2. • According to the world health organization >two third (68%) deaths in
children caused by infectious disease.
• Several studies have demonstrated:
Delay in recognition and treatment of pediatric sepsis increases
mortality
Rapid recognition and aggressive treatment protocols in children with
sepsis significantly improves survival
3. Goals of management
• Reversal of tissue hypoperfusion
• Prevent multiple organ dysfunction
• Early and rapid control of infection
4. 4 key components of treatment
Initial 5-minute management
Appropriate use of Inotropes
Fluid resuscitation
Appropriate use of Antibiotics
7. Open airway
• Airway:
• Positioning the child's head and neck in sniffing position to
optimize breathing
• Suctioning excess upper airway secretions
• Administer 100% oxygen to all patients with septic shock via non -
rebreathing mask (> 10 L/min)
8. Endotracheal Triggers (indications)
• Increased work of breathing
• Refractory hypoxemia
• Combination of these signs
• Still hypoperfused despite 60ml/kg fluid bolus-> intubate to
reduce the body oxygen consumption to perfuse the vital
organs well
• Anticipation is the key towards successful management
10. Circulation: IV Access
• 2 wide bore venous access should be established as quickly as
possible
• If the procedure is unsuccessful, then intraosseous access is
recommended
• Send appropriate labs and check spot blood glucose
11. Circulation: Fluid Resuscitation
• Aggressive fluid resuscitation with isotonic crystalloid
• Boluses of 20 ml/Kg normal saline by push-pull system
• Usually patient requires up to or over 60cc/kg boluses
• Assessment through the POCUS -> image IVC
12. After Each Fluid-bolus: Assess for
Improvement of Perfusion
• Reversal of tachycardia
• Better CRT
• Better peripheral pulses and skin
temperature
• Decreasing shock index
• Normal mental status
• Better urine output
Fluid Overload
• Worsening tachycardia
• Gallop
• Hepatomegaly
• respiratory distress
• Desaturation
• Crepitus
• Increasing shock-index
12
14. Red-Flag of Fluid boluses
• Anemia
• Severe malnutrition
• Pneumonia
15. After 15 Minutes
• After 15 minutes of aggressive fluid resuscitation if the clinical targets
of hemodynamic improvement are not achieved, shock will be
classified as “fluid refractory septic shock”
16. Fluid refractory septic shock
• Hemodynamic management is very important.
• Appropriate selection of cardiovascular drugs for optimization of
hemodynamic and oxygen delivery
• Need for central access and invasive pressure monitoring
17. Terminology
• Inotrope: Increase contractility of heart muscle
• Chronotrope: Increase heart rate
• Lusitrope: Diastolic relaxation
• Vasoactive drugs: constriction of arteries
• Vasodilator drugs: dilatation of arteries
• Inodilator: Increase contractility and dilate vessels
19. Antibiotics
• Broad spectrum antibiotics must be administered within 15 min
• Vigilant and judicious use of Antibiotics
• Factors consider:
Age
Site
Institution
Patient
21. Correct Metabolic Abnormality
• Check and correct hypoglycemia
• 10% Dextrose water: 4mL/kg IV/IO
• Correct electrolyte imbalance
• Correct hypocalcaemia
• Anticipation for dialysis- either IHD or CRRT
22. Catecholamine-resistant shock
• Use of Hydrocortisone in a dose of 2 mg/kg/dose bolus and then
0.5mg/kg/dose q 6 hourly for 48 hours
child is not responding to Vasoactive drugs
Child has been on steroids for a long time because of underlying adrenal
insufficiency
Purpura fulminans
23. Pediatric Severe Sepsis & Septic Shock
Do’s
• Think early sepsis and shock
• Timely used diagnostic tool
• Resuscitate vigorously
fluids and inotropes
• Set goals of resuscitation
follow trends & multiple
parameters
Don’ts
• Don’t wait for hypotension
for treatment of shock
• Don’t delay in antibiotics
• Don’t give too little or excessive
fluid
• Don’t focus on one number
KSTB 23
24. Monitoring: clinical end points
• Normal volume pulses; Warm peripheries
• Capillary refill time < 2 sec
• Normal mental status
• Urine > 1 ml/kg/hr
• Normal HR, BP for age
• Central venous oxygen saturation > 70%
• Consider keeping Hb > 10
• Lactate trend
