Pediatric Septic Shock

PICU Resident Talk Stanford School of Medicine Pediatric Critical Care Medicine June 2010

Learning Objectives

• • • After this lesson, the participant will be able to: Distinguish the terms SIRS, sepsis & septic shock.

List physiologic changes that occur in sepsis and explain how each factor affects O 2 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 or <36.

- Tachycardia - Tachypnea - Leukocyte count increased or decreased or > 10% bands.

Sepsis

- SIRS in the presence of infection.

Severe sepsis

- Sepsis plus end organ dysfunction i.e. ARDS, renal dysfunction, coagulopathy.

Septic shock

- Sepsis plush 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 micro vascular occlusion, vascular instability, and organ failure through complex interactions between pathogens, immune cells, and the endothelium.

Cohen, Nature 2002

The predominant cause of mortality in adult sepsis is vasomotor paralysis.

Parker, et al. Crit Care Med. 1987

Contrary to adults low cardiac output not low SVR is associated with mortality in septic shock in children.

Pollack et al. Crit Care Med 1984, 1985

Early Intervention in the treatment of septic shock is vital: The first hour in the ED Maintain and restore airway, oxygenation, and ventilaton Monitoring Therapeutic endpoints

Therapeutic Endpoints

Fluid Resuscitation & Hemodynamic Support • Threshold heart-rates • Age appropriate perfusion pressure • UOP > 1 cc/kg/hr • CI> 3.3 and less than 6 L/min/m 2 • Scvo 2 >70% • Normal perfusion • CRT< 2 seconds • Normal INR, anion gap, lactate

Hemodynamic Support

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.

Consider CI, BP, and SVR when implementing CV support.

Low CI Normal blood pressure High SVR Afterload reduction may improve blood flow by increasing ventricular emptying.

Nitroprusside (Beware of Cyanide toxicity) Milrinone.

Low CI, Low blood pressure Low SVR Norepinephrine can be added to epinephrine to increase DBP and SVR.

Once adequate BP is reached dobutamine, or Milrinone can be added to improve CI and Scvo 2 .

High CI Low or normal Blood Pressure Low SVR Norepinephrine, fluid If shock persists consider Vasopressin

Pediatric Septic Shock Algorithm Brierley, Carcillo et al. Pediatr Crit Care Med 2009

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

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

Summary of Key Points

• • Early goal directed therapy can improve outcomes in septic shock Pediatric septic shock is different from adult septic shock