septic shock.pdf

Pediatric Special Article Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine* Joe Brierley, MD; Joseph A. Carcillo, MD; Karen Choong, MD; Tim Cornell, MD; Allan DeCaen, MD; And rea s Dey mann, MD; All an Doc tor , MD; Ala n Dav is, MD; Joh n Duf f, MD; Mar c-An dre Dugas , MD; Ala n Duncan, MD; Bar ry Evans, MD; Jonathan Fel dma n, MD; Kath ryn Felmet, MD; Gen e Fisher, MD; Lorry Frankel, MD; Howard Jeffries, MD; Bruce Greenwald, MD; Juan Gutierrez, MD; Mark Hall, MD; Yong Y. Han, MD; James Hanson, MD; Jan Hazelzet, MD; Lynn Hernan, MD; Jane Kiff, MD; Niranjan Kissoon, MD; Alexander Kon, MD; Jose Irazusta, MD; John Lin, MD; Angie Lorts, MD; Michelle Mariscalco, MD; Renuka Mehta, MD; Simon Nadel, MD; Trung Nguyen, MD; Carol Nicholson, MD; Mark Peters, MD; Regina Okhuysen-Cawley, MD; Tom Poulton, MD; Monica Relves, MD; Agustin Rodriguez, MD; Ranna Rozenfeld, MD; Eduardo Schnitzler, MD; Tom Shanley, MD; Sara Skache, MD; Peter Skippen, MD; Ada lberto Tor res , MD; Bet tina von Dessau er, MD; Jac ki Wei nga rte n, MD; Timoth y Yeh , MD; Arno Zar its ky, MD; Bonnie Stojadinovic, MD; Jerry Zimmerman, MD; Aaron Zuckerberg, MD *See also p. 785. The American College of Criti cal Care Medi cine (ACCM), which honors individuals for their achieve - ment s and cont ribut ions to multidisciplin ary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM) that possesses rec- ognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care prac- titioner. New guidelines and practice parameters are continually developed, and current ones are system- atically reviewed and revised. Dr. Brierley received meeting travel expenses from USCOM Ltd. Dr. Nadel has consulted, received hono- raria, and study funding from Eli Lilly. Dr. Shanley has received a research grant from the National Institutes of Health. The remaining authors have not disclosed any potential conflicts of interest. For info rmat ion rega rding this arti cle , E-ma il: [email protected] Copyright © 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0 b013e31819323c6 Background: The Insti tut e of Medicine cal ls for the use of cli nic al gui del ine s and pra ctice para meters to pro mote “be st practices” and to improve patient outcomes. Objective: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelin es for Hemod ynami c Suppo rt of Neonates and Children with Septic Shock . Participants: Society of Critical Care Medicine members with spe cia l int eres t in neonatal and pediatric sep tic sho ck wer e identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001–2006). Methods: The Pubmed/MEDLINE literatur e datab ase (1966– 200 6) was searched usi ng the key wor ds and phr ase s: sepsis , septicemia, septic shock, endotoxemia, persistent pulmonary hy- perte nsion , nitri c oxide , extracorporeal membr ane oxyge natio n (ECMO), and American College of Critical Care Medicine guideline s. Best practice centers that report ed best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. Results: The 2002 guidelines were widely disseminated, trans- lated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Cen- ters that imp leme nted the 2002 guid elin es reported best practice outcomes (hospital mortality 1%–3% in previously healthy, and 7%– 10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emer- genc y depa rtme nt (nu mber need ed to trea t 3.3 ) and tert iary pediatric intensi ve care setting (number needed to treat 3.6); every hour that went by without guideline adherence was associated with a 1.4- fold increas ed mort alit y risk. The upda ted 2007 guidelines continue to recog nize an increased like liho od that children wit h septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydro- cortisone for absolute adrenal insufficiency, and 4) ECMO for refrac- tory shock. The major new recommendation in the 2007 update is ear li er us e of in otrope su pport thr oug h per ip heral acc es s unt il cen tra l access is attained. Conclusion: The 2007 update continues to emphasize early use of age-specific ther apies to atta in time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill <2 secs, and 2) subsequent intensive care unit he- mody nami c supp ort dire cted to goal s of cent ral veno us oxyg en saturation >70% and car di ac ind ex 3.3 –6.0 L/min /m 2 . (C ri t Ca re Me d 2009; 37:666–688) K EY WORDS: guidelines; sepsis; severe sepsis 666 Crit Care Med 2009 Vol. 37, No. 2

septic shock.pdf

Documents

Transcript of septic shock.pdf