Severe Sepsis and Septic Shock	88
Praveen Khilnani

A 2-year-old boy was brought to the emergency department with lethargy, poor feeding, fever for the past 24 h, cold extremities, mild respiratory distress for the past 3 h, and no urine output for the past 8 h. He was lethargic but arousable. His rectal temperature was 104°F, with heart rate 170/min, blood pressure 60 mmHg, respiratory rate 45 breaths/min, and SpO2 92% at room air. Capillary refill time was 5 s, and extremities were cold with palpable but feeble pulses.

Severe sepsis and septic shock involve clinical SIRS (systemic inflammatory response syndrome) with suspected or proven infection (blood culture not always positive) with cardiovascular involvement and dysfunction (septic shock) or multiple organ involvement (severe sepsis with multiple organ dysfunction syndrome). This chapter describes the step-by-step management of severe sepsis and septic shock.

Step 1: Initial resuscitation

•This includes fast recognition and action done almost simultaneously.

•Shock should be clinically diagnosed before hypotension occurs by clinical signs, which include the following:

–Hypothermia or hyperthermia

–Altered mental status

–Peripheral vasodilation (warm shock) or vasoconstriction with capillary refill more than 2 s (cold shock)

–Tachycardia

–Tachypnea out of range for age and level of fever or anxiety

P. Khilnani, M.D., F.C.C.M. (*)

Pediatric Critical Care and Pulmonology, BL Kapur Memorial Hospital, New Delhi, India

e-mail: [e-mail]

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,	703
DOI 10.1007/978-81-322-0535-7_88, © Springer India 2012

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Zero minutes

Recognize decreased mental status and perfusion

Maintain and establish vascular access—use intraosseous if IV fails in 90 s

5–15 min: Push 20 mL/kg normal saline/colloid × 3 up to 60 mL/kg

Assess between each push

Correct hypoglycemia and hypocalcemia

•There should be no time wasted in gaining access. If access is not easily obtained in about 90 s, the interosseous route is a must, as almost everything can go in by that route including inotropes.

•Because mortality goes up with delay in time to inotrope drug use, now it is recommended to use the peripheral line for inotropes—dopamine and dobutamine (not vasopressors)—until central access is attained.

•Optimizing fluids in the first 15 min or as soon as possible: Pediatric septic shock is associated with severe intravascular volume depletion, and children frequently respond well to aggressive volume resuscitation.

•The continued emphasis is on the first-hour fluid resuscitation, and appropriate inotrope drug therapy is directed to achieve the following goals:

–Reducing heart rate to the threshold level for age

–Getting peripheral pulse to match central pulse volume

–Improving mentation

–Improving urine output to at least 1 mL/kg/h

–Reducing clot retraction time to less than 3 s.

This assessment for quick check for overload is done after each bolus of fluid.

•Rapid expansion of the liver span

•Rales and increased work of breathing

•Enlargement of the cardiac silhouette on chest X-ray

•Drop in SPO2

Step 2: Manage 15-min fluid-refractory shock

•Establish central venous access.

•Start dopamine 10 mcg/kg/min.

•Establish arterial access.

•Continue maintenance fluids 4 mL/kg/h and boluses of .9% normal saline/colloid as needed.

•Thirty to sixty minutes have passed—fluid-refractory, dopamine-resistant shock.

Scenarios

1. When pediatric patients are normotensive with a low cardiac output (CO) and high systemic vascular resistance (SVR), initial treatment of fluid-refractory patients consists of the use of an inotropic agent such as dobutamine. Dopamine at a dose of 10–15 m/kg/min should be administered at this time.

88 Severe Sepsis and Septic Shock	705

However, fluid-refractory, dopamine-resistant shock is an important defining step as the mortality changes when the patient fails to respond to fluids and dopamine.

2. When pediatric patients are hypotensive with a low CO and high SVR (cold shock), EPI (epinephrine) is started at a dose of 0.1 mg/kg and titrated to effect. When BP improves, an inodilator (dobutamine, milrinone, and nitroglycerine) is added to improve tissue perfusion. This can be done using the same clinical parameters described above or additional laboratory data such as base excess of more than 5 or increasing lactate levels.

3. When pediatric patients are hypotensive with a high CO and low SVR (warm shock), then norepinephrine is the vasopressor of choice. Since the pulse pressure is wide and diastolic pressures are usually low, the need is to increase the mean arterial pressure (MAP). Here, a vasodilator can be added.

There is no magic formula for inotrope or fluid titration. The guidelines are there to give a framework for initiating and adding drugs based on clinical examining and parameter readings of central venous pressure (CVP), BP, etc. Many children by now may be on more than three agents including vasopressors and vasodilators.

Step 3: Early goal-directed therapy

•It restores the balance between delivery and demand quickly by manipulating preload, afterload, and contractility using fluids, inotropes, and vasodilators to

enhance delivery and PRBCs to deliver more oxygen by increasing O2 content (Table 88.1).

•All four goals to be met for success

Table 88.1 Early goal-	1. Normal MAP (>60 mmHg)
directed therapy	2. Mixed venous saturation >70%
	3. Urine output >1 mL/kg/h
	4. CVP >8–12 cm H2O

Step 4: Give antibiotics within the first hour and control the source

•An increased mortality rate due to delay in the administration of an appropriate antibiotic has been clearly shown in several pediatric and adult studies. Therefore, every attempt should be made to get appropriate cultures earlier, but this should not hold up the administration of the drug.

•The choice should be on the basis of the site of infection and local patterns. A broad-spectrum antibiotic like a third-generation cephalosporin should be used. De-escalate antibiotics once the culture results are available.

•Along with this, there must be an active search for a source of infection, and immediate action for source control should be taken wherever possible.

Step 5: Mechanical ventilation and sedation

•There are many reasons to ventilate patients with septic shock. This step should be considered in any patient who is not rapidly stabilized with fluid resuscitation and peripherally administered inotropes.

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Step 6: Give steroids

•If a child is at risk of absolute adrenal insufficiency (e.g., purpura fulminans, congenital adrenal hyperplasia, prior recent steroid exposure as in asthma, or nephrotic syndrome) and remains in shock despite epinephrine or norepinephrine infusion, fluids and inotropes are optimized for an hour (catecholamineresistant shock) and then hydrocortisone can be administered.

•Hydrocortisone may be administered as an intermittent or continuous infusion at a dosage of 50 mg/m2/day (2 mg/kg 6-hourly) till hemodynamic stability is achieved.

Step 7: Glucose control

•Glucose-containing fluids D5 or D10 along with insulin should be used for maintenance, and insulin is titrated to keep blood glucose between 100 and 150 mg/ dL. This prevents catabolism as well as the ill effects of hyperglycemia.

•Tight glucose control leads to hypoglycemia and this can be brain damaging, so avoid this and maintain higher glucose value. Hyperglycemia should not be treated by reducing fluid concentrations to glucose-free fluids and removing insulin as there is poor glucose utilization and insulin is needed.

Summary of guidelines for pediatric septic shock management in resourcelimited environment

•Immediate recognition of shock state from decreased perfusion state and altered mental status.

•Airway, breathing, and circulation approach with high-flow O2.

•Rapid intraosseous access immediately, if IV is not available.

•Up to 60 mL/kg isotonic nonglucose-containing fluid can be given for 0–15 min.

•Clinical evaluation of improvement of shock by decreasing heart rate, clot retraction time less than 2 s, improved mental status, improved peripheral pulse and central pulse, improved urine output, warmer extremities, and MAP more than 60 mmHg (age-related values).

•Evaluate for fluid overload.

•Rapid decision to start dopamine/dobutamine by the peripheral line, not wait for the central line.

•Start appropriate antibiotics in first hour.

•Continue fluid boluses as needed throughout the process—in the first few hours— and continue maintenance fluids.

•Mechanical ventilation with sedation and analgesia.

•If fluid-refractory, dopamine-resistant shock, insert CVP and arterial line.

•Epinephrine for cold shock, norepinephrine for warm shock ± vasodilators.

•Steroids for catecholamine-resistant shock at 2 mg/kg/day q8.

•Early goal-directed therapy with ScVO2 more than 70%, hemoglobin 10 g/dL, CVP 8–12 cm H2O, and MAP more than 60 mmHg.

•Source control as soon as possible.

•Glucose control with insulin if needed (<150 mg/dL).