University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
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Last updated December 9, 2014 1:59 PM

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University Hospital of Wales Heath Park
Cardiff
CF14 4XW
02920 747747

Guidelines for managing septic shock

These guidelines are derived from the ACCM guidelines.

Go to algorithm

Sepsis is one of the most common causes for PICU admission, and the emphasis is on aggressive early treatment.

Treatment in the first hour (Pre-ICU)

Therapeutic endpoints:

  • CRT ≤ 2secs
  • normal peripheral and central pulses
  • warm extremities
  • >1ml/kg/hr urine output
  • normal mental status
  • normal bp
  • normal glucose
  • normal ionised calcium

 

Monitoring

  • pulse oximeter
  • continuous ECG
  • BP (NIBP fine if pulses palpable)
  • Temperature
  • Urine output
  • Glucose
  • Ionised calcium

Antibiotics

Cefotaxime or ceftriaxone (see here for ceftriaxone caution)
Full antibiotic guideline

Airway and Breathing

Oxygen
Clinical assessment is determinant of need for ventilation, but need for 60ml/kg fluid in first hour is indication forintubation.
40% of cardiac output is used to power work of breathing – intubation and ventilation can reverse shock.
Ketamine plus NMJ blocker recommended for intubation.
Other induction agents may cause a fall in BP (Propofol, sevoflurane, thiopentone)
Pre-load with volume.
Consider concomitant IV inotropes peripherally to cover intubation

Circulation

  • IO access if IV access is not obtained within minutes
  • Fluid bolus (09% saline or 4.5% albumin) 20ml/kg immediately if no hepatomegaly or lung creps. If hepatomegaly or creps, give fluid bolus more cautiously, and consider other diagnoses (heart disease, metabolic disease, pneumonia)
  • Repeat fluid bolus to achieve normal CRT and BP. 60ml/kg or more is often required in paediatric sepsis in the first hour.
  • If Fluid Refractory Shock star inotrope peripherally (low dose dopamine or adrenaline) while establishing circulatory access. Patient will already have been intubated and ventilated at this point.
  • peripheral inotrope can be stopped when haemodynamic effect of central inotrope is seen.
  • Fluid and dopamine refractory shock – add adrenaline (cold shock) or noradrenaline (warm shock)
  • Start hydrocortisone ( also see below) in divided doses after obtainng random cortisol if there is clinical suspicion of adrenal suppression, or if shock is adrenaline/noradrenaline refractory.

Beyond the first hour (PICU)

Goals and therapeutic endpoints

  • CRT ≤ 2secs
  • Threshold heart rates
  • Normal perfusion pressure (MAP-CVP)
  • SVC sats >70%
  • CI 3.3 – 6 L/min/m2
  • Urine > 1ml/kg/hr
  • Normal anion gap
  • Normal INR

Monitoring

  • Pulse oximetry
  • ECG
  • Invasive BP – pay attention to pulse pressure (wide in warm shock, narrow in cold shock)
  • Core temperature
  • Urine output
  • CVP
  • Lactate, glucose, coags

Fluids

  • Requirement for boluses may be required for days – direct against endpoints
  • Crystalloid (normal saline, Hartmann’s)
  • If Hb < 10g/dL, give blood
  • If coags abnormal give FFP – but not as a push bolus

 

Once resuscitated from shock, consider diuretics or CVVH if >10% fluid overloaded and not maintaining losses adequate to achieve a negative balance.

Cold normotensive shock

Normal BP, high SVR, low CI
Milrinone or glyceryl trinitrate or nitroprusside
Noradrenaline may become necessary as vasodilation occurs
Volume requirement may also increase

Warm shock

Low BP, low SVR, low CI
Noraderenaline
Vasopressin 2nd line

Refractory cold shock

Consider additional diagnoses:

Problem

Treatment

Pericardial effusion

Drain

Pneumothorax

Drain

Hypoadrenalism

Hydrocortisone

Hypothyroidism

Thyroxine

Ongoing fluid losses

Replace losses

Increased intra-abdominal pressure

Drain

Necrotic tissue

Surgery

Immune compromise

Consider GCSF, Immunoglbulin

ECMO may be considered if all else failing – chance of survival 50% or less.

Thresholds

Age

Heart rate bpm

Perfusion pressure (mean arterial pressure – CVP) mmHg

Term newborn

120-180

55

Up to 1y

120-180

60

Up to 2y

120-160

65

Up to 7y

100-140

65

Up to 15y

90-140

65

Algorithm

algorithm

 


Controversies

FEAST study

This study published in 2011 appears to demonstrate an increase in mortality in setic shock in patients receiving aggressive fluid resuscitation. However, the population studied was very different form that encountered in the UK, and the provision for PICU was extremely limited, so no firm conclusions can be drawn. There is no recommendation that current practice should change.

Maitland K, Kiguli S, Opoka RO et al. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med 2011. DOI: 10.1056/NEJMoa1101549

Fever management

There are theoretical reasons why fever may be helpful in fighting infections – not least because it has evolved as a response to infection. There is evidence that viral replication may be impaired by higher temperatures. On the other hand, control of high temperatures may have metabolic advantages in reducing oxygen consumption. An observational study in adults in 2012 demonstrated an association between paracetamol use and mortality, but other studies have produced conflicting results. As yet, there is no compelling reason to stop antipyretic treatment in sepsis in children.

Steroids in sepsis

Evidence form adults has suggested that treatment with hydrocortisone may be benificial, but there is no clear consensus in children. Below is the policy for our PICU.

  1. To be considered as a rescue therapy by the PICU Consultant in patients with:

  1. Perform a random Cortisol level prior to commencing steroids
  2. Hydrocortisone (HC) should be used rather than Dexamethasone
  3. There are no indications for high dose steroids in sepsis
  4. Stress doses should be used: HC 30 mg/m2/day IV divided 6 hourly  
  5. Stop steroids if Cortisol level >500nmol/l
  6. Steroids should be weaned once patient has improved and off inotropes
  7. Involve endocrinology if any suspicion of adrenal insufficiency as an underlying diagnosis.  

    A normal stress response in meningococcal disease is a CORTISOL VALUE ON ADMISSION > 950 NMOL/L.

    RELATIVE ADRENAL INSUFFICIENCY IS DEFINED AS A RANDOM CORTISOL LEVEL < 500 NMOL/L

 

Steroids in sepsis algorithm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Links

Medscape sepsis

Surviving sepsis campaign

 

Allan Wardhaugh September 2012