sepsis - in children - Þórólfur guðnason. sepsis - definitions - bacteremia septicemia sepsis -...
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Sepsis- in children -
Þórólfur Guðnason
Sepsis- definitions -
• Bacteremia
• Septicemia
• Sepsis - (SIRS)– systemic response to an infection; localized,
in the blood or focus not found
• Sepsis syndrome - severe sepsis
• Septic shock
• MODS
Sepsis- definitions -
Infectious agent
In the bloodLocalized
Sepsis
• Sepsis– infection
+
Two or more of the following:– temperature >38C or <36 C – tachycardia (>2 SD above nl) – tachypnea (>2 SD above nl) – WBC >12.000, <4.000, or >10% band forms
Sepsis- definitions -
Sepsis- definitions -
Infectious agent
In the bloodLocalized
Sepsis
Sepsis syndrome / severe sepsis
• Sepsis syndrome / severe sepsis- sepsis
+
at least one of the following:- acute CNS changes- hypoxemia- elevated lactate in plasma- oliguria
Sepsis- skilgreiningar -
Sepsis- definitions -
Infectious agent
In the bloodLocalized
Sepsis
Sepsis syndrome
Septic shock
Septic shocksepsis syndrome / severe sepsis + progressive hypotension / hypoperfusion
Sepsis- definitions -
Multiorgan dysfunction syndrome (MODS)DIC, ARDS, renal failure, hepatic failure, CNS dysfunction,
myocardial dysfunction
Sepsis- definitions -
Infectious agent
In the bloodLocalized
Sepsis
Sepsis syndrome
Septic shock
Death
Sepsis- pathophysiology -
Infectious agents or parts of...
Hormones Cytokines Enzymes
Immune system Coagulation system Endothelium damage
Sepsis/Sepsis syndrome
• Age <3 months- non-specific, sometimes afebrile, NB fever !!!!- mottled skin, irritability
Sepsis- clinical symptoms -
• Age >3 months- fever, tachypnea, tachycardia- poor perfusion- petechial rash- irritability
• 700.000 cases per year in USA (all ages)• 20-70% positive blood cultures (all ages).• Mortalitet
- sepsis/sepsis syndrome• 35% all ages • children 10%
- septic shock/MODS• >90%
Sepsis- epidemiology -
0-1 mo.gram neg. bacteriagr. B streptococcienterococciListeriastaph. aureusHerpes simplex
Sepsis- treatment -
• Consider: Age, circumstances, origin of infection
Ampicillin andaminoglycosides
or3rd gen. cephalosporins?? Acyclovir
1-3 mo.meningococcipneumococcigram neg. bacteriagr. B streptococcienterococciListeriastaph. aureus
Ampicillin and3rd gen. Cephalosporins
orAminoglycosides
Sepsis- treatment -
>3 mo.meningococcipneumococci(gram neg. bacteria)
3rd gen. cephalosporins
Sepsis- treatment -
Children at hospitals staph. aureus, gram neg. bacteria, fungi
Immune deficiency gram neg. bacteria, staph. aureus, fungi
Foreign bodies staphylococci
Sepsis- immunomodulating treatment -
Infection
Parts of microorganism
TNF, IL-1, IFNTNF, IL-1, IFN
Activation ofendothelial cells and WBC.
Secondary mediatorsIL, PAF o. fl
ACTH / endorphins
Increased coagulation
Kallikrein - kininstimulation
endothelial damagevasodilation
complement activation
Stimulation of PMN´s
endothelial damagecapillary leak
SHOCK
Death
• Protein C• Tissue factor• Polyclonal IgG• anti-LPS (anti-lipid A)• Steroids• anti-TNF• anti-IL-1• Nitric oxide• Naloxon• CD-18 monoclonal Ab• pentoxyfyllin
Sepsis- immunomodulating treatment -
- fluids- vasopressors- oxygen- acid-base- respirator- platelets- plasma- plasma exchange ??- nutrition
Sepsis- treatment -
How can outcome be improved ?
• Outcome not improved for several years ?
• Improve diagnosis– clinical– laboratory
• Preventive measures– vaccinations