When does a septic child need tracheal intubation?
I went ahead and gave many of the case questions and discussions so that the context of the question, “When Does a Septic Child Need Tracheal Intubation?”, is clear. To jump to the answer to the title question click here.
The following recommendations are from Case 3 of Clinician’s Guide to Recognition and Early Management of Meningococcal Disease in Children: An interactive e-learning tool for doctors in training. For a great algorithm, see Early Management of Meningococcal Disease in Children*, 5th ed.
The synopsis of Case 3: “2.5 year old boy admitted with purpura and fever. Paediatric assessment: Temp 39.3, Pulse 134, RR 40, CRT 6 seconds, BP unrecordable, femoral pulses present but weak. Cyanosed, Saturation 75% in air. Widespread creps. GCS 9/15, Neck stiffness+Purpuric rash on chest. Bloods sent for FBC, clotting, U&E, and culture” Then there are 14 questions on the adequacy of treatment for the doctor to answer.
Q1 asks, is this an adequate assessment? And the answer is no. “A full assessment would have recorded pupil size/ reaction. However this assessment was comprehensive enough to provoke urgent action, and provided enough information about the child’s condition that a clear picture of what was wrong should have been evident.
Then based on the information above the doctor makes the diagnosis and initiates treatment: Diagnosis: Meningococcal meningitis. Treatment:Antibiotics intravenously. Fluids 40 ml/kg colloid in 2 boluses and 10 ml/kg crystalloid over 1 hour, then maintenance fluids. Some improvement of CRT so left on the ward. [emphasis added]<–Note: This is an error as noted in a subsequent question and answer.
Q3 asks: Is meningococcal meningitis a reasonable diagnosis? And authors say no. The correct diagnosis is “advanced septicaemia not meningitis.” And they give the Characteristics of meningococcal disease:
“The two major clinical forms of meningococcal disease are meningitis and septicaemia. Most patients will have a mixed presentation. A minority will have pure septicaemia and it is these patients who carry the worst prognosis and maximum effort must be made to identify them early12. There are important differences in the pathophysiology of meningitis and septicaemia which underlie the clinical presentation and management of the two main forms of the condition (see pathophysiology).”
Q4 asks: Were adequate investigations performed? And the authors say no. “Signs of advanced septicaemic shock [are] present: venous blood gas, biochemistry, glucose and blood for meningococcal PCR should have been done.” And they further state:
“The tests below should be done on all suspected cases of MD and children who are suspected of having an invasive bacterial infection:
- Full blood count
- Electrolytes and urea
- Calcium and magnesium ( metabolic derangements are common in septicaemia and may contribute to myocardial dysfunction)
- Clotting studies
- Venous blood gas to measure base excess
- Blood culture
- Throat swab culture
- Meningococcal PCR whole blood (EDTA specimen) to send to reference laboratory
|Hb||10.5 to 13.5 g/dL|
|WCC||5.0 to 15.0 (×109)|
|Platelets||150 to 450 (×109)|
|Base Excess†||0 to -3 mmol/L|
|pH||7.35 to 7.45|
|HCO3||22 to 26 mmol/L|
|PaO2||10 to 13.5kPa or 75 to 100mmHg|
|PaCO2||4.6 to 6kPa or 34.5 to 45 mmHg|
|Urea||2.5 to 6.0 mmol/L|
|Creatinine||19 to 43 mmol/L|
|Na||133 to 146 mmol/L|
|K+||3.5 to 5.5mmol/l|
|Mg++||0.66 to 1.0 mmol/L|
|Total Calcium||2.17 to 2.44 mmol/L|
|PT||9.9 to 12.5 seconds|
|APTT||26.0 to 38.0 seconds|
|TT||9.2 to 15.0 seconds|
|Fibrinogen||1.7 to 4.0 g/L|
*Please note that normal ranges for many variables can differ among hospitals.
†Blood gas reports measurement of base excess (BE), which, when negative indicates that there is a base deficit (acidosis).”
Repeating the Case History: “2.5 year old boy admitted with purpura and fever. Paediatric assessment: Temp 39.3, Pulse 134, RR 40, CRT 6 seconds, BP unrecordable, femoral pulses present but weak. Cyanosed, Saturation 75% in air. Widespread creps. GCS 9/15, Neck stiffness+Purpuric rash on chest. Bloods sent for FBC, clotting, U&E, and culture. Diagnosis:Meningococcal meningitis. Treatment:Antibiotics intravenously. Fluids 40 ml/kg colloid in 2 boluses and 10 ml/kg crystalloid over 1 hour, then maintenance fluids. Some improvement of CRT so left on the ward.
Q7 asks: Was treatment fast enough? Aggressive enough? The authors say no. “No — persistent shock despite improvement in CRT– child needed intensive care treatment with early elective intubation, ventilation, aggressive fluid resuscitation.”
They explain that:
“Rapid fluid resuscitation should be initiated. Boluses of 20ml/kg of colloid (preferably 4.5% albumin44) or crystalloid solutions should be given rapidly (over 5-10 minutes) whilst monitoring the clinical response (HR, RR, BP, CRT, O2 sats, urine output, conscious level). If the clinical response is short-lived or absent, and shock does not improve or progresses, large volumes may be required (over 60ml/kg in the first hour).
- There is evidence from adults that early goal-directed resuscitation of patients with septic shock is associated with an improvement in outcome45.
- Hypoglycaemia (<3.3 mmol/l) is common and should be corrected: 5ml/kg 10% dextrose bolus i.v., then check glucose hourly and correct if necessary.
- If signs of shock persist after 40-60 ml/kg of fluid resuscitation, there is significant risk of pulmonary oedema, so elective tracheal intubation and mechanical ventilation should be initiated even if there are no signs of respiratory failure3. This will optimise oxygenation, reduce the work of breathing, and improve cardiac function.
- Advice to guide further management should be sought early.
- Invasive monitoring and central venous access will be required to guide fluid therapy and optimise support.
- Inotropic support may be required to optimise tissue perfusion and improve myocardial function.
- Metabolic acidosis is common and impairs myocardial contractility. If pH<7.2 due to base deficit, give half correction NaHCO3 iv.
- Volume (ml) to give = (0.3 x weight in kg x base deficit ÷2) of 8.4%NaHCO3 over 20 mins.
- In neonates, volume (ml) to give = (0.3 x weight in kg x base deficit) of 4.2% NaHCO3.
- Metabolic derangements of calcium, magnesium and potassium are common, and need frequent checking and correction .
- In cases of severe bleeding or profound clotting disorder, consider correction of coagulopathy with fresh frozen plasma, platelets and, if fibrinogen is low, cryoprecipitate. Correction of thrombocytopaenia is not generally required, but if uncontrolled haemorrhage from venepuncture sites or mucous membranes occurs despite replacement of clotting factors, platelet transfusion may be required if platelets are below 50,000/mm3.”
Personal Note: Don’t hesitate to call the pediatric intensivist at your referral hospital for management help.