Abstract
This chapter provides the reader with a succinct review on the continuum of the systemic inflammatory response syndrome through septic shock. The author provides a review on the pathophysiology of shock in children, the diagnostic criteria, and relevant monitoring considerations. The surgical procedures often required for patients with sepsis as well as the relevant anesthetic considerations are discussed.
A six-year-old female with newly diagnosed acute lymphoblastic leukemia is in day two of induction chemotherapy. She has developed fever with diarrhea and abdominal pain. An abdominal CT demonstrates typhlitis, and a short segment of necrotic large bowel and free air under the diaphragm. She requires emergent surgery for partial bowel resection.
Her current vital signs are: blood pressure 79/31, heart rate 163/min, respiratory rate 32/min, SpO2 89% on room air, currently on nasal cannula 2L with SpO2 increased to 93%. Weight is 26 kg.
Chest X-ray shows bilaterally increased interstitial markings. A gallop is heard on cardiac exam. Capillary refill time is three to four seconds peripherally and she is cool in the extremities. The patient has already received 80 cc/kg in crystalloid and has not produced urine since spiking the fever. A recent arterial blood gas showed a pH 7.23, pCO2 32, pO2 65, bicarbonate 19, base deficit −7, and a lactate of 5.1.
What Is Sepsis?
Sepsis is a syndrome caused by over-activation of the immune response secondary to an overwhelming infection. This inflammatory reaction leads to physiologic and biochemical abnormalities in the body, which define the clinical diagnosis of sepsis and septic shock. Sepsis and septic shock are leading causes of mortality in critical care medicine and can significantly raise the risk of anesthetic and surgical mortality.
What Is Systemic Inflammatory Response Syndrome (SIRS)?
Recent revisions of the definition of the systemic inflammatory response syndrome (SIRS) have simplified the definition of the inflammation associated with infection, which, when combined, define sepsis. The new definition of SIRS includes two or more of the following: temperature >38°C or <36°C, heart rate >90/min, respiratory rate >20/min or PaCO2 <32 mmHg, or white blood cell count >12,000/mm3 or <4,000/mm3 or >10% immature bands. This definition currently applies to adults only, but similar criteria are used for children. These were set forth along with age specific vital signs and were defined in 2005 by an international consensus conference. These vital signs, listed in Table 11.1, are used to define the SIRS response for pediatrics.
SIRS
Temperature greater than 38.5°C or less than 36°C
Tachycardia or, for children less than 1 year of age, bradycardia, without other explanation
Tachypnea or requirement for mechanical ventilation without underlying respiratory disease
Leukocytosis
Sepsis
SIRS with suspected or proven infection
Severe Sepsis
Sepsis plus cardiovascular dysfunction, respiratory failure, or two or more other organ failures
Septic Shock
Sepsis with multiorgan dysfunction
Table 11.1 Vital sign reference by age used to define the systemic inflammatory response syndrome in children
| Age | Tachycardia (beats/min) | Bradycardia (beats/min) | Respiratory rate (breaths/min) | Normal leukocyte count (x103/mm) | Systolic blood pressure (mmHg) |
|---|---|---|---|---|---|
| 0 days – 1 week | >180 | <100 | >50 | <34 | <59 |
| 1 week – 1 month | >180 | <100 | >40 | 5–19.5 | <79 |
| 1 month – 1 year | >180 | <90 | >34 | 5–17.5 | <75 |
| 2 years – 5 years | >140 | N/A | >22 | 6–15.5 | <74 |
| 6 years – 12 years | >130 | N/A | >18 | 4.5–13.5 | <83 |
| 13 years – 18 years | >110 | N/A | >14 | 4.5–11 | <90 |
What Is the Definition of Septic Shock?
When patients meet the criteria for SIRS and there are signs of end-organ dysfunction, patients meet criteria for septic shock. When patients have multiple organ systems affected, they meet the criteria for multiorgan dysfunction syndrome (MODS), a syndrome which significantly increases overall mortality.
What Are Important Diagnoses to Consider in a Child with Sepsis?
The clinical presentation of sepsis emerges from a combination of host factors, such as genetics and predisposing conditions, and pathogenic factors, including virulence and pathogen load. The pathogen can be a wide range of infections, including all variety of viral, bacterial, and fungal disease. The likelihood of each different pathogen to cause infection varies by patient comorbidity. For example, the youngest children and babies are more vulnerable to viral illness and spontaneous bacterial infection, while older patients can have medical comorbidities such as rheumatologic or oncologic disease that can predispose to sepsis because of a weakened immune response.
Viral illnesses such as influenza, rhinovirus, and Epstein-Barr virus can all present with symptoms that can meet clinical criteria for sepsis. The most common and obvious cause of sepsis include bacterial infections. These can occur in many different sites as manifestation of pneumonia, urogenital tract infection, and blood stream infections.
Fungal infection can also cause sepsis, though the presentation of this type of disease tends to be more indolent and is significantly more dependent on a previously weakened immune response.
The patient in the vignette at the beginning of the chapter meets clinical criteria for septic shock with end-organ dysfunction including respiratory compromise, renal dysfunction, and hemodynamic failure. She also has leukemia and has recently undergone chemotherapy, leading to significant immunosuppression. Both of these represent significant predisposing comorbidities. Typhlitis is a neutropenic colitis seen in oncologic patients leading to a dilated large bowel, with high chance of perforation, which is the likely cause of septic shock in this patient.
What Are the Most Common Sites for Infection Leading to Sepsis?
The cause of severe sepsis can vary significantly by location, age, and institution. The most common site of primary infection in severe sepsis is the respiratory system followed by bloodstream infection, genitourinary tract infections, abdominal, and central nervous system infections.
What Are the Most Common Pathogens Leading to Severe Sepsis?
Common bacterial causes include both gram-negative bacteria including Escherichia coli, Klebsiella species and Pseudomonas aeruginosa and gram-positive bacteria such as Staphylococcus and Streptococcus. It is important to consider early involvement of infectious disease specialists and to follow local antibiotic guidelines for appropriate treatment of at-risk populations to ensure broad coverage to cover all likely causative agents. Without appropriate source control, septic shock will continue to worsen and will lead to severe morbidity.
What Is the Incidence and Most Common Age of Presentation of Sepsis?
Sepsis and septic shock are leading causes of worldwide morbidity and mortality and a leading cause of critical illness. Approximately 1/3 of mortality in tertiary pediatric intensive care units (PICUs) is attributable to sepsis. A recent international survey of PICUs demonstrated a prevalence of 8.2% among patients admitted to a PICU with a median age of 3 years and a range from 0.7 years to 11 years.
What Is the Pathophysiology of Septic Shock?
The understanding of the cause of sepsis is incomplete, but the fundamental etiology is a significant release of vasoactive cytokines and bacterial derived products. Certain pathogens contain products such as lipopolysaccharides that have a higher potential to cause this cytokine storm. Similarly, certain individuals will have a more exaggerated response to pathogenic products, which will also lead to a higher cytokine response.
The specific response of each individual patient varies widely and depends on the pathogen load and virulence, and on the host with significant genetic variation and coexisting disease. The initial immune response also triggers several other cascades including complement and coagulation activation and catecholamine release.
What Are the Major Hemodynamic Consequences of Septic Shock?
Septic shock is most commonly seen in adults as warm shock with significant peripheral vasodilation leading to a high-output shock state. Tachycardia will increase total cardiac output to compensate for a greater volume of distribution secondary to vasoplegia caused by cytokine release. While warm shock is still the most common presentation in pediatrics, a considerable proportion of patients may also present in a cold shock state with decreased perfusion and delayed capillary refill. This version of septic shock is associated with depressed cardiac function and decreased cardiac output. The cause of this variation is incompletely understood but the consequences are the same as the majority of cases present with metabolic acidosis and end-organ dysfunction.
During early resuscitation, it is important to distinguish between warm and cold shock. Both instantaneous capillary refill and delayed capillary refill are seen in sepsis and management of septic shock should be adapted accordingly. Current guidelines for septic shock recommend initial volume resuscitation with crystalloid, up to 200 mL/kg, though most children will be given 40–60 mL/kg. Central venous pressure monitoring is useful to guide volume resuscitation with a common goal of approximately 8–12 cm H2O, while monitoring for signs of fluid overload. There do not seem to be any advantages to colloid therapy.
Early initiation of inotropic support is recommended, preferably via central access if available. Epinephrine is the first-line choice for cold vasoconstricted shock, but dopamine has also been used successfully. Norepinephrine is the first-line therapy for warm vasodilatory shock. The role for other vasoactive medications in pediatrics has not been defined, though phenylephrine may provide peripheral vasoconstriction to treat hypotension secondary to warm shock, while dobutamine often provides significant inotropy.
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