Page 128 - JSOM Summer 2022

respiratory failure and fatigue, aggressive airway management increased support. In children who have failed to respond to
is often indicated. If acute respiratory concerns exist that can- initial fluid therapy and vasoactive medications, intubation is
not be addressed promptly with patient positioning and sup- often indicated. With the increase of stand-alone flow-driven
plemental oxygen, especially if clinical signs suggest end-organ CPAP systems being carried by field clinicians and the increas-
perfusion dysfunction, intubation should be considered. 10,19 ing popularity of bubble CPAP in the developing world, CPAP
10
In the critically ill child with such presentation, the risk of is often more accessible than BiPAP. Many field clinicians
peri-intubation arrest/hypotension is higher due to the likely are also now equipped with safe, compact, transport-rated
degree of oxygen debt and hemodynamic instability. Clinicians ventilator systems capable of producing BiPAP ventilation. If
should resuscitate these patients as much as possible before the these options are available, austere clinicians should strongly
intubation attempt. Administration of supplemental O with consider the benefits to the patient but recognize situational
2
non-invasive ventilation, fluid boluses, and vasoactive medica- constraints such as gas supply and battery life.
tions are likely to be needed. Etomidate is not recommended
due to a higher association of mortality and adrenal insuffi- Vasoactive medications are indicated in fluid-refractory hypo-
ciency observed across multiple studies. Nevertheless, this tension. Current guidelines recommend epinephrine or norepi-
recommendation remains weak due to lack of conclusive evi- nephrine. Epinephrine and norepinephrine both elicit inotropic
dence and should not prevent the use of etomidate if clinicians and alpha-1 effects, are commonly used, easily attainable, and
feel it is the safe option over other available medications. 19 proven to be an effective treatment of fluid-refractory hypo-
19
tension in septic children. Dopamine, while not preferred, is
Fluid therapy in the austere environment has a more conser- still considered an acceptable first-line medication in the ab-
vative and goal-driven approach but should still be started as sence of epinephrine and norepinephrine. 19,28 Current evidence
early as possible. 10,19,35 While fluid resuscitation is often neces- is not definitive about whether epinephrine or norepinephrine
sary due to hypovolemia secondary to sepsis, a more nuanced should be used as the first-line medication of choice as there is
approach is necessary in the austere setting. Traditionally in no difference in mortality comparatively. Both show fewer in-
resource-rich environments where intensive care resources stances of arrhythmias or other adverse events when compared
are more accessible, clinicians are often encouraged to initi- to dopamine in adult trials. Ultimately clinicians should not
19
ate a 40–60mL/kg bolus of fluids over an hour (often regard- hesitate to use any of said medications as first-line agents in the
less of whether hypotension is present). Fluids are titrated to austere setting. Although all three medications can safely be
signs of improved cardiac output and stopped if evidence of administered via peripheral or intraosseous access, central ac-
19
fluid overload becomes apparent. However, in the austere cess is preferred and should be obtained as early as possible. 19,28
environment, the risk of fluid overload should be mitigated
entirely due to the known association with high mortality Administration of antibiotic therapies as soon as possible re-
rates. Instead, in the absence of hypotension, fluid boluses mains key in treating septic children, but in the austere en-
37
should not be administered and maintenance fluids should be vironment, the absence of laboratory resources can make it
started. In the presence of hypotension in the austere environ- challenging to create a treatment plan for these patients’
ment, current guidelines recommend a 40mL/kg bolus over an course of care. 6,10,19,35 Sepsis in children is most frequently as-
hour, again titrating to signs of improved cardiac output but sociated with gram-negative or gram-positive bacteria, how-
stopping this therapy if evidence of fluid overload appears. ever, geographic region, nature of sepsis onset, and patient age
19
Crystalloids are recommended over albumin for initial resus- are all significant factors that change likely infection culprits.
citation, to include lactated Ringer’s, PlasmaLyte, and Nor- 19 Empiric broad-spectrum antibiotics should be administered
mosol preferred. 10,19 Normal saline (0.9% sodium chloride) to cover the most likely pathogens at hand, with time goals
is acceptable in the absence of balanced crystalloids for fluid within one hour of recognition for initially stable patients and
resuscitation. Colloids show no difference in clinical outcomes within three hours for initially unstable patients. 10,19,28 For pre-
though they may be more difficult to obtain and store in the hospital providers in the austere environment, this is often not
resource-limited setting. 10,19,28 Crystalloids are routinely avail- a decision they are equipped to make. IV antibiotics carried
able in supplies brought into the field. into the field are generally limited and may not be appropri-
ate for the patient at hand. Telemedicine should be utilized if
Maintenance fluids should consist of dextrose 5% if possible possible; there is strong evidence to support the use of tele-
due to concern for hypoglycemia. If IV dextrose is unavail- medicine in any prehospital setting, specifically when complex
18
able, ensure blood sugar is assessed regularly and consider al- patients are involved. 38
lowing patients to have minimal PO intake in relation to blood
glucose levels. In intubated patients in which dextrose cannot Goals for fluid and vasoactive medications should also include
be administered IV, clinicians may have to improvise. One solu- urine output. With the risk of AKI being high in septic chil-
tion could be placing an orogastric or nasogastric tube and ad- dren, urine output and quality are important clinical markers.
ministering electrolyte-rich solutions such as sports beverages Urine output should be measured every hour if possible. Stan-
or oral rehydration salts. However, this is an opinion and not dard urine output in a child is 1–2mL/kg/hr and varies based
associated with any of the reviewed literature or evidence. on age. Again, the use of telemedicine is strongly encouraged
4
if the worsening renal status is noted despite adequate fluid
In the presence of increased respiratory effort and fatigue, resuscitation and initiation of vasoactive therapies.
non-invasive ventilation with continuous positive airway pres-
sure (CPAP) or bilevel positive airway pressure (BiPAP) should
be considered if available. 10,19 These options decrease respi- Conclusion
ratory workload and increase oxygenation, proving highly Sepsis remains a challenging and diverse disease process that
beneficial. These options should be mainly considered when a continues to present challenges across the globe. With new re-
patient has responded well to initial therapies but still requires search and technologies allowing increased care capabilities

124 | JSOM Volume 22, Edition 2 / Summer 2022