What is the treatment for pediatric septic ileus?

Treatment of Pediatric Septic Ileus

The treatment of pediatric septic ileus requires prompt antimicrobial therapy within 1 hour of recognition for septic shock cases, along with aggressive fluid resuscitation of 40-60 mL/kg in the first hour, source control interventions, and supportive care to address the underlying sepsis and resultant intestinal dysfunction. 1, 2

Initial Management

Antimicrobial Therapy

• Start antimicrobial therapy as soon as possible - within 1 hour for septic shock and within 3 hours for sepsis-associated organ dysfunction without shock 1
• Obtain blood cultures before initiating antibiotics when this does not substantially delay treatment 1, 2
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 1
• For neonates, a combination of ampicillin plus gentamicin is recommended as first-line empiric therapy 3
• For older children, coverage should include gram-negative enteric organisms that commonly cause intra-abdominal infections 2

Fluid Resuscitation

• Administer up to 40-60 mL/kg in bolus fluid (10-20 mL/kg per bolus) over the first hour 1, 2
• Titrate to clinical markers of cardiac output including heart rate, blood pressure, capillary refill time, level of consciousness, and urine output 1, 2
• Discontinue fluid boluses if signs of fluid overload develop (hepatomegaly, rales) 2, 4
• Use crystalloids rather than colloids for initial resuscitation 2, 4

Source Control

• Implement emergent source control intervention as soon as possible after diagnosis 1, 2
• Consult surgical specialists early for potential surgical intervention if intra-abdominal source is suspected 2
• Remove intravascular access devices confirmed to be the source of sepsis after establishing alternative vascular access 1, 2

Specific Management for Ileus

Gastrointestinal Decompression

• Place nasogastric tube for decompression to relieve abdominal distension and prevent aspiration 2
• Maintain nil per os (NPO) status until bowel function returns 2
• Monitor abdominal distension, bowel sounds, and passage of flatus/stool 2

Hemodynamic Support

• For fluid-refractory shock, initiate vasoactive medications 2
• For cold shock (increased systemic vascular resistance), use central dopamine or epinephrine 2
• For warm shock (decreased systemic vascular resistance), use central norepinephrine 2

Supportive Care

• Provide parenteral nutrition if enteral feeding is not possible due to prolonged ileus 2
• Monitor electrolytes closely and correct imbalances, particularly potassium, which affects intestinal motility 2
• Consider stress-dose hydrocortisone for fluid-refractory, catecholamine-resistant shock 2

Ongoing Management

Antimicrobial Stewardship

• Perform daily assessment for de-escalation of antimicrobial therapy 1
• Narrow therapy once pathogen(s) and sensitivities are available 1
• Determine duration of therapy according to site of infection, microbial etiology, response to treatment, and ability to achieve source control 1, 5

Monitoring and Follow-up

• Assess for resolution of ileus through physical examination (decreased abdominal distension, return of bowel sounds) 2
• Monitor for complications of prolonged ileus including bacterial translocation and malnutrition 5
• Gradually advance diet when bowel function returns, starting with clear liquids and progressing as tolerated 2

Common Pitfalls and Caveats

• Delaying antimicrobial therapy significantly increases mortality; do not wait for all cultures before starting antibiotics 2, 5
• Continuing fluid administration despite signs of fluid overload can worsen outcomes 2, 4
• Failing to reassess frequently for clinical improvement and potential de-escalation of therapies 1, 2
• Overlooking the need for source control, which is critical in managing septic ileus 1, 2
• Initiating enteral nutrition too early before resolution of ileus, which can worsen abdominal distension and respiratory compromise 2