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Guidelines on management of sepsis and associated organ dysfunction in children - Page 2
Ventilation
· We were unable to issue a recommendation about whether to intubate children with fluid-refractory, catecholamine-resistant septic shock. However, in our practice, we commonly intubate children with fluid-refractory, catecholamine-resistant septic shock without respiratory failure.
· We suggest not to use etomidate when intubating children with septic shock or other sepsis-associated organ dysfunction.
· We suggest a trial of noninvasive mechanical ventilation (over invasive mechanical ventilation) in children with sepsis-induced pediatric ARDS (PARDS) without a clear indication for intubation and who are responding to initial resuscitation.
· We suggest using high positive end-expiratory pressure (PEEP) in children with sepsis-induced PARDS.
· We cannot suggest for or against the use of recruitment maneuvers in children with sepsis-induced PARDS and refractory hypoxemia.
· We suggest a trial of prone positioning in children with sepsis and severe PARDS.
· We recommend against the routine use of inhaled nitric oxide (iNO) in all children with sepsis-induced PARDS.
· We suggest using iNO as a rescue therapy in children with sepsis-induced PARDS and refractory hypoxemia after other oxygenation strategies have been optimized.
· We were unable to issue a recommendation to use high-frequency oscillatory ventilation (HFOV) versus conventional ventilation in children with sepsis-induced PARDS. However, in our practice, there is no preference to use or not use HFOV in patients with severe PARDS and refractory hypoxia.
· We suggest using neuromuscular blockade in children with sepsis and severe PARDS.
Corticosteroids
· We suggest against using IV hydrocortisone to treat children with septic shock if fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.
· We suggest that either IV hydrocortisone or no hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.
Endocrine and Metabolic
· We recommend against insulin therapy to maintain a blood glucose target at or below 140 mg/dL (7.8 mmol/L).
· We were unable to issue a recommendation regarding what blood glucose range to target for children with septic shock or other sepsis-associated organ dysfunction. However, in our practice, there was consensus to target blood glucose levels below 180 mg/dL (10 mmol/L) but there was not consensus about the lower limit of the target range.
· We were unable to issue a recommendation as to whether to target normal blood calcium levels in children with septic shock or sepsis-associated organ dysfunction. However, in our practice, we often target normal calcium levels for children with septic shock requiring vasoactive infusion support.
· We suggest against the routine use of levothyroxine in children with septic shock and other sepsis-associated organ dysfunction in a sick euthyroid state.
· We suggest either antipyretic therapy or a permissive approach to fever in children with septic shock or other sepsis-associated organ dysfunction.
Nutrition
· We were unable to issue a recommendation regarding early hypocaloric/trophic enteral feeding followed by slow increase to full enteral feeding versus early full enteral feeding in children with septic shock or sepsis-associated organ dysfunction without contraindications to enteral feeding. However, in our practice, there is a preference to commence early enteral nutrition within 48 hours of admission in children with septic shock or sepsis-associated organ dysfunction who have no contraindications to enteral nutrition and to increase enteral nutrition in a stepwise fashion until nutritional goals are met.
· We suggest not withholding enteral feeding solely on the basis of vasoactive-inotropic medication administration.
· We suggest enteral nutrition as the preferred method of feeding and that parenteral nutrition may be withheld in the first 7 days of PICU admission in children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against supplementation with specialized lipid emulsions in children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against the routine measurements of gastric residual volumes (GRVs) in children with septic shock or other sepsis-associated organ dysfunction.
· We suggest administering enteral feeds through a gastric tube, rather than a postpyloric feeding tube, to children with septic shock or other sepsis-associated organ dysfunction who have no contraindications to enteral feeding
· We suggest against the routine use of prokinetic agents for the treatment of feeding intolerance in children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against the use of selenium in children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against the use of glutamine supplementation in children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against the use of arginine in the treatment of children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against using zinc supplementation in children with septic shock and other sepsis-associated organ dysfunction.
· We suggest against the use of ascorbic acid (vitamin C) in the treatment of children with septic shock or other sepsis-associated organ dysfunction.
· We suggest against the use of thiamine to treat children with sepsis-associated organ dysfunction.
Source : Pediatric Critical Care Medicine
MSc. Biotechnology
Medha Baranwal joined Medical Dialogues as an Editor in 2018 for Speciality Medical Dialogues. She covers several medical specialties including Cardiac Sciences, Dentistry, Diabetes and Endo, Diagnostics, ENT, Gastroenterology, Neurosciences, and Radiology. She has completed her Bachelors in Biomedical Sciences from DU and then pursued Masters in Biotechnology from Amity University. She has a working experience of 5 years in the field of medical research writing, scientific writing, content writing, and content management. She can be contacted at editorial@medicaldialogues.in. Contact no. 011-43720751
Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751