Pediatric Sepsis

Management in Low
Resource Setting PICU
Irene Yuniar
UKK ERIA IDAI
Objectives
• The recognition of pediatric
sepsis
• To determine the magnitude
of the pediatric sepsis
problem in PICUs with
limited facilities
• To discuss how to improve
the management of
pediatric sepsis in PICUs
with limited resources
Introduction
Paediatric sepsis  an important cause of morbidity and mortality

standardized treatment guidelines, immunization programs, and advanced intensive care organ support techniques

WHO, 2019: Childhood infections (pneumonia, diarrhea, and malaria)

> 4.5 million childhood annually

The prevalence of sepsis in paediatric intensive care unit (PICU)

7.7%

6.2%

15.3%

23.1%
16.3%
Introduction
• Survivors of sepsis are increasing and continue to require long-
term care
• Patients recovering from sepsis:
- develop 1-2 new functional limitations
- 10–40% cognitive dysfunction
- reinfection due to loss of adaptive immunity and reduction in
lymphocytes

Ravikumar N. Frontiers in paed. 2022

https://www.lecturio.com/concepts/sepsis-in-children/
 The SSC guidelines and American College of Critical Care Medicine (ACCM)
Clinical Practice Parameters for Hemodynamic Support
of Paediatric and Neonatal Septic Shock

Reduced sepsis morbidity and mortality:

• Evidence-based guidelines
• Sepsis bundles
There is a great disparity in the levels of care provided
• Checklists management in different regions around the world
 Based on the availability of resources
• Antibiotic prophylaxis
• Immunization
• Quality improvement
 Predictors of mortality in Critical Ill Sepsis Children in 5 Years: Indonesia Experience
We identified 225 septics patients, with 65% of mortality rate

Mechanical Respiratory Used

Hypotension ventilation Infection inotropes
59% 31% 56% 51% PELOD-2 Bivariate Multivariate
SCORE Analysis Analysis
decrease of
The non- consciousness Multivariate logistic
survivors had (p=0,001), regression analysis
cut-off 8 for tachypnea (p=0,030), determined predictors
PELOD-2 score hypotension (p=0,001), of mortality in sepsis
with sensitivity CRT>2’’ (p=0,080) children were
73,42%, hypotension
specificity biomarkers showed (OR=4,294),
82,19% and neutrophils (p=0,153) neutrophilia (OR=3,102)
AUC 66%. and CRP ≥ 5 mg/L and CRP ≥ 5 mg/L
(p=0,155). (OR= 2,789).
 Pediatric sepsis in Low Resource PICU
• Rusmawatiningtyas et al: 58% of paediatric patients with sepsis died
(665 pt) 67.7% had inotropic support
85% were supported with mechanical ventilation

• Paediatric sepsis mortality percentage in high-resource settings vs lower

resource setting = 5 : 20

Rusmawatingtyas et al. BMC Pediatr 2021

Miranda M Current pediatr reports. 2023
Sepsis in Low Resource Country

• Problems:
- Designated ICUs
- Adequate number of trained healthcare staff
- Access to necessary medications and equipment
- Transport of sick patients
- Emergency stabilization
- Tertiary critical care

• Focus on:
Developing low-cost, interventions, short-term
outcomes
 What challenges are there when
applying the SSG to a critically ill
child in a RLS?

patient factors

pre-hospital factors hospital factors

- delay recognition - insufficient staffing and specialty
- emergency transport limitation - lack of equipment, monitoring,
- limited pre-referral management medications

Wooldridge G. Andes Pediatr. 2021

Sepsis
 Surviving Sepsis Campaign international guidelines for the
initial management of pediatric septic shock and
sepsis- associated organ dysfunction (2020)
1. Screening, diagnosis, and systematic management
2. Antimicrobial therapy
3. Source control
4. Fluid therapy
5. Hemodynamic monitoring
6. Vasoactive medications
7. Ventilation
8. Corticosteroids
9. Endocrine and metabolic
10. Nutrition
11. Blood products
12. Plasma exchange, renal replacement, and extracorporeal support
13. Immunoglobulins
14. Prophylaxis
1. Screening, diagnosis, and systematic management

1. Implement systematic screening for timely recognition

2. Consider using blood lactate values
3. Implement a protocol/guideline for management of sepsis-related organ dysfunction
4. Obtain blood cultures before starting antimicrobial therapy

• No reliable method of clinically diagnosing sepsis

• Heterogeneity in disease pattern and burden of sepsis in RLS
• Inconsistent triage in ER
• Limited validated pediatric mortality scoring systems in LMIC
• Lack of consensus on diagnostic criteria of shock
• Limited laboratory facilities
PICU trials website (http://picutrials.net/)  PICU RCTs (1986 – 2021):
483 RCTs  33 (6.8%) involved sepsis in children

De Souza. Rev Bras Ter Intensiva. 2021

Recognizing Sepsis in Children in Low-
Resourced Settings: Guidelines for
Frontline Clinicians

Tungal S, et al. Springerlink. 2023

Establishing the Diagnosis
No No Observation, re-
Suspect or confirmed Sepsis is still
evaluate the possibility
Suspicion of organ dysfunction (warning infection suspected
of sepsis

signs) if 2 of 3 signs are present : Yes

Warning signs organ

• Decreased level of consciousness as dysfunction Observation, re-
evaluate the possibility
indicated by GCS <11 Yes
No of sepsis

• SpO2 >92% only with oxygen therapy or PELOD-2 score  10

mechanical ventilation
Yes

• Cardiovascular disturbance, as defined at

least 2 of 3 signs are found :
SEPSIS

• Prolonged capillary refill time

• Core and peripheral temperature differences >30℃
• Urine output < 0.5ml/kg/hour

Sepsis is established if PELOD-2 score  10

 2. Antimicrobial therapy
1. Administer antibiotics within 1 h of (septic shock) OR
3 h (without shock)
2. Start with empiric broad-spectrum antibiotics
3. Narrow antimicrobial coverage after culture results
4. Considering site of infection, host risk factors and
clinical improvement
5. Immune compromise: empiric multi-drug therapy
6. Optimize antimicrobial based on pharmacokinetic data
7. Reassess daily for antimicrobial de-escalation
Antimicrobial therapy - RLS

• AMR
• Undocumented pre-hospital AB
• Limited laboratory facilities
• Limited AB stewardship
• Numerous areas of endemic disease (“sepsis like”)
• Lack reliable pharmacy service for pediatric dosing
 3. Source control - RLS
1. Emergently attain source control if possible
2. Remove intravascular access devices if confirmed to be source of sepsis

• Limited surgical and anaesthetic capacity

• Limited availability of personal protective equipment and
infection control
4. Fluid Therapy - RLS

• Occasionally first
line/recommended fluid
insufficient or poorly
available

• Fluid therapy complication in

severe malnutrition: fluid
overload, capillary leak
syndrome, electrolyte shifts
3 concepts of paediatric
sepsis:

- The early recognition of

paediatric septic shock
- Choices for initial haemodynamic
support
- Titration of ongoing resuscitation
to therapeutic endpoints

Ranjit S. The Lancet 2023

 5. Hemodynamic monitoring-RLS
1. MAP: between the 5th and 50th percentile or > 50th percentile for age
2. No “warm” or “cold” septic shock categorized based on clinical sign
3. Blood lactate levels to guide resuscitation
6. Vasoactive
1. Use epinephrine or/and norepinephrine
2. Initiating vasoactive agents through peripheral access in dilute

medications -
concentration, if central venous access is not readily accessible
3. Adding vasopressin or further titrating catecholamines if refractory

RLS shock
4. Adding inodilators if evidence of persistent hypoperfusion and cardiac
dysfunction despite other vasoactive agents
 7. Ventilation

1. Consider intubating children with fluid-refractory, catecholamine-resistant septic shock

2. Consider a trial of non-invasive mechanical ventilation without a clear indication for intubation
3. If severe sepsis-induced PARDS use high PEEP, prone positioning, neuromuscular blockage, and
use inhaled nitric oxide only as emergency rescue therapy

Limited access to:

- supplemental oxygen
- electrical power supply
- guidance on benefit of NIV in sepsis in RLS
- invasive and NIV equiptment
- critical care training and staff availability
 8. Corticosteroids
1. Do not use IV hydrocortisone if fluid resuscitation and vasopressor therapy are able to
restore hemodynamic stability
2. Consider either IV hydrocortisone or no hydrocortisone in refractory shock

Adrenal insufficiency syndrom: Hypotension, altered mental status, vomiting, fatigue

Hyponatremia, hyperkalemia, hypoglycemia
 9. Endocrine and metabolic
1. Do not use insulin to target lower blood glucose levels
2. Consider targeting blood glucose levels below 180 mg/dL
3. Consider targeting normal calcium levels if requiring vasoactive support
4. Use antipyretic therapy or a permissive approach to fever

Limited access to laboratory, insulin and blood

glucose monitoring
10. Nutrition
1. Consider early enteral nutrition, within 48 h of admission if no
contraindications
2. Do not withhold enteral feeding because vasoactive-inotropic support
3. Prefer enteral nutrition through a gastric tube
4. Parenteral nutrition may be withheld in the first 7 days of PICU admission

NGT feeding is often left to parents to administer due to

lack of pumps and human source
11. Blood products
1. Do not transfuse RBCs if the hemoglobin concentration is ≥ 7 g/dL in
hemodynamically stabilized
2. Do not transfuse platelet or plasma prophylactic in nonbleeding children

• Access to blood products is varied

• Limited capacity to measure volumes of blood lead to frequent overload/over-transfusion
• Transfusion targets poorly defined in RLS
12. Plasma exchange, renal replacement,
and extracorporeal support
1. Do not use plasma exchange (PLEX) if patient does not have TAMOF
2. Use renal replacement therapy to prevent/treat fluid overload, unresponsive to fluid restriction and
diuretic therapy, with standard hemofiltration
3. Use venovenous ECMO in children with sepsis-induced PARDS and refractory hypoxia, and
venoarterial ECMO as a rescue therapy only if refractory to all other treatments
13. Immunoglobulins
Do not routinely use IV immunoglobulin, apart from those with toxic shock syndrome

14. Prophylaxis
1. Do not routinely do stress ulcer prophylaxis, except for high-risk patients
2. Do not routinely do deep vein thrombosis prophylaxis (mechanical or pharmacologic),
although consider in high-risk populations
 Recommendations for improving sepsis
management in Low Resource Setting

Early management of
sepsis, ICU care, Appropriate timely Adequate fluid
monitoring, and antibiotics resuscitation
rehabilitation

Decreasing pathogen
invasion, better host
Vasoactive support Source control
response, optimizing
host–pathogen interaction

Ravikumar N. Frontiers in paed. 2022

Conclusion
• The needs and resources of
those working in a RLS differ
substantially from those in
resource-rich settings
• The various challenges to SSG
implementation of the SSG
• Urgent need the specific
guidelines for use in the RLS