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Pediatric Septic Shock

Pediatric Septic Shock. PICU Resident Talk Stanford School of Medicine Pediatric Critical Care Medicine June 2010. Learning Objectives. After this lesson, the participant will be able to: Distinguish the terms SIRS, sepsis & septic shock.

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Pediatric Septic Shock

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  1. Pediatric Septic Shock PICU Resident Talk Stanford School of Medicine Pediatric Critical Care Medicine June 2010

  2. 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

  3. 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. PediatrCrit Care Med 2005

  4. American College of Critical Care Medicine Hemodynamic Definitions of Shock Brierley, Carcillo et al. PediatrCrit Care Med 2009

  5. Sepsis leads to micro-vascular occlusion, vascular instability, and organ failure through complex interactions between pathogens, immune cells, and the endothelium. Cohen, Nature 2002

  6. The predominant cause of mortality in adult sepsis is vasomotor paralysis. Parker, et al. Crit Care Med. 1987

  7. Contrary to adults low cardiac output not low SVR is associated with mortality in septic shock in children. Pollack et al. Crit Care Med 1984, 1985

  8. Early Intervention in the treatment of septic shock is vital: The first hour in the ED

  9. Therapeutic Endpoints

  10. Hemodynamic Support

  11. Consider CI, BP, and SVR when implementing CV support.

  12. Pediatric Septic Shock Algorithm Brierley, Carcillo et al. Pediatr Crit Care Med 2009

  13. Refractory Shock?? Immune? Mechanical Problem? Excessive immunosuppression Uncontrolled infection Pericardial effusion Pneumothorax Increased abdominal Pressure. Necrotic tissue. Ongoing blood loss ? ? Endocrine? ? ? Hypothyroid Hypoadrenal

  14. 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

  15. 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

  16. Goal directed therapy causes a significant reduction in 28 day mortality in children with septic shock Oliveira et al. Intensive care med 2008

  17. Summary of Key Points • Early goal directed therapy can improve outcomes in septic shock • Pediatric septic shock is different from adult septic shock

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