paediatric infectious-septic-shock
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Paediatric Septic Shock
Abraham Chiu En Loong
6th year 1st semester
Group 1
Kursk State Medical
University
Department of Pediatrics
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1:15am: 3 year old female arrives at Triage with HR 180,
RR 35, looks tired. Has had URTI symptoms for past coupleof days.
1:25am: ICU/Paeds Reg called by ED doctor saying can you
come and have a look
135am:You make your first assessment
HR 180
Quiet, tired, opens eyes
Mod respiratory distress
Cap refill 4 seconds
WHAT DO YOU DO?
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Why are we worried about it?
Still remains significant cause of morbidity and
mortality
5-30% of paediatric patients with sepsis will develop
septic shock.
Mortality rates in septic shock are 20-30% (up to 50% in
some countries).
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Recognition
Most people dont recognise shock
Resuscitation must be done in a proactive time-sensitive
manner
Every minute counts golden hour
Every hour without appropriate resuscitation and
restoration of blood pressure increases mortality risk by
40%
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How do we define it
Systemic Inflammatory Response Syndrome
Infection
Sepsis
Severe Sepsis
Septic Shock
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Systemic Inflammatory Response
Syndrome
Presence of 2 of the following criteria:
Core Temp >38.5 or < 36 degrees
Mean HR > 2SD for age or persitant elevation over 0.5-4hrs
If < 1yr old: bradycardia HR < 10th centile for age
Mean RR > 2 SD above normal for age
Leucocyte abnormality
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SEPSIS
SIRS in presence of suspected or proven infection
Severe Sepsis
Sepsis + one of the following
CV organ dysfunction
ARDS
2 or more organ dysfunction
Septic Shock
Sepsis + CV organ dysfunction
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Cardiovascular dysfunction
Despite >40ml/kg Isotonic fluid bolus in 1 hour:
Decrease in BP 5 seconds
Core-peripheral temp gap >3 degrees
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Risk factors for Sepsis in Children
< 1 year of age
Very low birthweight infants
Prematurity
Presence of underlying illness eg chronic lung, cardiacconditions, malignancy
Co-morbidities
Boys
Genetic factors
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What makes you suspect shock?
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Clinical Manifestations
Fever
Increased HR
Increased RR
Altered mental state
Skin:
Hypoperfusion
Decreased capillary refill
Petechiae, purpura
Cool vs warm.
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Cold Shock Warm Shock
HR Tachycardia Tachycardia
Peripheries Cool Warm
Pulses Difficult to palpate Bounding
Skin Mottled, pale Flushed
Capillary refill Prolonged Blushing
Mental state Altered Altered
Urine Oliguria Oliguria
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Blood Pressure in Children
This is main difference with adults.
Blood pressure does not fall in septic shock until very
late.
CO= HR x SV
HR in children much higher therefore BP falling is late.
Pulse pressure is often useful Normal: Diastolic BP > systolic BP.
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Investigations
Basic bloods:
FBC, EUC, LFT, CMP, Coags, Glucose
Inflammatory markers: PCT, CRP
Acid- Base status
Venous or arterial blood gas:
Lactate
Base deficit
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Investigations
Septic Work up
Urine, blood, sputum cultures
Viral cultures: throat, NPA, faeces, Never do CSF in shocked patient
Imaging:
CXR, CT, MRI, PET scan, ECHO, Ultrasound
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Management
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General Principles
Early Recognition
Early and appropriate antimicrobials
Early and aggressive therapy to restore balancebetween oxygen delivery and demand
Early and goal directed therapy
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What is Goal Directed Therapy?
Based on studies in adults initially
Use fluid resuscitation, vasoactive infusions, oxygen to
aim to restore balance between oxygen delivery and
demand
Goals:
Capillary refill < 2 seconds
Urine ouptut > 1ml/kg/hr
Normal pulses Improved mental state
Decreased lactate and base deficits
Perfusion pressures appropriate for age
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Recognise decreased mental status and perfusion
Maintain airway and establish access
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Responsiveness FluidRefractoryshock
O min
5 min
15 min
Observe in PICU
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Recognise decreased mental status and perfusion
Maintain airway and establish access
Vascular Access:
Only few minutes to be spent on obtaining IV access
Need to use IO if cant get access
May need to put 2 x IO in
Intubation + Ventilation
Clinical assessment of work of breathing , hypoventilation or
impaired mental state
Up to 40% of cardiac output is used for work of breathing
Volume loading and inotrope support is recommended before and
during intubationRecommended: Ketamine, atropine and short acting neuromuscular
blocking agent.
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Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Resuscitation:
Needs to be given as push
May need to give up to 200mls/kg
Give fluid until perfusion improves.
Which Fluids
Isotonic vs collloid
Most evidence extrapolated from adults
Wills et al RCT of cystalloid vs colloid in children with dengue fever
No difference between the two groups.
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Fluid Refractory Shock15min
Begin dopamine or peripheral adrenaline
Establish central venous access
Establish arterial access
Titrate Adrenaline for cold shock and noradrenaline for
warm shock to normal MAP-CVP and SVC sats>70%
Catecholamine resistant shock60 min
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Catecholamine Resistant Shock
At Risk of adrenal insufficency give
hydrocortisone
Not at Risk - dont give
hydrocortisone
Normal Blood Pressure
Cold ShockSVC < 70%
Low Blood Pressure
Cold ShockSVC < 70%
Low Blood
PressureWarm Shock
Add vasodilator or
Type III PDE inhibitor
Titrate volume and
adrenalineTitrate volume &
Noradrenaline
Consider
Vasopressin
ECMO
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Drug Dose Comments
Dopamine 2-20mcg/kg/min Historically 1st choice in kidsAlpha, beta and dopamine receptor
activation
Can be given peripherally
Dobutamine 5-10mcg/kg/min Chronotropic as well as inotropic
Afterload reduction
Adrenaline 0.05- 1mcg/kg/min Initially increases contractility/heart
rate
High doses increase PVR
Noradrenaline 0.05 1
mcg/kg/min
Vasopressor
Increases PVR
Milrinone 0.25-
0.75mcg/kg/min
Phosphodiesterase inhibitor
Afterload reduction
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Rivers et al, NEJM 2001 Single Centre , RCT in Emergency Department
Goal directed vs standard care in septic adults in first 6 hours
in ED
Goal directed therapy consisted of
CVP 8-12mmHg
MAP > 65mmHg
Urine output >0.5ml/kg/hour
ScVO2 > 70%
Showed significant decrease in mortality
Cristisms: control group had higher mortality rate and
benefits may be because group was monitored more closely
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Ceneviva et al, Pediatrics 1998
Single centre, 50 children
Used goal directed therapy : CI 3.3-6Lmin/m2 in
children with fluid refractory shock
Mortality from sepsis decreased by 18% when compared
to 1985 study
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De Oliveira ICM 2008
RCT , single centre
Use of 2002 guidelines with continous central venous O2
saturation monitoring and therapy directed to maintain
ScVO2 > 70%
Mortality decreased from 39% to 12 %,
Number needed to treat 3.6
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Brierley and Carcillo CCM 2009
Update of 2002 guidelines for goal directed therapy
Look at all studies who had adopted 2002 guidelines and
their success.
Reported studies that showed decrease in mortality with
adoption of 2002 guidelines.
New changes :
Inotrope via peripheral access Fluid removal considered early
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What about Hydrocortisone?
Controversial
Rational is that there is hypothalamic-pituitary adrenal
axis dyfunction in patients with septic shock
Current recommendations:
If child is at risk of adrenal insufficency and remains in
shock should receive hydrocortisone
At risk defined as purpura fulminans, congenital adrenal
hyperplasia, recent steroid exposure,hypothalamic/pituitary abnormality
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Evidence Controversial
Annane D JAMA 2002
Multicentre , RCT looked at use of hydrocortisone and
fludrocortisone in septic shock.
Corticus Trial, NEJM 2008
Mutlicentre, RCT
Hydrocortisone vs placebo in septic shock
No significant difference in mortality
Many criticisms Inadequate power
Selection bias
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Evidence- paediatrics
No RCT in paediatric patients with sepsis
Markovitz : PCCM 2005
Retrospective cohort study , 6000 paediatric patients
Systemic steriods associated with increased mortality
But no control in place for severity of illness or for dose.
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Other treatment
Maintain Glucose control
Nutrition
Maintain Hb > 10g/dL
GI protection
Early CVVH
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Activated Protein C
Inhibits factors Va and VIIIa prevent generation of
thrombin
Decreased inflammation through inhibition of platelet
activation, neutrophil recruitment
Initially had popularity as possible treatment option in
septic shock
Concern with it is risk of serious haemorrhage
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RESOLVE Study, Lancet 2007
RCT, multicentre, international study in 477 children
with severe sepsis.
Compared APC to placebo for 96 hrs
Primary end point: time to complete organ failure
resolution
Study stopped early as interim analysis showed no
benefit
More bleeding in APC group but not significantly
different
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ECMO
Study published this month from RCH Melbourne
Looked at ECMO use in paediatric septic shock
96% had at least 3 organ failure and 35% had a cardiac arrest
prior to ECMO
23 patients with refractory septic shock received central
ECMO
17 (74%) patients survived to be discharged from hospital.
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