Management of Sepsis and Septic Shock in Infants and Children

Abstract

Sepsis and septic shock constitute an important cause of morbidity and mortality in critically ill children. Thus, the systemic response to infection and its management remains a major challenge in clinical medicine. Apart from antibiotic administration, the majority of available therapies are limited to supportive strategies, although considerable efforts are being undertaken to devise innovative approaches that modulate host inflammatory responses. In suspected sepsis, 2 or 3 days' empiric antibiotic therapy should begin immediately after cultures have been obtained without awaiting results. Antibiotics should be re-evaluated when the results of the cultures and susceptibility tests are available. The initial antibiotic (combination) is determined by the likely causative agent, susceptibility patterns within a specific institution, CNS penetration, toxicity, and the patient's hepatic and renal function. The likely offending micro-organism in turn depends primarily on the patient's age, coexistence of any premorbid condition leading to impaired immune response, and the presenting signs and symptoms. Close attention to cardiovascular, respiratory, fluid and electrolyte, haematological, renal and metabolic/nutritional support is essential to optimise outcome. Fluid resuscitation is of utmost importance to overcome hypovolaemia on the basis of a diffuse capillary leak. Monitoring and normalisation of the heart rate is essential. In case of nonresponse to fluid resuscitation, inotropic and vasoactive agents are commonly used to increase cardiac output, maintain adequate blood pressure and enhance oxygen delivery to the tissue. Because respiratory distress syndrome is seen in about 40% of critically ill children with septic shock, increased inspired oxygen is essential. To provide optimal relief from respiratory muscle fatigue and facilitate the provision of positive airway pressure, early intubation and mechanical ventilation should be considered. Renal support is essential to avoid prolonged renal shutdown in hypoperfusion states. Haematological support comprises replacement therapy of clotting factors to overcome disseminated intravascular coagulation. Metabolic support may include glucose support, extraction of ammonia from the body and recognition of liver dysfunction. Nutritional support may modify the inflammatory host response, and early enteral feeding can improve outcome in critical illness. To date, glucocorticoid and non-glucocorticoid anti-inflammatory agents have not shown significant benefit in septic patients.

Sitagliptin attenuates inflammatory responses in lipopolysaccharide-stimulated cardiomyocytes via nuclear factor-κB pathway inhibition

“…During sepsis, the pathological production of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) may also have harmful effects on cardiomyocyte and impair cardiac contractile function (6,7). Interventions for sepsis involving anti-inflammatory agents have been demonstrated to reduce risk of cardiovascular complications (8,9).…”

Nursing considerations to complement the Surviving Sepsis Campaign guidelines

“…Sepsis tends to peak at two primary times in the child's life and correspond to significant times in the maturity of the immune system (245). The first peak is in the neonate with an incidence of 4.3 per 1000 neonates.…”

Management of septic shock in childhood

“…Infants and young children are unable to increase myocardial contractility (i.e. stroke volume) 12,17 thus improving cardiac output can only be achieved by increasing heart rate. Frequently, tachycardia as a presenting feature of shock is thought to be a result of fever; however, the heart rate tends to rise by only 10 beats per minute for every Centigrade degree of pyrexia.…”

“…Some suggest colloid is more appropriate in situations of impaired capillary integrity 24–26 and reduces the volume required for resuscitation. A review of several studies showed that colloids also improve oxygen delivery, myocardial contractility and cardiac output 17 . Crystalloids on the other hand, are inexpensive and do not carry a risk of anaphylactoid reaction or infection.…”

“…Management focuses on optimization of myocardial function, meticulous attention to fluid management (to prevent and remove extravascular fluid accumulation), and ventilation strategies designed to reduce pulmonary barotrauma 16 . A high positive end‐expiratory pressure (up to 15–20 cm H 2 O) 17 may be required depending on the severity of the pulmonary oedema; permissive hypercapnea and inverse ratio ventilation may also be used to minimize peak inspiratory pressure 6,8,16 . If conventional ventilation fails, high frequency oscillation may be instituted.…”