SEVERE SEPSIS&SEPTIC SHOCK IN PEDIATRICS.

Abdel Razzaq Abu Mayaleh, MD

PRCS _ New Hospital - Hebron

Based partially on www.picucourse.org

INTRODUCTION

SEPSIS:- its an infection plus systemic manifestation of

infection.

SEVERE SEPSIS :- Sepsis plus sepsis-induced organ dysfunction or tissue hypo perfusion.

. .

SEPTIC SHOCK:- sepsis-induced hypotension persisting despite adequate fluid resuscitation and elevated lactate. HYPOTENTION:- S.BP < 70 + 2 wt. (80 + 2 wt)

SHOCK:-

DO2 < VO2

A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. Crit Care Med 2004; 320(Suppl):S595S597

Septic Shock Epidemiology

During the last 2 decades the incidence of sepsis & septic shock has increased across all age groups. This is thought to be due to:
use of invasive procedures use of immunosuppressive drugs microbacterial ressistance Child mortality improved dramatically from 97% 9% due to the advance in critical care technology.

Septic Shock: Warm Shock

Early, compensated, hyperdynamic state Clinical signs

Warm extremities with bounding pulses, tachycardia, tachypnea, confusion. widened pulse pressure, increased cardiac ouptut and mixed venous saturation, decreased systemic vascular resistance. Hypocarbia, elevated lactate, hyperglycemia

Physiologic parameters

Biochemical evidence:

Septic Shock: Cold Shock

Late, uncompensated stage with drop in cardiac output. Clinical signs

Cyanosis, cold and clammy skin, rapid, thready pulses, shallow respirations. Decreased mixed venous sats, cardiac output and CVP, increased SVR, thrombocytopenia, oliguria, myocardial dysfunction, capillary leak Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.

Physiologic parameters

Biochemical abnormalities

MANAGEMENT-GENERAL
Goal: increase oxygen delivery and decrease oxygen demand: VO2 (O2 Extraction) Oxygen Fluid Temperature control Antibiotics septic Correct metabolic abnormalities . Spare WOB . ? Inotropes normal DO2 = C.O. x CaO2 Hg X SatO2 X 1.34

.
DO2

Fluid Resuscitation
Aggressive fluid resuscitation with boluses of 20 ml/kg over 5-10 min Blood pressure by itself is not a reliable endpoint for resuscitation Initial resuscitation usually requires 40-60 ml/kg, but more may be required

Therapeutic Endpoints

Capillary refill < 2 sec Warm extremities Urine output > 1 ml/kg/hr Normal mental status Decreased lactate Central venous O2 saturation > 70%

Hemodynamic Support

Hemodynamic profile may be variable Dopamine for hypotension Epinephrine or norepinephrine for dopaminerefractory shock Dobutamine for low cardiac output state Inhaled NO useful in neonates with post-partum pulmonary hypertension and sepsis

Other Therapies

Steroids: recommended for children with catecholamine resistance and suspected or proven adrenal insufficiency. Activated protein C not studied adequately in children yet. GM-CSF shown to be of benefit in neonates with sepsis and neutropenia. Extracorporeal membrane oxygenation (ECMO) may be considered in children with refractory shock or respiratory failure.

2005

Shock

ABC

FLUID BOLUS-20-60cc/kg
Dopamine/ dobutamine Cold shock Warm shock

EPI

NE

steroids
Milrinone

0 min
5 min

Recognize decreased mental status and perfusion. Maintain airway and establish access according to PALS guidelines.
Push 20 cc/kg isotonic saline or colloid boluses up and over 60 cc/kg. Correct hypoglycemia and hypocalcaemia. Administer antibiotics.

15 min

Fluid refractory shock * *

Fluid responsive * Establish central Venous access, begin dopamine or dobutamine therapy and establish arterial monitoring .

Fluid refractory dopamine/ dobutamine resistant shock

Observe in PICU

Titrate epinephrine for cold shock, norepinephrine for warm shock to normal clinical endpoints and ScvO2 saturation 70% .

Catecholamine-resistant shock
60 min

Begin hydrocortisone if at risk for absolute adrenal insufficiency

Normal Blood Pressure Cold Shock ScvO2 Sat <70%

Low Blood Pressure Cold Shock ScvO2 Sat < 70% Titrate volume and epinephrine

Low Blood pressure Warm Shock ScvO2 Sat 70% Titrate volume and norepinephrine

Add Vasodilator or type III phosphodiesgerase inhibitor with volume loading

Persistent Catecholamine- resistant shock

Start Cardiac output measurement and direct fluid, inotrope, vasopressor, vasodilator, and hormonal therapies to attain CL>3.3 and <6.0 L/min/m
Refractory shock

Consider ECMO

VENTILATOR MANAGEMENT

Assist control mode-volume ventilation Reduce tidal volume to 6ml/kg predicted body wt. Keep Pplat <30cm H2O Maintain SaO2 / pO2 88-95% Anticipated PEEP setting at various FiO2 requirements FiO2 0.3 0.4 0.5 0.5 0.6 0.7 0.8 0.9 1.0 PEEP 5 5 8 10 12 14 16 18 20

Sedation and Analgesia in Sepsis

Sedation protocol for mechanically ventilated patients with standardized subjective sedation scale target.
Intermittent bolus Continuous infusion with daily awakening/retitration Grade B

Kollef, et al. Chest 1998; 114:541-548 Brook, et al. CCM 1999; 27:2609-2615 Kress, et al. NEJM 2000; 342:1471-1477

Neuromuscular Blockers

Avoid if possible Used longer than 2-3 hrs

PRN bolus Continuous infusion with twitch monitor

Grade E

The Role of Intensive Insulin Therapy in the Critically Ill

100

In-hospital survival (%)

96

Intensive treatment
92
P=0.01 88 84 80 0

At

12 months, intensive insulin therapy reduced mortality by 3.4% (P<0.04)

Conventional treatment

50 100 150 200 250

Days after admission

Adapted from Figure 1B, page 1363, with permission from van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-67

Glucose Control

After initial stabilization

Glucose < 150 mg/dL Continuous infusion insulin and glucose or feeding (enteral preferred) Monitoring
Initially q3060 mins After stabilization q4h Grade D

Bicarbonate Therapy
Bicarbonate therapy not recommended to improve hemodynamics in patients with lactate induced pH >7.15
Grade C
Cooper, et al. Ann Intern Med 1990; 112:492-498 Mathieu, et al. CCM 1991; 19:1352-1356

Primary Stress Ulcer Risk Factors Frequently Present in Severe Sepsis

Mechanical ventilation Coagulopathy Hypotension

Choice of Agents for Stress Ulcer Prophylaxis

H2 receptor blockers Role of proton pump inhibitors

Grade C
Cook DJ, et al. Am J Med 1991; 91:519-527

Blood Product Administration Red Blood Cells

Tissue hypoperfusion resolved No extenuating circumstances

Coronary artery disease Acute hemorrhage Lactic acidosis

Transfuse < 7.0 g/dl to maintain 7.0-9.0 g/dL

Grade B

Blood Product Administration

Do not use erythropoietin to treat sepsisrelated anemia. Erythropoietin may be used for other accepted reasons.

Grade B

Blood Product Administration

Fresh frozen plasma Bleeding Planned invasive procedures.
Grade E

Blood Product Administration

Do not use antithrombin therapy.

Grade B

Warren et al. JAMA 2001; 1869-1878

Blood Product Administration

Platelet administration

Transfuse for < 5000/mm3 Transfuse for 5000/mm3 30,000/mm3 with significant bleeding risk Transfuse < 50,000/mm3 for invasive procedures or bleeding

Grade E