Paediatric Septic Shock
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Transcript of Paediatric Septic Shock
Paediatric Septic ShockCorrine Balit
1:15am: 3 year old female arrives at Triage with HR 180, RR 35, looks tired. Has had URTI symptoms for past couple of days. 1:25am: ICU/Paeds Reg called by ED doctor saying can you come and have a look135am:You make your first assessment
HR 180Quiet, tired, opens eyesMod respiratory distress Cap refill 4 seconds
WHAT DO YOU DO?
Why are we worried about it?Still remains significant cause of morbidity and
mortality5-30% of paediatric patients with sepsis will
develop septic shock. Mortality rates in septic shock are 20-30% (up to
50% in some countries).
RecognitionMost people don’t recognise shockResuscitation must be done in a proactive time-
sensitive mannerEvery minute counts – “golden hour”Every hour without appropriate resuscitation and
restoration of blood pressure increases mortality risk by 40%
How do we define itSystemic Inflammatory Response SyndromeInfectionSepsisSevere SepsisSeptic Shock
Systemic Inflammatory Response Syndrome
Presence of 2 of the following criteria:Core Temp >38.5 or < 36 degreesMean HR > 2SD for age or persitant elevation over 0.5-4hrsIf < 1yr old: bradycardia HR < 10th centile for ageMean RR > 2 SD above normal for ageLeucocyte abnormality
SEPSISSIRS in presence of suspected or proven infection
Severe SepsisSepsis + one of the following
CV organ dysfunctionARDS2 or more organ dysfunction
Septic ShockSepsis + CV organ dysfunction
Cardiovascular dysfunctionDespite >40ml/kg Isotonic fluid bolus in 1 hour:
Decrease in BP <5th centile for ageNeed for vasoactive drug to maintain BP2 of the following:
Unexplained metabolic acidosis Increase lactate Oliguria Prolonged cap refill > 5 seconds Core-peripheral temp gap >3 degrees
Risk factors for Sepsis in Children< 1 year of ageVery low birthweight infantsPrematurity Presence of underlying illness eg chronic lung,
cardiac conditions, malignancyCo-morbiditiesBoysGenetic factors
What makes you suspect shock?
Clinical ManifestationsFeverIncreased HRIncreased RRAltered mental stateSkin:
HypoperfusionDecreased capillary refillPetechiae, purpuraCool vs warm.
Cold Shock Warm Shock
HR Tachycardia Tachycardia
Peripheries Cool Warm
Pulses Difficult to palpate Bounding
Skin Mottled, pale Flushed
Capillary refill Prolonged Blushing
Mental state Altered Altered
Urine Oliguria Oliguria
Blood Pressure in ChildrenThis is main difference with adults. Blood pressure does not fall in septic shock until
very late. CO= HR x SVHR in children much higher therefore BP falling is
late.Pulse pressure is often useful
Normal: Diastolic BP > ½ systolic BP.
InvestigationsBasic bloods:
FBC, EUC, LFT, CMP, Coags, GlucoseInflammatory markers: PCT, CRPAcid- Base status
Venous or arterial blood gas:LactateBase deficit
InvestigationsSeptic Work up
Urine, blood, sputum culturesViral cultures: throat, NPA, faeces, Never do CSF in shocked patient
Imaging: CXR, CT, MRI, PET scan, ECHO,
Ultrasound
Management
General PrinciplesEarly RecognitionEarly and appropriate antimicrobialsEarly and aggressive therapy to restore balance
between oxygen delivery and demandEarly and goal directed therapy
What is Goal Directed Therapy?Based on studies in adults initiallyUse fluid resuscitation, vasoactive infusions,
oxygen to aim to restore balance between oxygen delivery and demand
Goals:Capillary refill < 2 secondsUrine ouptut > 1ml/kg/hrNormal pulses Improved mental stateDecreased lactate and base deficitsPerfusion pressures appropriate for age
Recognise decreased mental status and perfusionMaintain airway and establish access
Push 20mls/kg isotonic saline or colloid boluses up to and over 60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Responsiveness
Fluid Refractory shock
O min
5 min
15 min
Observe in PICU
Recognise decreased mental status and perfusionMaintain airway and establish access
Vascular Access:•Only few minutes to be spent on obtaining IV access•Need to use IO if cant get access•May need to put 2 x IO in
Intubation + Ventilation•Clinical assessment of work of breathing , hypoventilation or impaired mental state•Up to 40% of cardiac output is used for work of breathing•Volume loading and inotrope support is recommended before and during intubation•Recommended: Ketamine, atropine and short acting neuromuscular blocking agent.
Push 20mls/kg isotonic saline or colloid boluses up to and over 60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Resuscitation:•Needs to be given as push•May need to give up to 200mls/kg •Give fluid until perfusion improves.
Which Fluids•Isotonic vs collloid•Most evidence extrapolated from adults •Wills et al
• RCT of cystalloid vs colloid in children with dengue fever • No difference between the two groups.
Fluid Refractory Shock15min
Begin dopamine or peripheral adrenalineEstablish central venous access
Establish arterial access
Titrate Adrenaline for cold shock and noradrenaline for warm shock to normal MAP-CVP and SVC
sats>70%
Catecholamine resistant shock 60 min
Catecholamine Resistant Shock
At Risk of adrenal insufficency – give hydrocortisone
Not at Risk - don’t give hydrocortisone
Normal Blood PressureCold ShockSVC < 70%
Low Blood PressureCold ShockSVC < 70%
Low Blood PressureWarm Shock
Add vasodilator or Type III PDE inhibitor
Titrate volume and adrenaline
Titrate volume & NoradrenalineConsider Vasopressin
ECMO
Drug Dose CommentsDopamine 2-20mcg/kg/min Historically 1st choice in kids
Alpha, beta and dopamine receptor activationCan be given peripherally
Dobutamine
5-10mcg/kg/min Chronotropic as well as inotropicAfterload reduction
Adrenaline 0.05- 1mcg/kg/min
Initially increases contractility/heart rateHigh doses increase PVR
Noradrenaline
0.05 – 1 mcg/kg/min
VasopressorIncreases PVR
Milrinone 0.25-0.75mcg/kg/min
Phosphodiesterase inhibitorAfterload reduction
Rivers et al, NEJM 2001Single Centre , RCT in Emergency DepartmentGoal directed vs standard care in septic adults in first 6
hours in EDGoal directed therapy consisted of
CVP 8-12mmHg MAP > 65mmHg Urine output >0.5ml/kg/hour ScVO2 > 70%
Showed significant decrease in mortalityCristisms: control group had higher mortality rate and
benefits may be because group was monitored more closely
Ceneviva et al, Pediatrics 1998Single centre, 50 childrenUsed goal directed therapy : CI 3.3-6Lmin/m2 in
children with fluid refractory shockMortality from sepsis decreased by 18% when
compared to 1985 study
De Oliveira ICM 2008RCT , single centreUse of 2002 guidelines with continous central
venous O2 saturation monitoring and therapy directed to maintain ScVO2 > 70%
Mortality decreased from 39% to 12 %, Number needed to treat 3.6
Brierley and Carcillo CCM 2009Update of 2002 guidelines for goal directed
therapyLook at all studies who had adopted 2002
guidelines and their success. Reported studies that showed decrease in
mortality with adoption of 2002 guidelines. New changes :
Inotrope via peripheral accessFluid removal considered early
What about Hydrocortisone?ControversialRational is that there is hypothalamic-pituitary
adrenal axis dyfunction in patients with septic shock
Current recommendations: If child is at risk of adrenal insufficency and remains
in shock should receive hydrocortisoneAt risk defined as purpura fulminans, congenital
adrenal hyperplasia, recent steroid exposure, hypothalamic/pituitary abnormality
Evidence – Controversial Annane D JAMA 2002
Multicentre , RCT looked at use of hydrocortisone and fludrocortisone in septic shock.
Corticus Trial, NEJM 2008Mutlicentre, RCTHydrocortisone vs placebo in septic shockNo significant difference in mortality Many criticisms
Inadequate power Selection bias
Evidence- paediatricsNo RCT in paediatric patients with sepsis Markovitz : PCCM 2005
Retrospective cohort study , 6000 paediatric patientsSystemic steriods associated with increased
mortalityBut no control in place for severity of illness or for
dose.
Other treatmentMaintain Glucose controlNutritionMaintain Hb > 10g/dLGI protectionEarly CVVH
Activated Protein CInhibits factors Va and VIIIa – prevent generation
of thrombinDecreased inflammation through inhibition of
platelet activation, neutrophil recruitmentInitially had popularity as possible treatment
option in septic shockConcern with it is risk of serious haemorrhage
RESOLVE Study, Lancet 2007RCT, multicentre, international study in 477
children with severe sepsis. Compared APC to placebo for 96 hrsPrimary end point: time to complete organ failure
resolutionStudy stopped early as interim analysis showed no
benefit More bleeding in APC group but not significantly
different
ECMOStudy published this month from RCH MelbourneLooked at ECMO use in paediatric septic shock96% had at least 3 organ failure and 35% had a
cardiac arrest prior to ECMO23 patients with refractory septic shock received
central ECMO17 (74%) patients survived to be discharged from
hospital.