See also Sepsis6.
In reviews of child deaths, most significant recurrent avoidable factor is failure to recognize severe illness, most often at point of first contact with health services (Why children die, Pearson Arch Dis Child doi:10.1136/adc.2009.177071)
American College of critical care medicine 2007 shock update – central venous and arterial monitoring, dopamine within 15 mins, then warm vs cold shock, etc. 2009 Paed intensive care society audit in UK found majority of children (62%) targets were not met, for reasons that remain unclear. OR for death 3.8 where shock still present at time of PICU admission.
In 2011 goal directed therapy study, less intubations and inotropes, half the number of deaths. (But less severe group?) [Andrea Cruz, Pediatrics 2011;127;e758; DOI: 10.1542/peds.2010-2895]
Chinese study of antibiotic timing found reduced time to reversal of shock where given within 1 hour.
Definition of risk group – Paed CCM international consensus conference – at least 2 of the following 4, 1 must be abnormal temp (reported within 4 hours of admission if afebrile at presentation)
- Core temp <36 or > 38.5
- Tachycardia
- Bradycardia
- Tachypnoea
- Leucocyte count elevated for age or >10% immature neutrophils
(Not clear why different criteria used for sepsis6)
Def of inappropriate tachycardia?
Studies continue to be done looking for predictive factors esp young infants.
Management
- Give high flow O2, regardless of sats!
- Titrate fluids over 5-10 mins, repeat if necessary. Aim to reverse shock.
- Early inotropic support viz adrenaline (make up during 3rd bolus). 0.3mg/kg in 50ml 5% dextrose, 1ml/hr (0.1mcg/kg/min)
- 15 mins ideal, within 60mins acceptable.