UC Combined Conference

Adam A. Vukovic, MD
September 10, 2014
University of Cincinnati

The Simulation Sessions

Lets take a minute to review what
we gleaned from each of the
simulation sessions

Corinne Bria Table of ABC

Trouble
A

PATENT

IN TROUBLE

OBSTRUCTED

PPV
B

NORMAL

NORMAL

DISTRESS

FAILURE

compensated

decompensated

DISTRESS

FAILURE
SHOCK

ARREST

ARREST

Sepsis, the Continuum

SEVERE
SEPTIC
SEPSIS
SIRS
SEPSIS SHOCK

SIRS
Generally, a simple definition
We pediatricians, we like to
complicate things
But for all intents and purposes, well
uncomplicate it

Kinda depends

Goldstein et al., Pediatr Crit Care Med, 2005

All those normals

Goldstein et al., Pediatr Crit Care Med, 2005

SIRS, the definition

American College of Chest Physicians
and Society of Critical Care Medicine:
nonspecific inflammatory process occurring in
adults after trauma, infection, burns, pancreatitis
and other diseases

International Consensus Conference

on Pediatric Sepsis:

Bone et al., Crit Care Med, 1992; Goldstein et al., Pediatr Crit Care Med, 2005

Infection
A suspected or proven (by positive culture,
tissue stain, or polymerase chain reaction test)
infection caused by any pathogen OR a clinical
syndrome* associated with a high probability of
infection.
*Evidence of infection includes positive findings on
clinical exam, imaging, or laboratory tests (e.g., white
blood cells in normally sterile body fluid, perforated
viscus, chest radiograph consistent with pneumonia,
petechial or purpuric rash, or purpura fulminans)
Bone et al., Crit Care Med, 1992; Goldstein et al., Pediatr Crit Care Med, 2005

Sepsis
Systemic inflammatory response
triggered by a known or highly
suspected pathogen.
ICCPS:
SIRS in the presence of or as a result of
suspected or proven infection.

Bone et al., Crit Care Med, 1992; Goldstein et al., Pediatr Crit Care Med, 2005

Severe Sepsis
ICCPS:
Sepsis plus one of the following:
cardiovascular organ dysfunction OR
acute respiratory distress syndrome OR
two or more other organ dysfunctions.

Goldstein et al., Pediatr Crit Care Med, 2005

Septic Shock
Hypotension?
ICCPS:
Sepsis in the presence of cardiovascular
dysfunction.
Tachycardia with signs of decreased
perfusion:

Decreased peripheral pulses

Altered alertness
Flash capillary refill OR capillary refill > 2 secs
Mottled/cool extremities
Decreased urine output

Risk Factors
Likely more dependent on host
response to infection rather than a
function of an offending pathogen
Age
Chronic medical conditions
Chronic lung disease
Congenital heart disease
Neuromuscular disease
Hematologic & oncologic disease
Jaramillo-Bustamante, et al., Pediatr Crit Care Med, 2012; Maloney, Emerg Med Clin N
Am, 2013; Watson et al., Am J Respir Crit Care Med, 2003

Pathophysiology
Comparison
Pediatric

Adult
SVR
CO
AKA, warm shock:

Warm
Warm
Well-perfused
Well-perfused
Bounding
Bounding pulses
pulses
Brisk/flash
Brisk/flash CR
CR

SVR
CO
Goal:
Redistribute
Redistribute blood
blood from
from
non-essential
non-essential vascular
vascular
beds
beds to
to vital
vital organs
organs

AKA, cold shock:

Cold,
Cold, pale,
pale, cyanotic
cyanotic
Weak
Weak peripheral
peripheral pulses
pulses
Delayed
Delayed CR
CR
BP
BP maintained
maintained

Mahoney, Emerg Med Clin N Am, 2013

Management of Sepsis and Septic

Shock
First and foremost: EARLY RECOGNITION
Then: RAPID and AGGRESSIVE
RESUSCITATION
Goal: reversal of tissue hypoperfusion
More specifically, improve tissue oxygen delivery

Physiologic end points:

Normal BP
Capillary refill time 2 seconds
Normal pulses without difference between
central/peripheral pulses
UOP 1 mL/kg/hr or greater
Restoration of normal mental status
Brierley, et al., Crit Care Med; 2009; Mahoney, Emerg Med Clin N Am, 2013

Sepsis Guidelines
Early Goal-Directed Therapy effective in
adult literature (Rivers, et al., N Engl J Med, 2001).
Management guidelines developed to
reflect pediatric septic shock (Brierley et al., Crit Care
Med, 2009; El-wiher, et al., Open Inflamm J, 2011) .
PEM providers have demonstrated
improved recognition and reduction in time
to receipt of time-sensitive interventions
and a decrement in treatment variation (Cruz
et al., Pediatrics, 2011).

ICCPS
Algorithm

Brierley, et al. Crit Care

Take-home Points
Sepsis is a continuum
Hypotension is a LATE finding in pediatric
patients presenting in septic shock
Pediatric patients more often present in cold
shock, which suggests low CO with high SVR
Goal of treatment is to improve oxygen
delivery to tissue
Goal-directed therapy has improved
compliance with current sepsis guidelines

References
Brierley, J., Carcillo, J. A., Choong, K., et al. (2009). Clinical practice parameters for hemodynamic
support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care
Medicine. Critical Care Medicine, 37(2), 666-688. doi:10.1097/CCM.0b013e31819323c6
Cruz, A. T., Perry, A. M., Williams, E. A., et al. (2011). Implementation of goal-directed therapy for
children with suspected sepsis in the emergency department. Pediatrics, 127, e758-e766. doi:
10.1542/peds.2010-2895
El-wiher, N., Cornell, T. T., Kissoon, N., & Shanley, T. P. (2011). Management and Treatment Guidelines
for Sepsis in Pediatric Patients. The Open Inflammation Journal, 4(Suppl 1-M11), 101-109. doi:
10.2174/1875041901104010101
Goldstein, B., Giroir, B., Randolph, A., & the Members of the International Consensus Conference on
Pediatric Sepsis. (2005). International pediatric sepsis consensus conference: Definitions for sepsis and
organ dysfunction in pediatrics, Pediatric Critical Care Medicine, 6(1), 2-8. doi:
10.1097/01.PCC.0000149131.72248.E6
Jamarillo-Bustamante, J. C., Marin-Agudelo, A., Fernandez-Laverde, M., et al. (2012). Epidemiology of
sepsis in pediatric intensive care units: First Columbian multicenter study. Pediatric Critical Care
Medicine, 13(5), 501-508.
Maloney, P. J. (2013). Sepsis and septic shock. Emergency Medicine Clinics of North America, 31, 583
600. doi: 10.1016/j.emc.2013.04.0060733-8627/13/$
Rivers, E., Nguyen, B., Havstad, S., et al. (2001). Early goal-directed therapy in the treatment of severe
sepsis and septic shock. New England Journal of Medicine, 345(19), 1368-1377.
Watson, R. S., Carcillo, J. A., Linde-Zwirble, W. T., et al. (2003). The epidemiology of severe sepsis in
children in the United States. American Journal of Respiratory Critical Care Medicine, 167(5), 695-701.
doi: 10.1164/rccm/200207-682OC

Selected High-Yield
References
Brierley, J., Carcillo, J. A., Choong, K., et al. (2009). Clinical practice
parameters for hemodynamic support of pediatric and neonatal septic
shock: 2007 update from the American College of Critical Care
Medicine. Critical Care Medicine, 37(2), 666-688.
doi:10.1097/CCM.0b013e31819323c6
El-wiher, N., Cornell, T. T., Kissoon, N., & Shanley, T. P. (2011).
Management and Treatment Guidelines for Sepsis in Pediatric Patients.
The Open Inflammation Journal, 4(Suppl 1-M11), 101-109. doi:
10.2174/1875041901104010101
Maloney, P. J. (2013). Sepsis and septic shock. Emergency Medicine
Clinics of North America, 31, 583 600. doi:
10.1016/j.emc.2013.04.0060733-8627/13/$
Watson, R. S., Carcillo, J. A., Linde-Zwirble, W. T., et al. (2003). The
epidemiology of severe sepsis in children in the United States. American
Journal of Respiratory Critical Care Medicine, 167(5), 695-701. doi:
10.1164/rccm/200207-682OC