Current problems in pediatric and adolescent health care
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Sepsis brings about neuroendocrine dysfunction in children that differs significantly from that of adults and can thus be difficult to interpret and manage. Aggressive treatment of sepsis with appropriate and judicious use of antibiotics remains a top priority. ⋯ Fluid and electrolyte abnormalities must be corrected. Treatment of thyroid dysfunction has been shown to be beneficial in certain specific populations but cannot be extrapolated to all septic patients with the current available data.
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Mortality rates for sepsis and septic shock have not improved in the past decade. The Surviving Sepsis Campaign (SSC) guidelines released in 2012 emphasize early recognition and treatment of sepsis, in an effort to reduce the burden of sepsis worldwide. This series of review articles will discuss the pathophysiology of sepsis; comorbidities, such as multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and endocrine issues; and finally, management of sepsis and septic shock.
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Management of sepsis in the pediatric patient is guideline driven. The treatment occurs in two phases, the first hour being the most crucial. Initial treatment consists of timely recognition of shock and interventions aimed at supporting cardiac output and oxygen delivery along with administration of antibiotics. ⋯ For patients in whom this intervention does not reverse the shock medications to support blood pressure should be started and respiratory support may be necessary. Differentiation between warm and cold shock and risk factors for adrenal insufficiency will guide further therapy. Beyond the first hour of treatment patients may require intensive care unit care where invasive monitoring may assist with further treatment options should shock not be reversed in the initial hour of care.
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Acute respiratory distress syndrome (ARDS) is commonly associated with severe sepsis. While the criteria for diagnosis have evolved since the first description in 1967, the characteristics of hypoxemia, tachypnea, rapidly progressing acute respiratory failure, and poor lung compliance continue. Scoring systems have been developed in an effort to quantify the severity of lung injury, with the most recent being the Berlin Definition. ⋯ There is, however, gradual resolution of hypoxemia, lung function, and radiographic abnormalities in survivors of ARDS. Management of ARDS is mainly supportive with specific mechanical ventilation strategies and goal-directed therapies. Prevention of ventilator-induced lung injury (VILI) has been demonstrated to have a positive impact on outcomes in patients with ARDS.
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Initially known as multiple system organ failure, the term multiple organ dysfunction syndrome (MODS) was first described in the 1960s in adults with bleeding, respiratory failure, and sepsis. It is defined as "the development of potentially reversible physiologic derangement involving two or more organ systems not involved in the disorder that resulted in ICU admission, and arising in the wake of a potentially life threatening physiologic insult."(3) There are many risk factors predisposing to MODS; however, the most common risk factors are shock due to any cause, sepsis, and tissue hypoperfusion. ⋯ There are several nonspecific therapies for the prevention and resolution of MODS, mostly care is supportive. Mortality from MODS in septic pediatric patients varies between 11% and 54%.