ED Muskoka Physicians - Living the Dream

Pediatric Sepsis

https://www.cps.ca/en/documents/position/diagnosis-and-management-of-sepsis-in-the-paediatric-patient

A review of the CPS Practice Point on Pediatric Sepsis (2020)

Fortunately, pediatric sepsis is relatively rare. We all treat adults with sepsis multiple times a month, but a child in septic shock is a rare, and terrifying, presentation in our community ER. However, sepsis is a major cause of morbidity and mortality in children, and requires prompt recognition and treatment. Just like in adults, sepsis care guidelines have focused on creating a systematic approach to these cases. This ‘practice point’ article put out by the CPS in 2020 uses 4 cases to succinctly review current global guidelines (including the Surviving Sepsis Campaign’s Pediatric Subgroup’s 2020 update). It’s worth a quick read. Not a classic journal club article as I’m not going through critical appraisal of the literature, but thought it was worth a quick review! Also, ties into the sim we ran this month – see below ūüôā

We ran a simulated case this morning in Huntsville that highlighted a few practical points:

Case was a 7mo boy with ALL on chemo, presents with a fever, tachycardia, poor perfusion and altered mental status.


Key points : 

1. Early recognition of sepsis is key!  Worth regularly reviewing normal vitals in peds (chart in CPS article). Also we will be laminating a copy of a chart of normal pediatric vitals to hang on the side of the Peds crash carts (along with the NRP cards). Remember: a hypotensive septic kid is peri-arrest!

2. Practicalities of administering a fluid bolus in a baby ‚Äď NEVER hang fluid by gravity (risk of too much or too little fluid) can put on pump or (preferably) do a push-pull method (draw off IV line with¬†60cc syringe, then¬†push calculated amount over 5 minutes)¬†¬† – R/A for response/fluid overload after each¬†20cc/kg¬†bolus, aim for 60cc/kg in first hour of resuscitation and think about adding a vasopressor if not responding after 2nd bolus.

3. Vasopressors: 1st line is traditionally dopamine (which we have pre-mixed in crash cart) but this has changed officially in 2020  РEpinephrine (cold shock) or Norepinephrine (warm shock) is preferred, but these will need to be mixed up. (Look in dosing book on top of peds cart and be aware concentrations are vastly different from the way we mix it for adults!!)

4. Antibiotics – give early, give as IV push. Typically will be Ceftriaxone (100mg/kg) unless need broader coverage for risk MRSA/pseudomonas/immunosuppression etc.

5. Hydrocortisone Рuse more liberally in peds than adults, for fluid-refratory shock in sepsis, especially if history of steroid use (asthma/chemo etc). Dose = 2mg/kg IV push.

6. Hypoglycemia Рmore common in septic kids than adults. Remember D50 is caustic on veins, and not preferred in peds <2y. Can use D10W (1L bag kept1 in side of crash cart)  or dilute the D50 that is kept on the crash cart down to D25 with equal volume NS. Dose = 2.5-5mL/kg D10 IV push  OR 4ml/kg D25 IV


Great website for resources to review this topic including videos and a pdf algorithm which I’ve tried to attach:

https://trekk.ca/events/Sepsis-Announcement

What do you think the biggest barrier is in our department to providing excellent pediatric care? Do you have any suggestions for how we can improve?

PECARN Febrile infant tool

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Ultrasound and Honey

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Pediatric Vitals: Forget PALS and APLS

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Paediatric Head Injury Rules: PECARN Wins

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Paediatric Vomiting and Diarrhea Care Pathway

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