Pediatric Septic Shock

PICU Resident TalkStanford School of Medicine

Pediatric Critical Care Medicine(Updated June 2014)

Learning Objectives

• 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 ShockSystemic inflammatory response syndrome (SIRS)- The presence of at least two of the following one of which must be abnormal temperature or leukocyte count.

- Temperature. >38.5 or <36.- Tachycardia (or bradycardia for children <1yo)- Tachypnea - Leukocyte count increased or decreased or > 10% bands.

Sepsis- SIRS in the presence of suspected or proven infection.

Severe sepsis- Sepsis plus end organ dysfunction (cardiovascular organ dysfunction OR ARDS OR 2 or more other organ dysfunction)

Septic shock- Sepsis plus 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.

SIRS

PRO-inflammatory response

IL-1 TNF-alpha

ANTI-inflammatory

response

IL-10

CARS

PRO-inflammatory

response

IL-1 TNF-alpha

ANTI-inflammatory

response

IL-10

Immunologic Dissonance

PRO-inflammatory response

IL-1 TNF-alpha

ANTI-inflammatory

response

IL-10

What is our goal?

Deliver oxygen to end organs!

DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

Therapeutic Endpoints• capillary refill of < 2 s• normal blood pressure for age• normal pulses with no differential between

peripheral and central pulses• warm extremities• urine output ≥1 mL/kg/hr• normal mental status• ScvO2 saturation ≥70% • cardiac index between 3.3 and 6.0 L/min/m2 should

be targeted

[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

• Give oxygen–NC–Non rebreather–HFNC–CPAP

[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

• Volume– isotonic crystalloids or albumin boluses of up to 20

mL/kg over 5–10 minutes without inducing hepatomegaly or rales.

– If hepatomegaly or rales exist then inotropic support should be implemented, not fluid resuscitation

Surviving Sepsis Campaign 2012

[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

• Inotropes/vasopressors/vasodilators

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.

Pediatric Septic Shock Algorithm

Brierley, Carcillo et al. Pediatr Crit Care Med 2009

Pediatric Septic Shock Algorithm

Brierley, Carcillo et al. Pediatr Crit Care Med 2009

[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

• Transfuse– During resuscitation of low superior vena cava

oxygen saturation shock (≤ 70 %), hemoglobin levels of 10 g/dL are targeted

– After stabilization and recovery from shock and hypoxemia then a lower target ≥ 7.0 g/dL can be considered reasonable

Surviving Sepsis Campaign 2012

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

But is it??

• ProCESS group, NEJM, 2014– Randomized control, multi institutional study– ~1300 adult patients– No difference in protocolized early goal directed

therapy (EGDT), protocolized standard therapy and usual care at 60 or 90 day mortality

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

Take Home Points

• Septic shock is due to an imbalance in pro and anti inflammatory response

• Therapeutic goal is to deliver enough oxygen to end organs

• Early goal directed therapy improves survival (maybe?)