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Pediatric Septic Shock

Pediatric Septic Shock. PICU Resident Talk Stanford School of Medicine Pediatric Critical Care Medicine (Updated June 2014). Learning Objectives. 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 (Updated June 2014)

  2. 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

  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. >38.5 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. 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. SIRS PRO-inflammatory response IL-1 TNF-alpha ANTI-inflammatory response IL-10

  7. CARS PRO-inflammatory response IL-1 TNF-alpha ANTI-inflammatory response IL-10

  8. Immunologic Dissonance PRO-inflammatory response IL-1 TNF-alpha ANTI-inflammatory response IL-10

  9. What is our goal?

  10. Deliver oxygen to end organs! DO2 = [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

  11. 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

  12. [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q • Give oxygen • NC • Non rebreather • HFNC • CPAP

  13. [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

  14. [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q • Inotropes/vasopressors/vasodilators

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

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

  17. [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

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

  19. 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

  20. 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

  21. 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

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

  23. 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?)

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