Three Birds With One Stone: Successful Management Of Peritonitis Induced Pediatric Septic Shock With Peritoneal Washing

Introduction

The definition of septic shock (SS) has been updated in 2020 by Surviving Sepsis Campaign (SCC) International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children as severe infection leading to cardiovascular dysfunction and “sepsis associated organ dysfunction” in children as severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction (Weiss SL et al., Pediatr Crit Care Med 2020; 21(2): p. e52-e106). SS is one of the most common causes of death in pediatric intensive care units with a mortality rate of 40–60%. About 90% of patients with severe sepsis are presented with high fever. In critically ill pediatric patients fever control is crucial because the increase in oxygen consumption caused by high fever worsens the catabolic process and results in cardiopulmonary collapse. External cooling is an option to manage fever in sepsis which alleviate risk of drug side effect and might be insufficient (Honore PM et al. Ann Intensive Care 2019; 9:56). SCCM guidelines recommend emergent source control after resuscitation and initial stabilization.

Hypercytokinemia characterized with increased pro-inflammatory and anti-inflammatory cytokine levels is related with mortality in sepsis. Therefore, recently multiple studies about immunomodulation, immunosuppression and cytokine removal (immunoadsorption) have been reported as alternative implications (Honore PM, 2019). However, there is no strong evidence for routine use of these techniques.

We, herein, present a case of SS which developed due to peritonitis as a complication of gastrostomy. In the management of this case, we demonstrated the efficacy of percutaneous peritoneal washing and internal cooling in the control of refractory fever which was resistant despite antibiotic and antipyretic treatments.

Case Presentation

An 8-year-old female patient, who was followed with the diagnosis of cerebral palsy and familial epilepsy syndrome due to SLC 13A5 deletion and SLC18A2 frameshift mutation, was hospitalized for aspiration pneumonia. During the inpatient period, anti-reflux surgery (Nissen fundoplication) and Stumm gastrostomy was performed because of recurrent aspiration pneumonia, swallowing disorder and massive gastroesophageal reflux. On 22^nd post-operative day, the patient developed respiratory distress, abdominal distension and tenderness on physical examination. A leakage of enteral feeding solution from the gastrostomy suggesting gastrostomy tube displacement was observed. As no improvement was seen under non-invasive mechanical ventilation, the patient was intubated. Abdominal X-ray enhanced with a water-soluble contrast medium revealed leakage of the contrast medium into the peritoneum ([Fig. 1]). Abdominal ultrasonography revealed echogenic intra-abdominal free fluid with a 6 cm thickness, and then 650 ml enteral nutrition solution was drained out from the abdominal cavity through the peritoneal catheter instead of laparotomy since the patient’s clinical status was not stable to underwent general anesthesia.

Fig. 1 Anterior-posterior abdominal x-ray (left) from a gastrostomy tube injection with water soluble contrast shows extravasated contrast diffusing the abdominal cavity (black arrow), outlining the stomach contour (grey arrow), and reaching to the pelvis (white arrow). Lateral abdominal x-ray (right) shows extravasated contrast (black arrow) and there was no free gas within abdominal cavity.

Empiric antimicrobial therapy was extended with vancomycin, meropenem, ornidazole, fluconazole. She also had hypotension which required inotropic supports, including adrenaline, noradrenaline, and dopamine; her vasoactive-inotropic score (VIS) reached to 30 gradually ([Fig. 2]). Despite three days broad spectrum antibiotic treatment and first line source control with drain, there was no improvement in patient’s clinical status and the patient's fever persisted around 40°C under antipyretic therapy and aggressive external cooling. To cope with fever and the source of hyperinflammation, intraperitoneal sterile washing was applied through percutaneous peritoneal drainage catheter for effective source control and cold (+4°C) isotonic saline solution was used to provide internal cooling. 10 cc/kg of cold isotonic saline was filled into the peritoneum with two-hour cycles. After filling, the catheter was left for free drainage without keeping the liquid inside. The patient's fever dropped below 37.5°C after the third washing session. With the decrease of fever, the patient became hemodynamically stable and inotropic treatments were started to be tapered off (VIS:25) within first hours and the need for inotropic therapy was significantly reduced in the first 24 hours (VIS:10) ([Fig. 2]). After continuing the administration for 48 hours, the body temperature remained stable within normal ranges. We did not observe electrolyte imbalance, dehydration, and fluid overload with this intervention during three days of the procedure ([Table 1]). Once the patient’s situation became stabilized in Day 8, gastrostomy displacement was confirmed with the surgical exploration and gastrostomy was surgically revised and Jackson-Prett type peritoneal drain was inserted, and she was extubated on the second postoperative day. The feeding through gastrostomy, was reinstituted with a gradual increase up to 8×200 cc/day. The physical examination findings of the patient improved, and the drain was removed.

Fig. 2 Timeline of disease course and treatment. The figure illustrates the disease progression and treatments, depicting body temperature (left y-axis), heart rate (right y-axis), days of sepsis (upper x-axis), and medical interventions (lower x-axis). Vasoactive-inotropic Score (VIS)=Dobutamine dose (μg/kg/min)+Dopamine dose (μg/kg/min)+100×Epinephrine dose (μg/kg/min).

Table 1 Laboratory parameters of the case in sepsis.

Lab Values	Day 0	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Day 8	Day 10
Hemoglobin (g/dL)	9.6	12.1	11.7	7.4	9.8	10.4	9.6	10.9	9.0
Leucocyte (/µL)	10800	16200	4200	4400	8900	6900	8800	6100	8200
Neutrophil (/µL)	5900	13540	2080	3210	7210	5530	6940	4860	5060
Lymphocyte (/µL)	2660	1830	1710	860	1580	1210	1620	1010	2480
Thrombocyte (/µL)	255	383	292	123	55	52	70	112	169
CRP (mg/dL)	0.365	2.23	27	38.4		18.1	8.15
Ferritin (µg/L)			84.2	263	384	944.6	454.9
Procalcitonin (ng/mL)		2.1	646.0	98.3	504.7		199
Fibrinogen (mg/dl)			448.13	730.48	768.91	497.35	347.70	248.67	483.64
Albumin (g/dL)	3.31	3.37	2.24	2.94	3.09	2.9	3.15	2.87	2.56
AFR*			5.09	4.02	4.06	5.91	9.26	11.95	5.33
Troponin-I (ng/L)		19.10	19.9	39.80	1717.1	456.2	331.3
BNP (pg/mL)			1076	268	425	448	167
Creatinin (mg/dL)	0.12	0.22	0.29	0.52	0.36	0.32	0.19	0.13	0.14
Sodium (mEq/L)	137	139	136	151	144	146	144	150	146
Potassium (mEq/L)	3.28	4.31	3.87	2.29	3.51	3.2	3.87	4.22	3.35
ALT (U/L)	32	35	17	15	20	29	45	50	40
AST (U/L)	37	36	20	20	46	61	100	95	57
INR				2.54	2.31	1.62	1.13		1.09
pH	7.28	7.37	7.28	7.54	7.43	7.44	7.42	7.50	7.44
Lactate (mmol/L)	1.7	2.1	2.7	4.1	1.4	0.7	0.9	0.9	0.9

Day 0 represents the day the leakage of formula is likely to occur. Peritoneal washing with cold normal saline was performed on Day 5, 6, and 7. Abbreviations: CRP, C reactive protein; AFR, albumin-fibrinogen ratio; ALT, alanine transaminase; AST, aspartate transaminase; INR, international normalized ratio.

Publication History

Article published online:
10 December 2024