITIONS
ORGAN DYSFUNCTION DEFINITIONS
EPIDEMIOLOGY

Global Sepsis Alliance, 2020

, Lancet 2015
Leclerc, AJRCCM, 2005
Lins, PCCM 2017
PATHOGENESIS
PATHOGENESIS
 SEPTIC SHOCK AND

EMBO Mol Med, Volume: 12, Issue: 4, First published: 16 March 2020
ETIOLOGY
ETIOLOGY
 PRESENTATION
q Rapid Recognition, High index of suspicion
q Clinical Diagnosis of tissular hypoperfusion
qclassic constellation of clinical signs of sepsis:
qchange in temperature (either hyperthermia or hypothermia),
qtachypnea and tachycardia,
qchange in mental status.
q Others: abnormal CRT, Oliguria, skin changes, rash…
q HYPOTENSION not mandatory, late sign in the pediatric population
q Source of infection related signs
q Labs: inflammation markers, CBC, coagulation, BG, Organ
dysfunction…
MANAGEMENT ALGORITHM: the 2016 Algorithm
First Hour
MANAGEMENT ALGORITHM: the 2016 Algorithm
After the First Hour
 What changed with
the new recommendations?
 SCREENING, DIAGNOSIS, AND
SYSTEMATIC
MANAGEMENT OF SEPSIS
q Implemention of systematic screening for timely recognition of
septic shock and other sepsis-associated organ dysfunctionIn
children who present as acutely unwell.
q Implemention of a protocol/guideline for management of children
with septic shock or other sepsis-associated organ dysfunction
 ANTIMICROBIAL THERAPY

qStarting antimicrobial therapy as soon as possible, within 1 hour

of recognitionIn children with septic Shock.
qIn children with sepsis-associated organ dysfunction but without
shock, start antimicrobial therapy as soon as possible after
appropriate evaluation, within 3 hours of recognition.
qEmpiric broad-spectrum therapy with one or more antimicrobials
to cover all likely pathogens. Once the pathogen(s) and
sensitivities are available, do narrowing empiric antimicrobial
therapy coverage
 ANTIMICROBIAL THERAPY
qIn children without immune compromise and without high risk for multidrug-
resistant pathogens, No routine use of empiric multiple antimicrobial directed
against the same pathogen for the purpose of synergy.
qIn children with immune compromise and/or at high risk for multidrug-
resistant pathogens, it is suggested using empiric multi-drug therapy when
septic shock or other sepsis-associated organ dysfunction is present/suspected.
qusing antimicrobial dosing strategies optimized based on published
pharmacokinetic/ pharmacodynamic principles and with consideration of
specific drug properties.
qIn children with septic shock or sepsis-associated organ dysfunction who are
receiving antimicrobials, daily assessment (e.g., clinical, laboratory
assessment) for de-escalation of antimicrobial therapy is recommended.
 FLUID THERAPY

qArea with ICU available: up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per
bolus) over the first hour, titrated to clinical markers of cardiac output and
discontinued if signs of fluid overload develop, for the initial resuscitation of
children with septic shock or other sepsis-associated organ dysfunction.
qIf no ICU available:
qHypotension: up to 40 ml/kg the first hour, titrated to clinical markers
qNo hypotension: No Fluid bolus
qBalanced or Buffered Crystalloids > 0,9% NS>>>>>> Albumin, No Starches, No
Gelatin
 HEMODYNAMIC MONITORING
q Target Blood Pressure unknown, in Practice between 5th and 50s%
q Associate clinical parameter with advanced parameters if available:
Lactate, ScVO2, CO, SVR…
q Use Lactate Trend + Clinical assesement at least
 VASOACTIVE MEDICATIONS

qUse Epinephrine or Norepinephrine rather then Dopamine in patient with

septic shock
qIn practice, select either epinephrine or norepinephrine as the first-line
vasoactive infusion guided by clinician preference, individual patient
physiology, and local system factors.
qDilute concentration of the initial vasoactive medication through a peripheral
vein if central venous access is not readily accessible
qeither Add vasopressin or further titrating catecholamines in children with
septic shock who require high-dose catecholamines
 VENTILATION

qin practice, we commonly intubate children with fluid-refractory,

catecholamine-resistant septic shock without respiratory failure
qNo ETOMIDATE for intubation, Ketamine is a good choice

qTry NIV if p-ARDS with controlled shock

qHigh PEEP and PRONE position can be used for p-ARDS
qNo routine use of HFOV and iNO for p-ARDS
qNeuromuscular Blockaed is suggested for severe p-ARDS
CORTICOSTEROIDS, ENDOCRINE AND METABOLIC

q No routine use for IV Immunoglobuline

qNo IV hydrocortisone if shock is controlled by fluids / Vasopressors
q Can be used (or missed !!!!) for uncontrolled septic shock
q No routine use of insuline for Tight Glucose control
q Target serum Glucose less then 180 mg/dl and not 140 mg/dl
q No routine use of Levothyroxine
q Fever control and permissive fever are equal
 NUTRITION

q preference to commence early enteral nutrition within 48 hours of

admission in children with septic shock or sepsis-associated organ
dysfunction who have no contraindications to enteral nutrition and to
increase enteral nutrition in a stepwise fashion until nutritional goals
are met
qno withholding enteral feeding solely on the basis of vasoactive-inotropic
medication administration
q No routine use of GRVs
q No additives, micronutrient, specialized formula and no prokinetics
qNo routine use of ulcer prophylaxie
 BLOOD PRODUCTS

q No pRBCs for stable patient (2 hours at list) if Hb is greater or equl

to 7 g/l
q No prophylactic transfusion of Platelets based solely on Pt level
q No prophyalctic FFP for abnormal coagulation profile
qNo routine use for DVT prophylaxie
 PLASMA EXCHANGE, RENAL REPLACEMENT,
AND EXTRACORPOREAL SUPPORT

q No PLEX for septic shock / MOF with or without TAMOF

qUse CRRT to treat and prevent fluid overload
q Use standard rather then high volume hemofiltration
q Use VV-ECMO for refractory p-ARDS
qUse VA-ECMO for refractory septic shock
TO FINISH…
Thanks…
Any questions?