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Management of sepsis and septic shock in infants and children
N von Rosenstiel1, I von Rosenstiel, D Adam
1University Children's Hospital, Munich, Germany.
Insights
Sepsis in critically ill children requires immediate antibiotics and extensive supportive care, including fluids, oxygen, and organ support. Current anti-inflammatory agents offer no significant benefit.
Area of Science:
- Pediatric Critical Care Medicine
- Infectious Diseases
- Pediatric Critical Care Medicine
Background:
- Sepsis and septic shock are major causes of death in critically ill children.
- Management of pediatric sepsis presents significant clinical challenges.
- Current therapies are largely supportive, with ongoing research into novel anti-inflammatory approaches.
Purpose of the Study:
- To outline current best practices for managing sepsis and septic shock in critically ill children.
- To emphasize the critical role of timely antibiotic administration and comprehensive supportive care.
Main Methods:
- Immediate empiric antibiotic therapy (2-3 days) upon suspicion of sepsis, after obtaining cultures.
- Comprehensive monitoring and support of cardiovascular, respiratory, fluid/electrolyte, haematological, renal, and metabolic/nutritional systems.
- Consideration of inotropic/vasoactive agents, mechanical ventilation, and specific organ support based on patient response.
Main Results:
- Early, appropriate antibiotic selection is crucial, guided by likely pathogens and institutional susceptibility patterns.
- Aggressive fluid resuscitation is vital to address hypovolaemia from capillary leak.
- Multisystem organ support, including respiratory and renal support, is essential for optimizing outcomes.
Conclusions:
- Effective sepsis management hinges on prompt antibiotic treatment and meticulous supportive care tailored to the child's condition.
- While supportive measures are paramount, anti-inflammatory agents have not demonstrated significant clinical benefit to date.
- Optimizing oxygen delivery and organ function is key to improving survival rates in pediatric sepsis.
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.