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