Professor Li Deyuan: Explore the key points of diagnosis and treatment of sepsis and SAE in children to help patients maximize benefits

For reference only for medical professionals, the correct and rational application of antibiotics is a key part of the successful treatment of sepsis
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Sepsis is one of the leading causes of death in children in the pediatric intensive care unit (PICU)
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Sepsis-associated encephalopathy (SAE) is a common type of encephalopathy in patients with severe sepsis.
It is a diffuse or multifocal brain dysfunction caused by systemic infection and can leave long-term central nervous system damage
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In this issue, Professor Li Deyuan, director of the Department of Pediatric Intensive Medicine, West China Second Hospital of Sichuan University, is invited to share the latest diagnosis and treatment progress on the research status of sepsis and SAE in children
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Frightening childhood sepsis In high-income countries, approximately 8% of PICU admissions suffer from sepsis [1]
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According to epidemiological data from the United States, in recent years, the incidence of sepsis in children has shown a steady upward trend.
The mortality rate of severe sepsis in children is 10.
3%, and the mortality rate of patients with underlying diseases can be as high as 12.
8% [2]
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In China, childhood sepsis also has high morbidity and mortality, but there is no large-scale epidemiological data in China
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Professor Li Deyuan introduced that sepsis is an important factor causing death in children.
Compared with adults, there are certain differences in the pathogenic bacteria, epidemiology and clinical manifestations of children infected
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Most of the children who died of sepsis had refractory shock and/or multiple organ dysfunction syndrome, and many deaths occurred within the first 48 to 72 hours of treatment
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Therefore, early intervention is an important means to reduce the mortality rate of childhood sepsis [1]
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In 2020, the American Society of Critical Care Medicine (SCCM) and the European Society of Critical Care Medicine (ESICM) proposed the new International Guidelines for the Save Sepsis Movement: Management of Childhood Septic Shock and Sepsis-Related Organ Dysfunction (hereinafter referred to as the "Guidelines").
"), provides new recommendations for the management of sepsis in children, and provides practical advice and guidance for clinical practice [1]
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The timing of antibacterial drug initiation is the key point of treatment.
Correct and reasonable application of antibacterial drugs is a key part of the successful treatment of sepsis, and it is also one of the main factors to reduce the mortality rate
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The updated "Guidelines" mentioned that the mortality rate increased by 7% for every 1 hour delay in the use of antibiotics after the occurrence of septic shock [1]
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Professor Li Deyuan pointed out that children with septic shock should start anti-infective therapy within 1 hour, and children with sepsis-related organ dysfunction but no shock should start anti-infective therapy within 3 hours
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Obtaining accurate and reliable pathogen detection results in infected children is the premise of targeted antibacterial therapy and an important basis for the adjustment of antibacterial regimens
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Therefore, relevant research points out that it is recommended to collect blood culture specimens without delaying the use of antibiotics (within 45 minutes) to identify the infectious pathogen as soon as possible
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Broad-spectrum antibiotics (such as carbapenems) should be used empirically before the pathogen is identified.
Once the pathogen is identified, sensitive narrow-spectrum antibiotics should be used.
The anti-infective course of treatment is generally 7-10 days
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Brain dysfunction is one of the more serious sequelae of sepsis.
SAE is a common type of encephalopathy in patients with severe sepsis.
A survey shows that the incidence of SAE is as high as 8%-70% [3]
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Compared with non-SAE sepsis patients, SAE patients are more severely ill, have a significantly increased risk of death, and patients and their families have to bear higher hospitalization costs
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In addition, children with SAE are prone to long-term cognitive impairment.
A behavioral questionnaire survey found that children with SAE had significant problems such as decreased academic performance, disobedience, and stubborn/irritable behavior after discharge [4]
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In addition, children with SAE often experience a dramatic deterioration in mental status, and delirium is usually the first clinical symptom in children with SAE
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Delirium is a transient state of confusion caused by a variety of causes.
It is mainly characterized by disturbance of consciousness and cognitive function changes.
Other features include motor changes, epilepsy, and electrolyte disturbances.
Clinically, screening scales are often used to evaluate the occurrence of delirium and the relationship between them.
severity
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The diagnosis of SAE is still a clinical difficulty, Professor Li Deyuan pointed out that due to the involvement of neurological symptoms, the current diagnosis of SAE is very difficult.
Generally, the diagnosis is made by the exclusion method, and the influence of drug factors, electrolyte disturbances and central nervous system disturbances must be excluded
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In addition, clinical symptoms are the basis for the diagnosis of SAE.
When acute mental state changes occur in children with sepsis, SAE is often considered, and the following three conditions must be combined: 1.
The patient has a systemic inflammatory response caused by infection; 2.
.
Acute changes in mental state, such as delirium, disturbance of consciousness inconsistent with the level of sedation, abnormal sleep-wake cycle, hallucinations, agitation, etc.
; 3.
Exclude primary brain diseases, intracranial infections,
etc.

Laboratory and instrumental examinations can be used as the basis for auxiliary diagnosis of SAE, such as electroencephalography (it is one of the more sensitive methods for judging SAE), computed tomography (CT), magnetic resonance examination (MRI), transcranial Doppler diagnosis ( TCD), biomarkers,
etc.

Treatment is preferably antibacterial regimen with low neurotoxicity.
At present, there is no essential difference between the treatment plan of SAE and the treatment of sepsis.
The main body of drug treatment is antibacterial treatment
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Professor Li Deyuan pointed out that systemic anti-infective therapy is the main goal of the treatment of SAE, and adjuvant supportive therapy should also be combined
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Professor Li Deyuan mentioned that the risk of neurotoxicity of different types of antibiotics is very different, and antibacterial drugs with low neurotoxicity should be preferred in clinical practice
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In addition, although the incidence of neurotoxicity of carbapenems is generally low, there are still differences: it is mainly related to the basicity of the C-2 side chain.
The stronger the basicity, the stronger the binding ability of the drug to GABA receptors.
The greater the central excitatory effect, the greater the neurotoxicity
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The C-2 side chain of meropenem is less basic than imipenem and panipenem, so meropenem has less neurotoxicity and is a better choice of antibiotics for the treatment of SAE
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Finally, Professor Li Deyuan added that the management of delirium symptoms also plays an extremely important role in improving the treatment and prognosis of children.
Pain, anxiety, and unreasonable sedation are all factors that trigger delirium.
Effective analgesia and reasonable sedation are essential for reducing stress.
The resulting physical and psychological dysfunction can play a positive role
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Expert Profile Professor Li Deyuan/Chief Physician/Master's Supervisor Incumbent Director of the Department of Pediatric Intensive Medicine, West China Second Hospital, Sichuan University The thirteenth batch of academic and technical leaders of the Sichuan Provincial Health Commission National Health Emergency Response Guidance Expert Committee member, secretary of the disaster group of the Pediatrics branch of the Chinese Medical Association, member of the infection cooperation group of the respiratory group of the Chinese Medical Association Pediatrics branch, deputy head of the critical care group of the Pediatric Special Committee of the Sichuan Medical Association 1 Science Foundation Youth Fund, presided over 1 key R&D project of Sichuan Provincial Department of Science and Technology, won the first prize of Sichuan Medical Science and Technology Award, and the first prize of Sichuan Medical Science and Technology Award Youth Award References: [1] Weiss SL, Peters MJ, Alhazzani W, et al.
Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children.
Intensive Care Med.
2020 Feb;46(Suppl 1):10-67.
[2] Li Yang.
Pus in children Research progress on the etiology and pathogenesis of viral diseases[J].
The World's Latest Medical Information Abstracts (Continuous Electronic Journal), 2019,19(63):80,83.
[3] Algebaly H, ElSherbini S, Galal A, et al .
Transcranial Doppler Can Predict Development and Outcome of Sepsis-Associated Encephalopathy in Pediatrics With Severe Sepsis or Septic Shock.
Front Pediatr.
2020 Aug 20;8:450.
[4] Kaur J, Singhi P, Singhi S, et al.
Neurodevelopmental and Behavioral Outcomes in Children With Sepsis-Associated Encephalopathy Admitted to Pediatric Intensive Care Unit: A Prospective Case Control Study.
J Child Neurol.
2016 May;31(6):683-90.
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