Pediatric Sepsis

Background:

Sepsis is a deadly medical condition characterized by a whole-body inflammatory response and the presence of known or suspected infection. Sepsis causes massive vasodilatation, typically leading to hypotension and decreased tissue perfusion. Decreased tissue perfusion and sepsis is called septic shock and commonly occurs in children. [1,2] Septic shock is the 11th leading cause of death in the United States and the number 1 cause of death in the intensive care unit. [3] Because adults and pediatrics respond differently to septic shock, clinical guidelines for treating pediatric septic shock were established in 2002 and updated in 2007. [2]

Current Protocol:

Treatment of septic shock begins in the Emergency Department as soon as septic shock is suspected (sepsis plus decreased mental state and low perfusion levels). The first step is to attempt aggressive fluid resuscitation. If fluid resuscitation fails to reverse shock, inotrope therapy should begin. Clinical endpoints during the first hour are threshold heart rates, normal blood pressure and capillary refill =<2 secs. [2]

After one hour, if the shock is still irreversible, the patient should be moved into the pediatric intensive care unit. It is critical to understanding the hemodynamic status of the patient, specifically cardiac index (CI) and systemic vascular resistance (SVR), as it guides the course of treatment. Hemodynamic support should be directed at achieve goals of central venous oxygen saturation and CI of 3.3-6.0 L/min/m 2. [2]

Surrogates such as central venous pressure, mean article pressure, and central venous oxygen saturation are used to monitor cardiac function. If the hemodynamic goals are not achieved with these surrogates, other hemodynamic monitoring techniques that measure cardiac output directly, such as thermodilution, Doppler ultrasound, or EC Monitors should be used to guide therapies. [2]

In children, blood pressure alone is not a reliable end point for assessing the adequacy of treatment. Pediatric patients have a lower blood pressure than adults and can prevent reduction in blood pressure by vasoconstriction and increasing heart rate. [1]

Impact of Non-Invasive Hemodynamic Monitoring:

Cardiotronic’s EC Monitors can have a tremendous impact on guiding septic shock therapies and could potentially reduce mortality rates and length of stay associated with septic shock. Several ways in which EC Monitoring can improve the current protocol are discussed below.

Earlier Early Goal Directed Therapy:

If EC Monitors are used immediately in the Emergency Department, the endpoints for therapy no longer have to be surrogates of cardiac output such as heart rate or blood pressure. Instead, goal-directed therapy targeting CI could start sooner. Studies have shown that for every hour delay in administrating proper treatment, there is an associated 7% rise in mortality rates. [1]

Determining Fluid Status Quicker:

The first line of defense against septic shock is aggressive fluid resuscitation. Using heart rate and blood pressure thresholds, a physician may need to wait up to 15 minutes to determine if the patient is fluid responsive.2 With the EC Monitors, a patient’s fluid status can be determined in less than 3 minutes, saving valuable time by allowing proper therapy to begin sooner.

Guiding Treatment of Septic Shock:

Pediatric patients with septic shock can have High CI/Low SVR, Low CI/High SVR, or Low CI/Low SVR. Understanding the hemodynamic status of the patient is critical to choosing the proper therapy as outlined below. [2]

High CI/Low SVR: Vasoconstrictors

Low CI/High SVR: Vasodilators

Low CI/Low SVR: Vasoconstrictors and dobutamine

Using EC Monitors, the hemodynamic status of the patient can be monitored quickly and continuously, allowing for real-time therapy guidance.


[1] Hauser, G. J. (2007). Early Goal-Directed Therapy of Pediatric Septic Shock. Israeli Journal of Emergency Medicine, 2.

[2] Brierley, J et al. (2009). Clinical practice parameters for hemodynamic support of pediatric and neonatal sepctic shock: 2007 update from the American College of Critical Care Medicine, Crit Care Med, Vol 37, No. 2.

[3] Kenneth et al. (2011) National Vital Statistics Reports, Vol. 59, No. 4.