Surviving Sepsis 2020 Guidelines- Pediatrics

Start IV Fluid Boluses in Case of Hypotension

Balanced/buffered crystalloids- Preferred over 0.9% i.e., Ringer’s lactate is preferred over normal saline. Amount- 40 to 60 ml/kg in the first hour of management, given as 10-20 ml /kg blouses. If the care center does not have an ICU (e.g., PHC), give only 40 ml/kg maximum fluid. Avoid colloids like albumin. Avoid using boluses, if there is no hypotension.

Antimicrobial Therapy 

Start empirical IV antibiotics. Therapy with antibiotics is used in combination, if needed for covering all possible pathogens. Antibiotics should be started within the first hour of management. Send blood culture. Change antibiotics according to culture sensitivity reports. Blood lactate levels in septic shock management are not mandatory.

Consider Vasoactive agents/Inotropic Agents- if Poor Response to IV Fluids

Epinephrine/Norepinephrine is preferred over Dopamine. Whether to use Epinephrine or Norepinephrine is left to the treating physician. Dose for both is the same: 0.1-1 µg/kg/min IV/IO as infusion. Dopamine may be used if Epi/NE is not available, in a dose of up to 10 µg/kg/min as an infusion. Vasopressin may be added to Epi/NE in case of poor response or high doses needed. Dose of  Vasopressin: Up to 0.002 U/kg/min as the infusion. Indicators are needed only if there is cardiac dysfunction and hypoperfusion despite the above agents. Either Milrinone 0.75 µg/kg/min or Dobutamine - up to 10 µg/kg/min.

Use of IV Hydrocortisone

Only if hypotension does not improve despite the use of IV fluids and vasopressor agents as described.  Dose is 100 mg/m²/day in 4 divided doses.

Blood Glucose Level

Keep blood glucose levels less than 180 mg/dL. Lower value is not defined.

Intubation

Routine intubation is not needed, it can be considered in the fluid and catecholamine shock. Avoid using etomidate.

In Children Requiring Ventilation or Developing Paediatric ARDS (PARDS) Due to Septic Shock

Prefer non-invasive ventilation (NIV) over invasive ventilation. High PEEP up to 10-15 cm H2O may be needed. Give a trial of prone positioning during ventilation. Routine use of inhaled NO should be avoided but can be used as a rescue therapy if oxygenation is not improving despite high PEEP due to pulmonary hypertension. Neuromuscular blockade may be useful in patients requiring ventilation if asynchrony happens.

Enteral Feeds to be Preferred over TPN

Wherever possible use enteral feeds. Orogastric feeds can be given. Simply the use of catecholamines is not enough to stop enteral feeds.

• Avoid any blood transfusion if the child is stable and Hb is more than or equal to 7 g/dl.
• Avoid regular use of levothyroxine, zinc, plasma exchange, and high-volume hemofiltration.
• Early renal replacement can be done. Haemodialysis or peritoneal dialysis can be used for the treatment or fluid overload in children with renal dysfunction.
• Veno-venous ECMO can be used in children with sepsis-induced PARDS and refractory hypoxia.
• There is no routine use of IVIG, stress ulcer prophylaxis or DVT prophylaxis.

Key Points from Nelson 21^st Ed

Hallmark of an uncompensated shock is an imbalance between oxygen delivery (DO2) and oxygen consumption (VO2). DV imbalance is an imbalance between oxygen delivery and consumption. The gold standard measurement of SvO2 is from a pulmonary artificial catheter, but measurements from this location are often clinically feasible. Sites such as right ventricle, right atrium, superior vena cava (SvCO2) or inferior vena cava can be surrogate measures of mixed venous blood to follow the accuracy of oxygen delivery and effectiveness of the therapeutic intervensions. Elevated blood lactate levels reflect poor tissue oxygen delivery noted in all forms of shock.

Summary of Drugs Used

Prognosis in Septic Shock

In septic shock, mortality rates are as low as 3% in previously healthy children and 6-9% in children with chronic illness (compared with 25-30% in adults). With early recognition, the mortality rate for paediatric shock continues to improve, but shock and MODS are the leading cause of death in infants and children.

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