The document presents an overview of pediatric sepsis and septic shock, highlighting its definitions, epidemiology, pathophysiology, and management strategies. Key points include the importance of early recognition, the role of fluid resuscitation and vasoactive medications, and the need for appropriate antibiotic therapy. Continuous monitoring and prompt intervention are crucial for reducing mortality in affected children.

1. Pediatric Sepsis
and Septic Shock
Presenter: Dr Chebet Kimeto
Pediatric Intensivist

2. Outline
• Introduction
• Epidemiology of sepsis/septic shock
• Normal cardiovascular physiology
• Pathophysiology of septic shock
• Guidelines for the management of
septic shock

3. Definitions and classification of
shock
Acute syndrome characterized by reduction in circulatory
volume that results in impaired tissue perfusion, oxygen
and substrate delivery as well as waste removal.
Shock
Hypovolemic shock
Cardiogenic shock
Distributive shock
Obstructive shock
Septic shock
Types of
shock

4. Definitions have evolved:
Previous Definitions
Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of Critical Care Medicine Consensus
Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med.
1992;20(6):864-874.
Systemic
inflammatory
response
syndrome
(SIRS):
• Core temperature of >38.5ºC or <36ºC
• HR > 2SD above the normal for age(or
bradycardia if <1year)
• RR > 2SD above the normal for age
• Abnormal WBCs or >10%immature neutrophils.
Sepsis • 2 of 4 SIRS with suspected or proven infection.
Severe sepsis • Sepsis complicated with organ dysfunction
Septic shock • Sepsis- induced hypotension despite adequate
fluid resuscitation

5. Current Definitions
Weiss SL, Peters MJ et al. Executive summary: Surviving sepsis campaign international guidelines for management of septic shock and sepsis-
associated organ dysfunction in children. Pediatric Crit Care Med 2020
Sepsis Life-threatening organ dysfunction
caused by a dysregulated host
response to infection
Septic
shock
Severe infection leading to
cardiovascular dysfunction (including
hypotension, need for treatment with a
vasoactive medication, or impaired
perfusion
“Sepsis” in place of “Severe Sepsis”

6. Epidemiology
• 7.5 million paediatric deaths per year globally
• 49% have predisposing co-morbid condition: chronic lung
disease, cancer, malnutrition
• Greater than 50% of sepsis fatalities occur within 24 hours
and half of these patients die before transfer to Pediatric Intensive
Care Unit (PICU) care
• No single biomarker that has proven specific or sensitive enough
to diagnose sepsis or prognosticate outcome

7. Normal cardiac physiology
Cardiac output is the most important
determinant of tissue perfusion.
Cardiac output
Preload
Contractility
Heart Rate Stroke Volume
Afterload
+ -
+
+
+

8. Risk factors for sepsis/septic
shock
• Age (prematurity, newborns,
<1year old)
• Primary and acquired
immunodeficiencies
• Neutropenia
• Underlying co-morbid conditions
• Indwelling invasive catheters
• Boys
Kawasaki T. Update on pediatric sepsis: a review. J Intensive Care. 2017;5:47. Published 2017 Jul 20. doi:10.1186/s40560-017-0240-1

9. Pathophysiology
• Complex interaction between the pathogen and the host’s immune
system.
• Physiologic response to infection:
 activation of the host defence mechanisms
 influx of activated neutrophils and monocytes
 a release of inflammatory mediators
 local vasodilation
 increased endothelial permeability
 activation of coagulation pathways.

10. Pathophysiology

11. Clinical Findings
• Hyperthermia/hypothermia
• Tachycardia
• Tachypnea
• Abnormal pulse (diminished, weak, or bounding)
• Abnormal capillary refill (central refill ≥3 seconds or flash
refill [<1 second])
• Altered mental status
• Purpura anywhere on the body or petechiae below the
nipple line
• Hypotension- may be present

12. Management of
septic shock

13. Initial resuscitation
Martin K, Weiss SL. Initial resuscitation and management of pediatric septic shock. Minerva Pediatr. 2015;67(2):141-58.
Focuses on:
Rapid recognition of abnormal tissue perfusion and
restoration of adequate cardiovascular function
Eradication of the inciting invasive infection,
including prompt administration of empiric broad-
spectrum antimicrobial medications
Supportive care of organ system dysfunction

14. Recognition bundle
Weiss SL, Peters MJ et al. Executive summary: Surviving sepsis campaign international guidelines for management of septic shock and sepsis- associated
organ dysfunction in children. Pediatric Crit Care Med 2020
Systematic screening for identification
of sepsis or septic shock
Rapid clinical assessment for patients
with possible sepsis/septic shock
Rapid initiation of resuscitation

15. Resuscitation bundle
American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock
Obtain vascular(IV/IO)
access
Collect blood
cultures.
Start broad spectrum
antibiotics
Measure blood
lactate.
Start appropriate fluid
therapy
Start vasoactive drugs if shock
persists

16. Resuscitation
A B C as per the ETAT+ guidelines
• No obstruction , position and secure the airway
Airway
Breathing
• Supplemental oxygen to optimize blood
oxygen content (Spo2 92-96%)
• Trial if NIV in children with paediatric ARDS.
• Mechanical ventilation

17. Mechanical ventilation
Indications
Benefits
Martin K, Weiss SL. Initial resuscitation and management of pediatric septic shock. Minerva Pediatr. 2015;67(2):141-58.
• Respiratory failure
• Altered mentation
• Fluid refractory shock
• Need for invasive hemodynamic
monitoring
• Reduced oxygen consumption
• Reduced work of breathing
• Protects airway
• Assists ventilation and promotes
oxygenation

18. Fluid resuscitation
• 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
ICU facility
available
• No bolus fluid administration while starting
maintenance fluids
ICU facility not
available and
no hypotension
• Up to 40 mL/kg in bolus fluid (10–20 mL/kg
per bolus) over the first hour with titration to
clinical markers of cardiac output and
discontinued if signs of fluid overload develop
ICU facility not
available and
hypotension is
present
Circulation

19. Inotropes/Vasopressors/Vasodilators
• Start within one hour of resuscitation
• Central Venous Access is preferred
• Determined by Blood pressure- normal /hypotensive for age
Hypotensive fluid refractory septic
shock
Normotensive fluid refractory
septic shock
Epinephrine or Norepinephrine
Epinephrine doses-0.05- 0.1mcg/kg/min
titrate to response upto1.5mcg/kg/min
Norepinephrine doses-0.05-
0.1mcg/kg/min
Max dose 2mcg/kg/min
Modification of drugs and doses guided
by advanced hemodynamic monitoring
Persistent signs of shock but normal BP
Low doses of epinephrine infusion(0.03-
0.05mcg/kg/min plus IVF
Need for vasodilatory agents-
dobutamine, Milrinone.

20. Catecholamine - Resistant Septic
shock
• Evaluate for unrecognized morbidities-
pneumothorax, pericardial effusions, on-
going blood losses
• Start hydrocortisone 2-4mg/kg /day. max
dose 200mg/day.
• Critical illness related corticosteroid
insufficiency.

21. Hemodynamic monitoring
Target MAP:
Between 5th and 50th
centile or > 50th centile
for age
Bedside clinical signs:
Not use in isolation to categorize
septic shock in children as
“warm” or “cold”
Advanced hemodynamic
variables:
Use when available, in addition
to bedside clinical variables to
guide the resuscitation of
children

22. Antibiotic Therapy
• Empirical antibiotic therapy within 1hour of recognition
of septic shock
• In sepsis associated organ dysfunction but without
shock, start antimicrobial therapy as soon as possible
after appropriate evaluation within 3 hrs of recognition
• Samples for cultures should be taken prior to antibiotic
administration where possible.
• If no pathogen is identified on blood culture, de-escalate
based on daily assessment-clinical and laboratory,
narrow or stop empiric antimicrobial according to clinical
presentation, site of infection, host risk factors and
adequacy of clinical improvement.
Narrow or stop empiric antimicrobial therapy according to clinical
presentation, site of infection, host risk factors, and adequacy of
clinical improvement

23. Source control
Emergent source control interventions as
soon as possible.
• Removal of intravascular
access devices that are
confirmed to be the source of
sepsis or septic shock after
other vascular access has
been established

24. Blood products
• During resuscitation, hemoglobin
levels of 10 g/ dL are targeted.
• After stabilization and recovery
from shock and hypoxemia, then
a lower target > 7.0 g/dL can be
considered reasonable
• No routine prophylactic use of
platelets and FFP based on
platelet counts in non-bleeding
children
Weiss SL, Peters MJ et al. Executive summary: Surviving sepsis campaign international guidelines for management of septic shock and sepsis- associated
organ dysfunction in children. Pediatric Crit Care Med 2020

25. Endocrine and metabolic
• No insulin therapy to maintain a
blood glucose target at or below
140 mg/dL (7.8 mmol/L)
• Consensus to target blood
glucose levels below 180 mg/dL
(10 mmol/L)
• No consensus about the lower
limit of the target range
• Calcium replacement when blood
levels are below normal range

26. Nutrition
● Preference to commence early EN within 48 hours of
admission
● EN as the preferred method and PN may be withheld in the
first 7 days of PICU admission
● Do not withhold EN solely on the basis of vasoactive-inotropic
administration
● Gastric tube preferred rather than post-pyloric feeding tube
No Routine use of prokinetic agents for the treatment of feeding
intolerance

27. Prophylaxis
• No consensus on routine
use of stress ulcer
prophylaxis
• No routine use of IV
immunoglobulins
• No routine use of DVT
prophylaxis in children

28. Summary
Fluid resuscitation followed by vasoactive medication is
the cornerstone of management of pediatric septic shock.
Early recognition of septic shock and prompt intervention
is key to reduction of mortality.
Continuous monitoring of clinical parameters guides
management.
Use RRT to prevent or treat fluid overload in children who
are unresponsive to fluid restriction and diuretic therapy

31. References
1. Venkat Raman, Narayanaswamy & Shiraz, Mohamed & Boban, DD.
(2014). Sepsis in Obstetrics.. Foundation Years Journal. Volume 8, Issue
9: Obstetrics and Gynaecology - Part 2. 72-79.
2. Randolph AG, McCulloh RJ. Pediatric sepsis: important considerations
for diagnosing and managing severe infections in infants, children, and
adolescents. Virulence. 2013;5(1):179-89.
3. Mbevi G, Ayieko P, Irimu G, Akech S, English M, Clinical Information
Network authors. Prevalence, aetiology, treatment and outcomes of
shock in children admitted to Kenyan hospitals. BMC Med.
2016;14(1):184. Published 2016 Nov 16. doi:10.1186/s12916-016-0728-
x
4. Surviving Sepsis Campaign: International Guidelines for Management of
Severe Sepsis and Septic Shock, 2020
http://www.survivingsepsis.org/Guidelines/Pages/default.aspx

32. Questions
Comments

33. Thank you