Infectious Disease
*in the PICU, order all antibiotics as STAT!*
*Use the PICU Sepsis Orderset for all patients in which a sepsis huddle is held and sepsis treatment is ongoig*
Antibiotic Overview
https://foamid182692890.files.wordpress.com/2018/02/antibiotic-spectrum-of-activity.jpegSepsis
Definition: Per the 3rd International Consensus Committee (2016) " life-threatening organ dysfunction caused by a dysregulated host response to infection."
Complex process involving endothelial activation, microvascular compromise/thromboses, immune system activation and subsequent inflammatory response, and direct effect of virus/bacteria/fungus on host cells
Check out all of this and more in a review article for a review of the pathophysiology. Key infographics are below.
Pathophysiology
(Arora et al)Immune System Activation
(Arora et al)Endothelial Activation and Coagulation Dysfunction
Pediatric Surviving Sepsis Campaign
Surviving Sepsis Pediatric Guidelines (2020)
By Weiss et al. the most recent guidelines published on pediatrics sepsis
The Surviving Sepsis Website is chalk full of information/summary of guidelines for reference
KEY POINTS:
RECOGNITION IS KEY TO SURVIVAL
Early administration of antibiotics!
Fluid resuscitation
Early vasoactive
Monitor end-organ function
Reduce metabolic demand and increase oxygen delivery (even with simple NC to increase PaO2)
Summary infomatics are below
Overview of Sepsis Treatment
Source: UpToDateAdditional Considerations
Obtain adequate vascular access
Weight risks vs benefits of corticosteroids in your patients
Investigate source and ensure adequate source control
May need to intubate and provide mechanical ventilation in order to reduce patient's metabolic demand during critical illness
Can then further reduce metabolic demand with sedation, NMB
Monitor end-organ function
May require CRRT for acute renal failure
May benefit from therapeutic plasma exchange (PLEX) for replenishing ADAMS-TS 13, removing protein inhibitors in setting of TAMOF (Thrombocytopenia Associated Multiple Organ Failure)
Controversial topic, beyond scope of this website. To learn more, check out Cortina et al and Fortenberry et al
May require ECMO if severe cardiac dysfunction as result of sepsis (VA-ECMO)
May consider immune modulation --> RBC PICU currently part of a large RCT
Examples: Il-1 inhibitors, IL-6 inhibitors, TNF-alpha inhibitors, steroids
Future research needed surrounding unique patient's sepsis "endotype" aka what their genetic make-up is and how that primes them to respond to infection (hyperinflammatory vs immunoparalysis etc). Also great need for better biomarkers and how to stratify septic patients