pediatric septic shock picu resident talk stanford school of medicine pediatric critical care...
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Pediatric Septic Shock
PICU Resident TalkStanford School of Medicine
Pediatric Critical Care MedicineJune 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 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 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
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
American College of Critical Care Medicine Hemodynamic Definitions of Shock
Cohen, Nature 2002
Sepsis leads to micro-vascular occlusion, vascular instability, and organ failure through complex interactions between pathogens, immune cells, and the endothelium.
The predominant cause of mortality in adult sepsis is
vasomotor paralysis.
Parker, et al. Crit Care Med. 1987
Pollack et al. Crit Care Med 1984, 1985
Contrary to adults low cardiac output not low SVR is associated with mortality in
septic shock in children.
Maintain and restore airway, oxygenation,
and ventilaton
Therapeutic endpointsMonitoring
Early Intervention in the treatment of septic shock is vital: The first hour in the ED
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/m2
• Scvo2 >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 Scvo2.
High CILow or normalBlood 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?
Endocrine?
Immune?
Pericardial effusionPneumothoraxIncreased abdominalPressure.Necrotic tissue.Ongoing blood loss Hypothyroid
Hypoadrenal
Excessive immunosuppressionUncontrolled infection
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