Sepsis and Shock (Circulatory Collapse)
Fever and neutropenia a common medical emergency.
- Neutropenia is defined as a neutrophil count of less than 1.
- The risk of significant infections increases the lower the neutrophil count drops.
- The greatest risk is when the absolute neutrophil count (ANC) drops to below 0.3 (increased risk for serious infection if the ANC < 0.5, and a very significantly increased if the ANC < 0.1).
- Infection can lead rapidly to shock and death in a patient with febrile neutropenia
Please see our febrile neutropenia section
Shock = Cardiovascular dysfunction which causes inadequate perfusion of vital organs.
Hypovolemic Shock
- Commonest.
- Bacterial sepsis is usual cause.
Investigation:
History and Physical
Blood pressure and pulse - should be checked regularly.
Temperature - Fever is usually seen, but hypothermia may be seen in septic shock
Mental status can be altered if there is hemodynamic compromise from septic shock.
Cardiovascular findings may include:
- Tachycardia and gallop rhythm
- Hypotension
- Murmur
- Prolonged capillary refill time.
- Edema
- Child will appear
- quite vasodilated and feel very warm (the so called 'warm shock') usually
- or cool and clammy with poor perfusion.
The patient may be in respiratory distress or show evidence of grunting.
A head to toe assessment should be done looking for a focus of infection.
- Common sites of infection include:
- the central line site
- the perianal area
Other Investigations
Routine blood work (CBC, lytes, creatinine, BUN and urinalysis)
- Blood cultures
- Cultures from other sites of suspected infection (swabs from areas of even mild inflammation, urine culture and sensitivity and all lumens of indwelling catheters).
- CXR
Management
1. Oxygen
2. Aggressive fluid resuscitation if hypotensive
- using 20 mg/kg boluses of Normal Saline
3. Patient usually requires inotropic support:
-
Dopamine is often used when the child is on the inpatient oncology ward.
- Start early if patient is in septic shock and you have given 40 mg/kg of Normal Saline
4. If the child has recently been on steroids (especially if the child has leukemia) or if they have endocrine dysfunction - then they may have adrenal insufficiency as a cause of hypotension and give a stress dose of hydrocortisone
5. Empiric broad-spectrum antibiotics:
Antibiotics must be given as soon as possible - immediately after cultures are drawn.
The choice of antibiotics to be used is reviewed by the oncology department every few years and is based upon the local resistance patterns from blood cultures in oncology patients.
In 2008, the current F & N antibiotic management plan is:
Stable patient - Pipracillin/Tazobatam 300mg/m2 divided q 6 hours
Unstable patient - Gentamycin + Meropenem + Vancomycin
Distributive Shock
- Inappropriate distribution of blood volume.
- Commonest cause for pediatric oncology patients is drug related anaphylaxis
Cardiogenic Shock
- Heart does not act as an efficient pump
Different causes of shock in children:
| Hypovolemic Shock | Sepsis | Bacterial septicemia |
| Clostridium Difficile | ||
| Aspergillus | ||
| Hemorrhage | Hemoptysis | |
| Endocrine | Addisonian crisis (after steroid administered and then stopped) | |
| Diabetes | ||
| Metabolic problem | Malignant hypercalcemia | |
| Direct tumor effect | Tumor invasion into great vessel and perforation | |
| CNS tumor | ||
| Inflammatory | Post pancreatitis | |
| Teflitis | ||
| Drug related | L-Asparaginase | |
Distributive Shock |
Drug and Treatment related | Etoposide,Teniposide, Carboplatin, L- Asparaginase Cytosine Arabinoside Amphotericin B Blood products Gamma Globulin Vitamin K Interleukin-2 Tumor Necrosis Factor
|
| Infective | Sepsis | |
| Other | Venous occlusive disease | |
| Inappropriate secretion of ADH | ||
Cardiogenic Shock |
Drug and Treatment related | Anthracycline |
| Cyclophosphamide | ||
| Tumor Effect | Pericardial Effusion and cardiac tamponade | |
| Intracardiac Tumor/Thrombus | ||
| Infective | Viral Myocarditis | |
| Fungus Ball |
Patients are peripherally shut down, very low blood pressure and rapid heart rate.
Treatment involves intensive support - usually in the Intensive Care Unit with oxygen, fluid resuscitation and treatment of the cause of the condition.
