Transcript Management of Increased ICP

Pediatric Septic Shock
PICU Resident Talk
Stanford School of Medicine
Pediatric Critical Care Medicine
(Updated June 2014)
Learning Objectives
• Distinguish the terms SIRS, sepsis & septic
shock
• List physiologic changes that occur in sepsis
and explain how each factor affects O2
demand/ delivery
• Understand the rationale for goal directed
therapy in septic shock
Septic Shock
Systemic inflammatory response syndrome (SIRS)The presence of at least two of the following one of which must be abnormal
temperature or leukocyte count.
- Temperature. >38.5 or <36.
- Tachycardia (or bradycardia for children <1yo)
- Tachypnea
- Leukocyte count increased or decreased or > 10% bands.
SepsisSIRS in the presence of suspected or proven infection.
Severe sepsisSepsis plus end organ dysfunction (cardiovascular organ dysfunction OR
ARDS OR 2 or more other organ dysfunction)
Septic shockSepsis plus cardiovascular organ dysfunction.
Goldstein et al. Pediatr Crit Care Med 2005
American College of Critical Care Medicine
Hemodynamic Definitions of Shock
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
Sepsis leads to microvascular occlusion,
vascular instability,
and organ failure
through complex
interactions between
pathogens, immune
cells, and the
endothelium.
Cohen, Nature 2002
SIRS
PRO-inflammatory
response
IL-1
TNF-alpha
ANTIinflammatory
response
IL-10
CARS
PROinflammatory
response
IL-1
TNF-alpha
ANTIinflammatory
response
IL-10
Immunologic Dissonance
PRO-inflammatory
response
IL-1
TNF-alpha
ANTIinflammatory
response
IL-10
What is our goal?
Deliver oxygen to end
organs!
DO2 =
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
Therapeutic Endpoints
• capillary refill of < 2 s
• normal blood pressure for age
• normal pulses with no differential between
peripheral and central pulses
• warm extremities
• urine output ≥1 mL/kg/hr
• normal mental status
• ScvO2 saturation ≥70%
• cardiac index between 3.3 and 6.0 L/min/m2 should
be targeted
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Give oxygen
–NC
–Non rebreather
–HFNC
–CPAP
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Volume
– isotonic crystalloids or albumin boluses of up to
20 mL/kg over 5–10 minutes without inducing
hepatomegaly or rales.
– If hepatomegaly or rales exist then inotropic
support should be implemented, not fluid
resuscitation
Surviving Sepsis Campaign 2012
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Inotropes/vasopressors/vasodilators
In the fluid
refractory
patient begin a
peripheral
inotrope while
establishing
central access.
If dopamine
refractory start
epinephrine in
cold shock.
If dopamine
refractory start
norepinephrine
in warm shock.
Goal is normal
perfusion and
blood pressure.
Pediatric Septic Shock Algorithm
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
Pediatric Septic Shock Algorithm
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Transfuse
– During resuscitation of low superior vena cava
oxygen saturation shock (≤ 70 %), hemoglobin
levels of 10 g/dL are targeted
– After stabilization and recovery from shock and
hypoxemia then a lower target ≥ 7.0 g/dL can be
considered reasonable
Surviving Sepsis Campaign 2012
Refractory Shock??
Mechanical Problem?
Pericardial effusion
Pneumothorax
Increased abdominal
Pressure.
Necrotic tissue.
Ongoing blood loss
Immune?
Excessive immunosuppression
Uncontrolled infection
? ?
? ?
Endocrine?
Hypothyroid
Hypoadrenal
Early Goal directed therapy
resulted in a 40% reduction in
mortality compared to control
in adult patients with septic
shock
Rivers et al. NEJM 2001
But is it??
• ProCESS group, NEJM, 2014
– Randomized control, multi institutional study
– ~1300 adult patients
– No difference in protocolized early goal directed
therapy (EGDT), protocolized standard therapy
and usual care at 60 or 90 day mortality
Early Shock REVERSAL resulted in 96% survival versus 63% survival
among patients who remained in persistent shock state
Han, Y. Y. et al. Pediatrics 2003
Goal directed therapy causes a significant reduction in
28 day mortality in children with septic shock
Oliveira et al. Intensive care med 2008
Take Home Points
• Septic shock is due to an imbalance in pro and
anti inflammatory response
• Therapeutic goal is to deliver enough oxygen
to end organs
• Early goal directed therapy improves survival
(maybe?)