This document describes the case of a 4-year-old girl admitted to the hospital for sepsis. Upon admission, she had a high heart rate, low blood pressure, prolonged capillary refill time, and low oxygen saturation. She received fluid resuscitation and vasopressor support. Her condition required treatment in the intensive care unit with additional monitoring, intravenous antibiotics and other supportive care measures outlined in the document.

1. SEPSIS

2.  4yr old girl
 Previously healthy
 Developed fever and productive cough on 09/03/19
 Treated by GP, fever settled by 12/03/19
 On next day,
 Developed high fever, cough and reduced intake on 14/03/19
 Vomiting >10 times
 Diarrhoea >6 times
 Reduced UOP (only 2 episodes)

3.  Admitted to BH-Panadura
 On admission,
 PR-204, BP-73/34, CRFT>5, SPO2-96%
 N.Saline 10ml/kg two boluses given
 Noradinaline 0.07mcg/kg/min started
 Blood culture taken started on IV Cefotaxim
 Direct transfer to PCU

4.  On admission
 BP
 PR
 RR
 CRFT
 20ml/kg N.Saline two boluses given.
 Following that
 BP
 PR
 RR
 CRFT

5.  Noradrinaline 0.1mcg/kg/min continued
 ABG done
 PH-7.04
 pCO2-40
 HCO3-13
 BE- (-19)
 Lactate-5
 IV Cefotaxime IV Metronidazole started

6.  Pheripheral pulses were low volume
 PR-191
 BP-62/42
 MAP-46
 SPO2-86%
 N.saline 10ml/kg bolus started
 Following bolus
 PR-183
 BP-78/49
 Adrenaline infusion started

7.  In ICU,
 IV Ranitidine,Biffilac stated
 Kept on 100%M
 VBG done
 PH-7.094
 pCO2-34
 BE-(-19)
 Lactate-3
 N.Saline 10ml/kg bolus given
 Started on Dobutamin 10mcg/kg
 Hydrocortisone 4mg/kg
 20% Albumin 5ml/kg started

8.  Blood 5ml/kg given after Albumin
 IV Vancomycin added

10. DEFINITION
 Sepsis-
 Life threatening organ dysfunction caused by a dysregulated host
response to infection.
 Septic Shock-
 Subset of sepsis with circulatory and cellular/metabolic dysfunction
associated with higher risk of mortality.

11. PATHOPHYSIOLOGY
 Foci of infection
 Multiplication at primary site and releasing into circulation
 Bacteraemia
 Circulating bacterial components mediate the release of cytokines
 Clinically evident effects

12. CLINICAL FEATURES
 May have a preceding fever.
 According to site of primary infection (GIT, Renal, RS, Etc.)
 Confusion
 Anxiety
 Malaise/Fatigue
 SOB
 Nausea/Vomiting

13.  If in septic shock,
 Impalpable pulse
 Un-Recordable blood pressure
 Prolonged capillary refill time/ flash capillary refill
 Peripheries may be warm
 Impaired consciousness

14. MANAGEMENT
 MEDICAL EMERGENCY!!!!!!
 Airway
 Breathing
 Circulation

15. FLUID RESSUCITATION
 Recommended volume- at least 30ml/kg of fluid in initial 3 hours
 After initial fluid resuscitation, volume and frequency guided by re-
assessment.
 However even higher volumes may be needed in severe refractory shock.
 Recommended Fluid-
 Crystalloids for initial resuscitation and subsequent fluid requirements.
 Human Albumin when needing large fluid volumes

16. THERAPEUTIC GOALS FOR
RESSUCITATION /EGDT/ RIVERS
PROTOCOL
 CVP 8-12mmhg
 MAP ≥65mmhg
 Urine output ≥0.5ml/kg/hr
 Scvo2 ≥70%

17.  Capillary refill <2s
 Normal blood pressure for age
 Normal pulse with no difference in central and peripheral pulses
 Warm extremities
 UOP >1ml/kg/hr
 Normal mental status
 Scvo2 saturation >70%

18.  When third bolus of fluid is needed,
 CVP measurement via multilumen catheter
 Femoral or internal jugular
 Norepinephrine is the first line of vasopressor in warm shock
VASO-ACTIVE AGENTS

19.  Addition of either vasopressin(0.03u/min) or adding epinephrine to norepinephrine to achieve
the desired MAP and to reduce norepinephrine dosage.
 Dopamine in low risk patients for bradycardia Arrhythmias, in high PVR (Cold shock)
 Dopamine 10mcg/kg/min and increase to 15-20mcg/kg/min if no response
 Dobutamin as an alternative in hypoperfution despite of adequate fluid and vasopressors
 Delay of inotropes increase mortality
 Can start in peripheral line

20.  Cardiac function assessment can be done in prolonged shock and if clinical assessment dose not
lead to a clear diagnosis
 Dynamic variables over static variables
 Blood lactate levels can be used a guide to the fluid adequacy
 Management can be directed towards normalising Lactate.
 All patients needing vasopressors-Arterial catheter(if available)

21. ANTIBIOTICS
 Empirical antibiotics(at least two) aimed at most likely bacterial pathogens.-IN SEPTIC
SHOCK
 Routine microbial cultures if not delaying antibiotics.(IN 1HR MAXIMUM)
 Combination therapy-not recommended for sepsis or serious infections.
 Narrowed once cultures available
 Continue for 7-10 days
 Prolactinonin levels

22.  If suspecting toxic shock syndrome, add a anti staph agent
 <3months add amoxicillin to cover Lysteria
 Cefotaxime is used over Ceftriaxone if premature,jaundiced,hypoalbuminaemi or if a calcium
infusion is continued
 If hospital acquired or neutropenic, add Tazobactum
 If vascular access device had been used >48hrs, add Vancomycin

23. ACIDOSIS
 DO NOT GIVE BICARBONATE TO CORRECT METABOLIC ACIDOSIS DUE
TO HYPOVOLAEMIA

24.  Use of hydrocortisone, if fluids and vasopressors restore haemo dynamic stability is not
recommended
 If not IV Hydrocortisone 50mg/kg per day

25.  Blood transfusion only when Hb is <7.0g/dl in absence of other circumstances such as ,
Myocardial ischemia
Severe hypoxia
Acute haemorrhage
 Prophylactic use of FFP in patients in septic shock without evidence of bleeding-Not
recommended
 Platlet transfusion when below 10,000 in absence of apparent bleeding and when below 20,000
with significant risk of bleeding
 >50,000 in active bleeding and invasive procedures

26.  Blood purification (haemofilteration,haemoadsorption) antithrombin thrombomoduline heparin
not recommended

27. MECHANICAL VENTILATION
 No single mode of ventilation have shown efficacy over the other
 Positive pressure ventilation
 Decreases cardiac work-load
 Decrease oxygen consumption of heart and respiratory muscles
 Reduce risk of pulmonary oedema

28.  Targeted tidal volume 6ml/kg
 Higher PEEP in sepsis induced moderate to severe ARDS
 Non invasive ventilation not recommended( failure to achieve desired PEEP, need for prolonged
ventilation)
 May need fluid conservative strategy in patients with no evidence of tissue hypoperfution.
 Continues SPO2, Capnography and frequent blood gasses

29. BLOOD GLUCOSE CONTROL
 If >2 measurements of blood glucose >180mg/dl protocol to initiate
glycaemic control
 Glucose infusion should accompany insulin as some children make no
insulin while others may be resistant
 Monitoring glucose 1hrly until insulin rate stable,
 Then 4hrly