Written by Michael Wolf
Recognize sepsis fast; have a protocol; tailor therapy to specific needs and available resources; be ready to resuscitate sick kids.
Why does this matter?
These recommendations leave a lot of room for individualized decision-making based on patient factors and local resources. Use your judgment when applying these principles to your patients in your practice. This review highlights a few guidelines especially applicable in emergency medicine.
Rapid assessment and recognition is crucial. The guidelines recommend a systematic approach to screening patients for sepsis, paired with an institutional protocol or “bundle” to improve the speed and reliability of care. This is a big deal—a recent single-center observational study associated bundle-compliant care with five-times lower mortality.
Not a huge change from what you already know: whatever you choose, give it fast. Get a blood culture (but don’t delay antibiotics!). For most previously healthy kids, ceftriaxone is great empiric first-line therapy. Tailor your therapy to the clinical concern. Worried about MRSA? Cover it! Neutropenic? Cover resistant gram negatives and candida. Neonates? Cover listeria and HSV. Toxic shock? Consider clindamycin. Recent hospitalization/infection/immunocompromise? Consider covering pseudomonas and multi-drug resistant organisms, and you may need multiple agents.
If intensive care is available, the guidelines suggest bolusing up to 40-60 mL/kg (10-20 mL/kg per bolus), titrating for clinical markers of cardiac output (heart rate, capillary refill, level of consciousness) and discontinuing for clinical signs of fluid overload. If no intensive care is available (based on data from resource-limited settings in Africa), the guidelines recommend against a bolus unless the patient is hypotensive. If hypotensive, up to 40 mL/kg is suggested, with caution.* Balanced fluids (i.e. plasmalyte or LR) are recommended over normal saline.
The Really Sick Ones
The guidelines stress the importance of reassessment during resuscitation. Bedside echo and other assessments of cardiac output and systemic vascular resistance can help guide therapy. Consider trending lactate.
Epinephrine and norepinephrine are the vasoactive drugs of choice. So long, dopamine!
When intubating, avoid etomidate (adrenal suppression) and expect to need high PEEP to maintain oxygenation in the setting of PARDS.
Does your hospital do a great job with protocolized pediatric sepsis recognition and management? Share your protocol with the campaign: firstname.lastname@example.org.
*Editor comment: Most of us are skeptical, as is Dr. Wolf, about cookie-cutter fluid boluses. I think most of you would do what I do when I am in our local community PED with no PICU – give a 20mL/kg; reassess; give another as needed and arrange for transfer as soon as possible.
Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(Suppl 1):10-67. doi: 10.1007/s00134-019-05878-6.
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