Sepsis recognition Sepsis Shock SIRS Signs of hypoperfusion Examinatiin

1. SEPSIS RECOGNITION

2. Scenario
• You are examining a 4 year old boy in the ER . He has fever, cough and breathing difficulty from last
2 days and is now dull and drowsy.
• His HR is 160/min, RR 50/min, BP 70/25 mm Hg, temperature 38.5 C, normal volume pulses and
normal CRT.
• GCS is 10/15, B/L crackles
• Assessment????......

3. 5/8/2020 3
Definitions & Organ Dysfunction
Shock; checklist & Stages
Examination; Clues towards
Diagnosis
Relevant Investigations
Objectives

4. DEFINITIONS

5. Systemic inflammatory
response syndrome (SIRS)
1- Temperature: >38.5°C or <36°C
2- Tachycardia: mean HR > 2SD for age in the
absence of external stimuli, drugs
OR
In children < 1 yr old, persistent bradycardia (HR
< 10th centile for age in the absence of CHD,
vagal stimuli or drugs
3- Tachypnea: mean RR > 2SD for age or need
for mechanical ventilation
4 - Leukocyte count high/low for age or >10%
immature neutrophils
Sepsis
• Sepsis: SIRS + suspected or proven infection

6. Severe Sepsis & Septic Shock
Severe Sepsis: Sepsis + 1 of the following:
1-CVS dysfunction, defined as :
• Hypotension(< 5th centile for age/ SBP < 2SD
OR
• Need for vasoactive drug to maintain BP
OR
• 2 of the following
• base deficit > 5
• lactate > X 2 times the upper limit
• CRT > 5 sec
• ∆T > 3⁰C
• Oliguria
ARDS
Sepsis + ≥ 2 organ dysfunctions
(respiratory, renal, neurologic, hematologic, or
hepatic)

7. Age-specific vital signs and Labs
Age Tachycardia Bradycardia Tachypnea SBP WBC x
103/mm3
1d-1wk >180 <100 >50 <60 >34
1wk-1mo >180 <100 >40 <65 >19.5 or <5
1mo-1yr >180 <90 >34 <70 >17.5 or <5
2-5 yrs >140 - >22 <75 15.5 or 6
6-12 yrs >130 - >18 <80 13.5 or <4.5
13-18
yrs
>110 - >14 <90 >11 or <4.5
International Consensus Conference on Pediatric Sepsis
Pediatr Crit Care Med 2005; 6:2-8

8. Organ Dysfunction Criteria
• Cardiovascular:
Despite IV fluid 40ml/kg in 1h
 Decreased BP <2SD for age
 Need for vasopressors
 Two of the following:
- Capillary refill >5 s,
- ΔTC >3oC
- Lactate x 2,
-BD >5
-Oliguria <0.5 ml/kg/h
• Respiratory:
- PaO2/FiO2 <300 (<200=ARDS)
- PaCO2 >65 or 20 mmHg above
baseline
- FiO2 >50% => SpO2 > 92%
-Need for invasive or non invasive MV
• Neurologic
- GCS ≤11
- Acute change in GCS ≥ 3pts from
baseline
• Hematologic:
- PL <80.000/mm3 or a decline >50%
-INR >2
• Renal
- 2-fold increased serum creatinine from
base line
-Serum creatinine ≥ 2 times upper limit of
normal
• Hepatic:
- Bilirubin >78 µmol/L (4mg/dL)
- AST/ALT x 2 times the upper limit of
normal

9. Pediatric Septic Shock Collaborative Triage Trigger Tool/
ACCM guidelines 2017

10. Pediatric Septic Shock Collaborative Triage Trigger Tool/
ACCM guidelines 2017

12. Septic Shock Checklist
• Temperature abnormality
• Hypotension
◦ Hypotension – BP below 5th percentile
◦ Systolic BP (mm Hg) = 70 + (2 x age in
years)
◦ Mean arterial pressure (mm Hg) = <40 +
(1.5 x age in years)
• Tachycardia
• tachypnea
• Capillary refill abnormality
• Skin abnormality
• Pulse abnormality
• Mental status abnormality

13. Septic Shock Checklist

14. High Risk Patients
• Malignancy
• Asplenia (including SCD)
• Bone marrow transplant • Central or indwelling line/catheter
• Solid organ transplant
• Severe MR/CP
• Immunodeficiency, immunocompromise or immunosuppression

15. Stages of Shock
Compensated
• Vital organ functions remain maintained
• BP: normal/increased
Uncompensated
• Clinical signs of shock is present (Hypotension + hypoperfusion)
Irreversible
• Failing compensatory mechanisms:
• Profound vasoconstriction
• Lactic acidosis
• MODS may occur

17. Examination
• CNS: Agitation/drowsiness/coma
• CVS: Hypotension – BP below 5th percentile
◦ Systolic BP (mm Hg) = 70 + (2 x age in years)
◦ Mean arterial pressure (mm Hg) = 40 + (1.5 x age in years)
• RESP: Acidotic breathing pattern/altered pattern
• ABD: Distention/tenderness/sclerema

18. Signs of Hypoperfusion
• Increasing tachycardia
• Diminished or absent pulses
• Weakening central pulses
• Narrowing pulse pressure
• Cold extremities with prolonged capillary refill
• Decreasing level of consciousness
• Hypotension (late finding)

19. Lab Workup
• CBC with differential count and PF
• Blood cultures
• CRP, procalcitonin
• Blood gas, lactate, Scvo2
• PT, APTT, INR, d-dimers
• Liver function tests
• BUN/creatinine
• Electrolytes
• Blood glucose levels
• Blood group and cross-match
• CXR
• Echocardiography

20. CentralVenous Saturation
• Because low CO is associated with increased oxygen extraction, ScVO2/MvO2 saturation
can be used as an indirect indicator of whether CO is adequate to meet tissue metabolic
demand.
• If tissue oxygen delivery is adequate, then assuming a normal SaO2 of 100%, mixed venous
saturation is greater than 70%.

22. Summary
• Early recognition of septic shock remains the key to reduction of mortality among children.
• Each pediatric institution should develop a multidisciplinary approach to early identification of septic
shock with employment of a septic shock screening tool

23. THANK YOU