Sepsis Notes

Sepsis

Sepsis or Septicemia

  • Systemic Inflammatory Syndrome (SIRS) that occurs in the presence of infection.
  • Refers to a state of immune/inflammatory activation
  • Severe sepsis leads to Septic Shock
  • In-patient mortality rate of 8.9%8.9\%.
  • Higher risk groups:
    • AIDS
    • Sickle Cell Disease
    • Burns
    • Compromised Immune Function
    • Prolonged Hospitalization (multiple invasive procedures, lines, catheters)

SIRS Criteria

Presence of 2 of the following (one must be fever):

  • Alteration in Temperature
    • >101.2^{\circ}F (38.5^{\circ}C)
    • <96.8^{\circ}F (36^{\circ}C)
    • >100.4^{\circ}F (38^{\circ}C) in neonates < 30 days
  • Alteration in Heart Rate
    • Tachycardia (without external stimuli) or unexplained tachycardia over 0.5-4 hours
    • In children >1 year: Bradycardia: Unexplained persistent depression over a 0.5-hour time period
  • Alteration in Respiratory Rate
    • Tachypnea
  • Alteration in White Blood Cell Count
    • Elevated Leukocytes or >10%10 \% immature neutrophils

Diagnosis of Sepsis

  • Clinical signs and symptoms
  • Cultures of blood, urine, CSF, and skin lesions
  • CBC: Increased WBCs
  • Chest radiograph consistent with pneumonia

Sepsis: Clinical Signs and Symptoms

  • Altered mentation
  • Complications and deterioration can unfold over days or hours
  • Early stages:
    • Fever or hypothermia
    • Elevated heart output (tachycardia)
    • Tachypnea
  • Signs of Septic Shock – Inadequate Perfusion:
    • Altered responsiveness
    • Prolonged cap refill
    • Diminished or bounding pulses
    • Mottled cool extremities
    • Decreased UOP

Severe Sepsis

  • Severe Sepsis - Tissue hypo-perfusion or insufficient end-organ perfusion
  • Hypotension (Systolic < 70+2×70 + 2 \times age in years)
  • Metabolic acidosis
  • Increased lactate
  • Oliguria (<0.5 ml/kg/hr)
  • Prolonged capillary refill >3 seconds
  • Glasgow Coma Scale (GCS) <11 OR acute change in mental status
  • Serum creatinine > 2 \times for age
  • Total Bilirubin >4mg/dl

Brighton Pediatric Early Warning Score

*Behavior:
*0: Playing Appropriately
*1: Within Normal Parameters
*2: Irritable
*3: Lethargic &/OR Confused &/OR Reduced Response to Pain
*Respiratory:
*0: No Recession or Tracheal Tug
*1: 10 Above Normal Parameters
*2: Parameters with Recessing/Retractions, Sternal
*3: >20 Above Normal Parameters, Using Accessory Muscles, &/OR recession/retraction tracheal tug or grunting
*Cardiovascular:
*0: Pink &/OR Capillary Refill 1-2 Seconds
*1: Pale &/OR Capillary Refill 3 Seconds
*2: Grey &/OR Capillary Refill 4 Seconds &/OR 30+% FiO2
*3: Grey and Mottled or Capillary Refill 5 Seconds or Above &/OR 40+% FiO2

Goals: Control the Infection

  • Obtain cultures
  • Start antibiotics
    • Newborns: ampicillin (+), gentamicin (-), cephalosporin (broad)
    • Older infants/children: 3rd gen cephalosporin (broad), vancomycin (- & +), clindamycin (anaerobes)
  • Oxygenate & Decrease O2O_2 Consumption
    • 100%100\% oxygen to keep saturations > 94%94\%.
  • Volume Resuscitation/Restoration
    • Treat hypotension-crystalloids/colloids
    • Vasopressors (for refractory shock): Dopamine, Norepinephrine
  • Prevent End-Organ Damage
    • Multi-system failure

Goals for Septic Child (First Hour)

  • Decrease Lactate
  • Capillary refill <2 seconds
  • Pulses normal
  • Warm Extremities
  • UOP>1 ml/kg/hr
  • Baseline mental status or EMV>11