Treatment of Sepsis and Septic Shock in Children From Emedicine/Medscape

All that follows is from Treatment of Sepsis and Septic Shock in Children from Emedicine/Medscape accessed 1/31/2015:

Recommendations and Regimens for Pediatric Sepsis and Septic Shock

The definition of severe sepsis and septic shock in children is similar to that in adults. However, in pediatric patients, a systemic inflammatory response includes an abnormal temperature or abnormal leukocyte count as part of the clinical presentation. In addition, there are age-specific normative values for vital signs.^[1]

Time-sensitive, goal-directed therapy is the rule. Consensus guidelines and reviews are available.^{[2, 3]}Most guidelines are available online through the Pediatric Sepsis Initiative.^[4]The Pediatric Advanced Life Support (PALS) Pocket Reference Card provides a summary algorithm.^[5]International guidelines, despite weak evidence for many therapies, have recently been updated.^[6]

Use of a triage protocol to recognize sepsis in children leads to more appropriate resuscitation management and shorter length of stay.^[7]Additionally, clinician adherence to sepsis resuscitation guidelines also results in shorter length of stay for children.^[8]

Recent reports question whether a fluid resuscitation – focused strategy is ideal in resource limited areas,^[9]but resource-poor pediatric sepsis resuscitation data remain limited.^[10]

Details of early recognition and treatment of sepsis and septic shock are provided below.

1. Recognize signs of poor perfusion (0-5min)

Decreased mental status
Cold extremities
Delayed capillary refill
Weak pulses, differential central and peripheral pulses
Low urine output
Hypotension or low BP: Minimum systolic BP by age: < 1mo: 60 mmHg; 1mo to 10y: 70 + (2 × age in years); ≥10y: 90 mmHg

2. Assess ABCs (0-5 min)

Provide 100% oxygen at high flow rate (15L)
Early intubation may be necessary in neonates and infants
Breathing assistance as necessary, including mechanical ventilation

3. Establish IV access and place on monitor (0-5min)

2 large-bore peripheral IVs (PIVs) preferred: if difficult IV, place IO access per PALS guidelines; 1 PIV may be sufficient unless vasoactive drugs needed (see Step No. 6, below)
Consider labs on IV placement: blood gas, lactate, glucose, ionized calcium, CBC, cultures (glucose check through finger stick preferred for rapid result)

4. Fluid and electrolyte resuscitation (5-15min)

Fluids:

Push 20 mL/kg fluid (isotonic crystalloid) IV/IO over 5-20min or faster if needed (reassess for signs of shock; see Step No. 11, below)
Repeat 20 mL/kg bolus push of fluid (up to 60 mL/kg) until clinical symptoms improve or patient develops respiratory distress/rales/ hepatomegaly
May continue to require additional fluid above 60 mL/kg (fluid refractory) (see Step No. 6, below)
Fluid needs may approach 200 mL/kg in warm septic shock (warm extremities, flash capillary refill)

Correct hypoglycemia:

Glucose levels in hypoglycemia: Neonates < 45 mg/dL; infants/children < 60 mg/dL
Glucose dosage: 0.5-1 g/kg IV/IO (max that can be administered through a peripheral vein is 25% dextrose in water) (see alternative treatments immediately below)
Treatment options to provide 0.5-1 g/kg glucose: For infant/child: dextrose 25% in water: 2-4 mL/kg IV/IO; dextrose 10% in water: 5-10 mL/kg IV/IO; for neonate: dextrose 10% in water: 2-4 mL IV/IO; consider maintenance fluid containing dextrose

Correct hypocalcemia for low ionized calcium:

Calcium gluconate 100 mg/kg IV/IO (max 2g) PRN
Calcium chloride 20 mg/kg IV/IO PRN (Note: central line administration preferred over 60min in nonarrest situation)

5. Infection control (5-60min)

Immediate considerations:

Administer antibiotics immediately after cultures obtained (blood, urine, +/- CSF/ sputum)
Do not delay antibiotics because of delay in obtaining cultures; initial antibiotics should be given within 1h

General treatment recommendations:

Empiric therapy should be used for unknown etiology of sepsis;
Tailoring of therapy to address suspected pathogens or to achieve adequate drug penetration may be necessary;
Broader initial coverage may be needed for initial stabilization
Dosing varies by age and weight (see specific recommendations and dosages immediately below)

Neonates < 2kg:

Consult institution pharmacist and primary medication references for your institution practice and for preterm infants and neonates < 2kg

Neonates >2kg:

Ampicillin plus gentamicin: Ampicillin for 0-7d: 50 mg/kg IV/IM/IO q8h; ampicillin >7d: 50 mg/kg IV/IM/IO q6h plus gentamicin (dosing institution dependent): 4mg/kg IV/IO/IM q24h (alternative for 0-7d: 2.5 mg/kg IV/IO/IM q12h; alternative for >7d: 2.5 mg/kg IV/IO/IM q8h) or
Ampicillin plus cefotaxime: Ampicillin for 0-7d: 50 mg/kg IV/IM/IO q8h; ampicillin >7d: 50 mg/kg IV/IM/IO q6h plus cefotaxime 50 mg/kg IV/IO q8h

Infants (>1mo) and children:

Ceftriaxone 75 mg/kg (max 2g) IV/IO/IM q24h plus vancomycin 15mg/kg (max 1g) IV/IO q8h

Immunosuppressed patients:

Vancomycin 15 mg/kg IV/IO (max 1 g/dose) q8h plus cefepime 50 mg/kg IV/IO (max 2g/dose) q8h; consider antifungal therapy

Duration of therapy:

Determined by ultimate source of infection; 7-10d is typically sufficient
Above regimens may be empiric therapy for 48-72h, until cultures and sensitivities are known, so as to accurately tailor treatment
If culture-negative sepsis, antibiotic choice and duration determined by severity of presentation and most likely pathogen
Infectious disease consultation may be necessary

6. Fluid-refractory shock (persisting after 60 mL/kg fluid) (15-60 min)

Continue fluid resuscitation and initiate vasopressor therapy titrated to correct hypotension/poor perfusion
Central line placement and arterial monitoring if not already established; vasopressors should not be delayed for line placements
Normotensive shock (impaired perfusion but normal blood pressure): Dopamine 2-20 mcg/kg/min IV/IO, titrate to desired effect; if continued poor perfusion, consider dobutamine infusion 2-20 mcg/kg/min IV/IO, titrate to desired effect (may cause hypotension, tachycardia)
Warm shock (warm extremities, flash capillary refill): Norepinephrine 0.1-2 mcg/kg/min IV/IO infusion, titrate to desired effect
Cold shock (cool extremities, delayed capillary refill): Epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrate to desired effect

7. Shock persists following vasopressor initiation (60 min)

Continued fluid replacement; obtain CVP measurement to guide
SvO2 < 70% (cold shock): Transfuse Hgb >10 g/dL; optimize arterial saturation through oxygen therapy, ventilation; epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrate to desired effect
SvO2 < 70% (normal BP but impaired perfusion): Transfuse Hgb >10 g/dL; optimize arterial saturation through oxygen therapy, ventilation; consider addition of milrinone 0.25-0.75 mcg/kg/min IV/IO (titrate to desired effect) ornitroprusside 0.3-5 mcg/kg/min IV/IO (titrate to desired effect)
SvO2 >70% (warm shock): Norepinephrine 0.1-2 mcg/kg/min IV/IO infusion, titrate to desired effect; consider vasopressin 0.2-2 mU/kg/min infusion, titrate to desired effect

8. Fluid refractory and vasopressor-dependent shock) (60 min)

Consider adrenal insufficiency
Hydrocortisone 2 mg/kg (max 100mg) IV/IO bolus; obtain baseline cortisol level; if unsure, consider ACTH stimulation test; duration depends on response, laboratory evaluation

9. Continued shock

Consider cardiac output measurement to direct further therapy
Consider extracorporeal membrane oxygenation (ECMO)

10. Supplemental therapies

Blood transfusion considered for Hgb < 10 g/dL (ideal threshold for transfusion unknown)
Sedation/analgesia while ventilated
Optimize oxygenation through ventilation
IV immunoglobulin can be considered (unknown benefit; see Step No. 6 Infection Control for dosing information)

11. Therapeutic endpoints

Clinical

Heart Rate normalized for age
Capillary refill < 2sec
Normal pulse quality
No difference in central and peripheral pulses
Warm extremities
Blood pressure normal for age
Urine output >1 mL/kg/h
Normal mental status
CVP >8 mmHg

Laboratory

Decreasing lactate
SvO2 >70%

Resources from the Emedicine/Medscape article above:

Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. Jan 2005;6(1):2-8. [Medline].
[Guideline] Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. Jan 2008;36(1):296-327. [Medline].
Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med. Jun 2002;30(6):1365-78. [Medline].
World Federation of Pediatric Intensive and Critical Care Societies. Pediatric Sepsis Initiative educational materials. Available at https://www.wfpiccs.org/education/doctors-nurses/documents/. Accessed June 23, 2013.
American Heart Association. EC90-1053. Distributed by Channing Bete Co. Pediatric Advanced Life Support Pocket Reference Card. Available at https://shop.aha.channing-bete.com/onlinestore/storeitem.html?iid=180286. Accessed Nov 9, 2011.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. Feb 2013;41(2):580-637. [Medline].
Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. Jun 2011;127(6):e1585-92. [Medline].
Paul R, Neuman MI, Monuteaux MC, Melendez E. Adherence to PALS Sepsis Guidelines and Hospital Length of Stay. Pediatrics. Aug 2012;130(2):e273-80. [Medline].
Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. Jun 30 2011;364(26):2483-95. [Medline].
Murthy S, Kissoon N. After the FEAST–fluid resuscitation in pediatric sepsis. Indian J Pediatr. Feb 2013;80(2):151-4. [Medline].