Define sepsis
systemic inflammatory response to infection (i.e. body has dysregulated immune response to infection)
Define sepsis spectrum
mild ——> severe
systemic inflammaotry response syndrome > sepsis > septic shock >multiple organ dysfunction
Criteria for SIRS
> /= 2 out of 4 of:
- temperature <36 or >38
- HR >90 adults (or tachycardia for age)
- RR >20 adults (or tachypnoea for age) or PaCO2 <32 (as RR increases CO2 falls)
- WBC >12000 or < 4000, or >10% band cells (immature WBCs)
Criteria for sepsis, and common symptoms of sepsis
SIRS + confirmed infection
- fever, chills, sweating, altered mental state, decreased urine output
Define septic shock
sepsis + hypotension + drop in tissue perfusion
due to infection +/- inflammation
How can temperature of skin relate to septic shock pathophysiology, and prognosis?
warm skin = blood vessels have dilated
can progress to cool skin (bad sign as had sepsis for long time)
Criteria for MODS
septic shock + irreversible organ failure
Pathophysiology of septic shock
1) WBC recruitment - as pathogen in blood
2) WBC release mediators - release nitrous oxide as WBC want to get to interstitial tissue where pathogens are, which increases blood vessel diameter and leakiness leading to drop in BP (as there is SVr drop as CO x SVR = BP)
3) decreased O2 to tissues/tissue perfusion as leaky vessels -> oedema so decreased O2 transport to tissues
3 complications of septic shock
- DIC - WBCs release ROS -> damage bv -> coagulation factor release to stop blood leaking to extravascular space -> coag factors in extravascular space cant keep up with bleeding in intravascular space
- ARDS - lungs highly vascularised and sepsis damages lung vasculature so cant carry O2 -> respiratory distress
- decreased CO - initially increased CO to compensate for drop in SVR and BP in sepsis, but ROS from WBC can dmaage heart
Evaluating sepsis in under 5s (NICE)
moderate- high criteria
- BEHAVIOUR - doesnt wake, respond to social cues, weak high-itched continuous cry, no smile
- HR - 0-1 years (160+ bpm), 1-2 years (150+ bpm), 3-4 years (140+ bpm), or <60 bpm at any age
- RR 0-1yr - 60 bpm, 1-2 yrs 50 + bpm, 3-4 yrs 40+ bpm, respiratory distress (grunting, apnoea, sats <90% in air
- TEMPERATURE <36, or >38 in babay <3months
- SKIN - mottles, cyanotic (lips+ tongue too), non blanching rash
(some other moderate criteria:
- cap refill >3s
- decreased urine output
- leg pain, cold hands or feet
- temperature >39 in 3-6month olds
How do signs of sepsis in neonates/infants differ from adults
more non-specific symptoms e.g. apnoea, bradycardia
High risk sepsis patients
- PMH or have malignancy
- immunocompromised (organ transplant, bone marrow transplant)
- asplenia (including sickle cell disease)
- central/in-dwelling catheter
- autism?
Findings compatible with septic shock
- Cap refill: cold shock > 3s warm shock <1s
- mental status: irritable, confused, poor interaction with parents, lethargy, diminished arousability, obtunded
- pulse quality: cold shock= reduced/weak, warm shock = bounding
- skin: petichiae, purpura, mottled or cold, flushed, erythroderma other than face
Sepsis screen
- administer O2 via rebreathing face mask, titrate aiming for SpO2 >94%
- IV/IO access for:
- blood culture (check source of infection)
- blood gas (glucose and lactate)
- FBC, CRP, U&E, coagulation
- lumbar puncture unless contraindicated (e.g. <1m old, severely
unwell) - consider other tests but dont delay Tx for these: urine,
meningococcal PCR, CSF or line cultures
- Give IV/IO antibiotics according to hospital guidelines
- Fluids:
- aim to restore to normal circulating volume
- If lactate >2mmol/L give 20ml/kg (10ml/kg if <1m) 0.9%
NaCl over 5-10mins and repeat if necessary - Be aware risk fluid overload,
- Get help from enior clinician
- Consider inotropic support (increase cardiac contractility e.f. dopamine, Adr) due to shock
Define wheeze
High pitched whistling heard usually on expiration (and sometimes inspiration), that is associated with increased work of breathing
Define 2 types of wheeze. Explain the difference between them
Viral episodic wheeze - URTI with wheezing associated only with viral colds
Multiple trigger wheeze - URTI with wheeze associated with exposure to aero allergens, cold, exercise, smoke
Does wheeze during preschool years mean the child has asthma?
Not sure.
Child may have fluctuating breathlessness and wheeze that needs treatment over time,
but asthma requires evidence of airway eosinophilic inflammation.
Studies have shown MTW as more airflow obstruction/ pathology associated with asthma.
No link between EVW and increased risk of asthma
PC: child with isolated dry cough presents to GP.
Could this be asthma
Isolated dry cough rarely due to asthma
Which is most efficacious for delivering wheeze treatment in preschool children: nebulisers, metred dose inhaler or spacer?
Don’t use nebulisers unless child to sick to use inhaler/spacer.
Metred dose inhaler and nebulisers as efficacious as each other
Initial treatment for moderate - severe EVW
Next step if symptoms aren’t controlled
Inhaled bronchodilator - salbutamol (b2 agonist) or ipratropium bromide (anticholinergic competitive inhibition muscarinic SM receptors -> bronchodilation)
If symptoms not controlled use:
First EDUCATE on use of inhaler/spacer
Then escalate tx to montelukast (leukotriene receptor agonist), inhaled steroids or both
Don’t use preednisolone if wheeze can be managed in the community
Side effects of steroids
Growth restriction and adrenal failure
Treatment for multiple trigger wheeze
Consider inhaled steroids or leucotriene receptor antagonist (montelukast) if children have symptoms on most days even without a viral cold
New experimental treatments for wheeze
- Hypertonic saline + salbutamol - reduced admission rates and length of stay. But given risk of bronchoconstriction with hypertonic saline needs to be given in hospital
- Palivizumab - prevents RSV infection in high risk infants e.g. premature. But very costly so not widely used
Scenario
Child well and thriving, but has wheeze, no other concerning features on history or examination.
What is type of wheeze?
Management?
Commonest kind of wheeze
Can be due to post viral cough, pertussis, overanxious parents
Management = reassurance
