Transcript Pediatric Shock - Latest Publications

SEVERE SEPSIS&SEPTIC
SHOCK
IN PEDIATRICS.
Abdel Razzaq Abu Mayaleh, MD
PRCS _ New Hospital - Hebron
Based partially on www.picucourse.org
INTRODUCTION

SEPSIS:- it’s an infection plus systemic manifestation of
infection.





SEVERE SEPSIS :- Sepsis plus sepsis-induced organ
dysfunction or tissue hypo perfusion.
..
.
SEPTIC SHOCK:- sepsis-induced hypotension persisting
despite adequate fluid resuscitation and elevated lactate.

HYPOTENTION:- S.BP < 70 + 2 ×wt.
(80 + 2 × wt)

SHOCK:-

DO2 < VO2
A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis:
hypotension, hypoperfusion and organ dysfunction. Crit Care Med 2004; 320(Suppl):S595S597
Septic Shock Epidemiology

During the last 2 decades the incidence of sepsis & septic
shock has increased across all age groups. This is thought
to be due to:
-
↑ use of invasive procedures
-
↑ use of immunosuppressive drugs
-
↑ microbacterial ressistance

Child mortality improved dramatically from 97% → 9%
due to the advance in critical care technology.
Septic Shock: “Warm Shock”
 Early, compensated, hyperdynamic state
 Clinical signs

Warm extremities with bounding pulses,
tachycardia, tachypnea, confusion.
 Physiologic parameters

widened pulse pressure, increased cardiac ouptut
and mixed venous saturation, decreased systemic
vascular resistance.
 Biochemical evidence:

Hypocarbia, elevated lactate, hyperglycemia
Septic Shock: “Cold Shock”
 Late, uncompensated stage with drop in cardiac
output.
 Clinical signs

Cyanosis, cold and clammy skin, rapid, thready pulses,
shallow respirations.
 Physiologic parameters

Decreased mixed venous sats, cardiac output and CVP,
increased SVR, thrombocytopenia, oliguria, myocardial
dysfunction, capillary leak
 Biochemical abnormalities

Metabolic acidosis, hypoxia, coagulopathy,
hypoglycemia.
MANAGEMENT-GENERAL
.
 Goal: increase oxygen delivery and decrease oxygen
demand:
VO2 (O2 Extraction)
 Oxygen
 Fluid
 Temperature control
 Antibiotics
septic
 Correct metabolic
abnormalities
.  Spare WOB
. ?
 Inotropes
normal
DO2 = C.O. x CaO2
Hg X SatO2 X 1.34
.
DO2
Fluid Resuscitation
Aggressive fluid resuscitation with boluses
of 20 ml/kg over 5-10 min
 Blood pressure by itself is not a reliable
endpoint for resuscitation
 Initial resuscitation usually requires 40-60
ml/kg, but more may be required

Therapeutic Endpoints


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Capillary refill < 2 sec
Warm extremities
Urine output > 1 ml/kg/hr
Normal mental status
Decreased lactate
Central venous O2 saturation > 70%
Hemodynamic Support

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Hemodynamic profile may be variable
Dopamine for hypotension
Epinephrine or norepinephrine for dopaminerefractory shock
Dobutamine for low cardiac output state
Inhaled NO useful in neonates with post-partum
pulmonary hypertension and sepsis
Other Therapies

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Steroids: recommended for children with
catecholamine resistance and suspected or proven
adrenal insufficiency.
Activated protein C not studied adequately in
children yet.
GM-CSF shown to be of benefit in neonates with
sepsis and neutropenia.
Extracorporeal membrane oxygenation (ECMO)
may be considered in children with refractory
shock or respiratory failure.
2005
Shock
ABC
FLUID BOLUS-20-60cc/kg
Dopamine/ dobutamine
Cold shock
Warm shock
NE
EPI
steroids
Milrinone
0 min
5 min
Recognize decreased mental status and perfusion.
Maintain airway and establish access according to PALS guidelines.
Push 20 cc/kg isotonic saline or colloid boluses up and over 60 cc/kg. Correct
hypoglycemia and hypocalcaemia. Administer antibiotics.
15 min
Fluid refractory shock * *
Fluid responsive *
Establish central Venous access, begin dopamine or dobutamine therapy
and establish arterial monitoring .
Fluid refractory – dopamine/ dobutamine resistant shock
Observe in PICU
Titrate epinephrine for cold shock, norepinephrine for warm shock to normal clinical
endpoints and ScvO2 saturation ≥70% .
Catecholamine-resistant shock
60 min
Begin hydrocortisone if at risk for absolute adrenal insufficiency
Normal Blood Pressure
Low Blood Pressure
Low Blood pressure
Cold Shock
Cold Shock
Warm Shock
ScvO2 Sat <70%
ScvO2 Sat < 70%
ScvO2 Sat ≥ 70%
Add Vasodilator or type
III phosphodiesgerase
inhibitor with volume
loading
Titrate volume and
epinephrine
Titrate volume and
norepinephrine
Persistent Catecholamine- resistant shock
Start Cardiac output measurement and direct fluid, inotrope, vasopressor,
vasodilator, and hormonal therapies to attain CL>3.3 and <6.0 L/min/m²
Refractory shock
Consider ECMO
VENTILATOR MANAGEMENT
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Assist control mode-volume ventilation
Reduce tidal volume to 6ml/kg predicted body wt.
Keep Pplat <30cm H2O
Maintain SaO2 / pO2 88-95%
Anticipated PEEP setting at various FiO2
requirements
FiO2 0.3 0.4 0.5 0.5 0.6 0.7 0.8 0.9 1.0
PEEP 5 5 8
10 12 14 16 18 20
Sedation and Analgesia in Sepsis

Sedation protocol for mechanically ventilated
patients with standardized subjective sedation
scale target.
Intermittent bolus
•
Continuous infusion with daily
awakening/retitration
Grade B
•
Kollef, et al. Chest 1998; 114:541-548
Brook, et al. CCM 1999; 27:2609-2615
Kress, et al. NEJM 2000; 342:1471-1477
Neuromuscular Blockers


Avoid if possible
Used longer than 2-3 hrs

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PRN bolus
Continuous infusion with twitch monitor
Grade E
The Role of Intensive
Insulin Therapy in the Critically Ill
 At
12 months, intensive insulin
therapy reduced mortality by
3.4% (P<0.04)
In-hospital survival (%)
100
96
Intensive treatment
92
P=0.01
88
Conventional treatment
84
80
0
0
50 100 150 200 250
Days after admission
Adapted from Figure 1B, page 1363, with permission from van den Berghe G, Wouters P, Weekers
F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-67
Glucose Control

After initial stabilization
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Glucose < 150 mg/dL
Continuous infusion insulin and glucose
or feeding (enteral preferred)
Monitoring
Initially q30–60 mins

After stabilization q4h
Grade D

Bicarbonate Therapy
 Bicarbonate therapy not recommended to
improve hemodynamics in patients with
lactate induced pH >7.15
Grade C
Cooper, et al. Ann Intern Med 1990; 112:492-498
Mathieu, et al. CCM 1991; 19:1352-1356
Primary Stress Ulcer Risk Factors Frequently
Present in Severe Sepsis
Mechanical ventilation
 Coagulopathy
 Hypotension

Choice of Agents for
Stress Ulcer Prophylaxis
H2 receptor blockers
 Role of proton pump inhibitors

Grade C
Cook DJ, et al. Am J Med 1991; 91:519-527
Blood Product Administration
Red Blood Cells
Tissue hypoperfusion resolved
No extenuating circumstances

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Coronary artery disease
Acute hemorrhage
Lactic acidosis
Transfuse < 7.0 g/dl to maintain 7.0-9.0 g/dL
Grade B
Blood Product Administration

Do not use erythropoietin to treat sepsisrelated anemia. Erythropoietin may be used
for other accepted reasons.
Grade B
Blood Product Administration
Fresh frozen plasma
• Bleeding
• Planned invasive procedures.
Grade E
Blood Product Administration
• Do not use antithrombin therapy.
Grade B
Warren et al. JAMA 2001; 1869-1878
Blood Product Administration

Platelet administration
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Transfuse for < 5000/mm3 Transfuse for 5000/mm3 – 30,000/mm3 with
significant bleeding risk
Transfuse < 50,000/mm3 for invasive
procedures or bleeding
Grade E