Septic shock (Monica)

Give a high - level overview of managing septic shock

1. Obtain IV/IO access

2. Collect blood culture

3. Start empiric broad-spec abx

4. measure lactate

5. administer fluid bolus(es) if shock present

6. start vasoactive agents if shock persists

Management step 1: obtain IV/IO access

• establish IO access if failed attempts at PIV access

• can use ultrasound-guided peripheral IV catheter and umbilical venous catheter

• PEARL:

  • consider for subq access (use hyaluronidase?)

What is hyaluronidase used for in septic shock?

it can break down skin barrier to make subq tissue more absorptive

• facilitate the administration of medications, particularly when IV/IO access is challenging.

Management step 2: Collect Blood Culture

• BEST PRACTICE

• recommended if it DOES NOT delay antimicrobial therapy

Management step 3: Start empiric broad-spec abx

sepsis

• administer within 3 hours of recommendation (weak recommendation)

septic shock

• administer within 1 hours of recognition (strong recommendation)

In children without immune compromise and without high risk for multi-drug resistant pathogens, should we have routine use of empiric multiple abx directed against the same pathogens for the purpose of synergy?

NO, routine use is not recommended.

In children with immune compromise and/or at high risk for multi-drug resistant pathogens, should we be using empiric multi-drug therapy when septic shock or other sepsis-assocaited organ dysfunction is present/suspected?

YES, empiric multi-drug therapy is recommended to improve outcomes.

Examples of broad spectrum antibiotics

• ceftriaxone

• cefepime

• ceftazidime

• tobramycin

• gentamicin

• vancomycin

• pip-tazo

• meropenem

management step 4: measure lactate

• lactate provides a valuable indirect marker of tissue hypo perfusion

  • increased lactate = increase hypo perfusion

What do we need to consider when administering lactate ringers?

• Different than lactate acids?

• Its a buffer that our body breaks down to sodium bicarb

Management step 5: administer fluid bolus(es) if shock present

• 10-20 ml/kg per bolus over the 1st hour

• crystalloids » albumin for initial resuscitation

• balanced/buffered crystalloids » 0.9% saline for initial resuscitation

  • associated with hypercholremia but probably outweighs undesirable consequence of saline

if absence of hypotension, what fluids should we provide?

• NOT FLUID BOLUS

• administer maintenance fluids

If hypotension is present, what fluids should we provide?

• up to 40 ml/kg bolus fluid in the first hour

Management step 6: start vasoactive agents if shock persists

• no recommended first line agent

• epi/norepi >> dopamine

• vasoactive agents

  • vasopressin

  • inodilators?

    • milrinone

    • dobutamine

    • levosimendan

What is septic shock

aka distributive shock

• response to infections organisms and inflammatory mediators

• capillary leak

• inadequate oxygen delviery to end organs

• low systemic vascular resistance

When could we possibly use corticosteroids - IV hydrocortisone?

In cases of persistent shock/still hemodynamically unstable despite adequate fluid resuscitation and vasopressors.

T/F

Hydrocortisone-ascorbic acid-thiamine (HAT) associated with lower mortality in peds septic shock?

TRUE

Should insulin therapy be used to maintain glucose to be at or below 140 mg/dl?

should not be used

When can we have routine use of stress ulcer prophylaxis?

only in high-risk patients

who should NOT have routine DVT prophylaxis

• critically ill children with septic shock or other sepsis-associated organ dysfunction

What does a Phoenix Sepsis Score of at least 2 indicate?

Severe sepsis!!

What are the implications of the Sepsis score?

no definition can fully substitute for the clinical judgement of an experienced, vigilant clinician caring for an unwell child

but offers us opportunity for rapid ID and future quality improvement study

What is the Phoenix Sepsis Score (PSS)

The Phoenix Sepsis Score (PSS) is based on points from organ dysfunction in 4 systems:

1. Cardiovascular (heart/blood pressure)

2. Respiratory (lungs/breathing)

3. Neurologic (consciousness/mental state)

4. Coagulation (clotting/platelets)