debate on aggressive vs restricted fluid resuscitation in childhood sepsis

Give fluids!

Dr David Inwald

Consultant in PICU

St Mary’s Hospital and CATS

Two pathophysiological reasons to give fluids in septic shock

• Fluid is in the wrong place

• The pump is not working

Increased capillary permeability

Sepsis

Warm shockHigh CO

vasodilation

Cold shockLow CO

vasoconstriction

Dysregulation of vascular tone

Depression of myocardial contractility

Shock

• A clinical syndrome of inadequate tissue perfusion

• DO2 < VO2

Increasing DO2

Therapeutic implications

GIVE FLUIDS

Frank-Starling curve

fluids

inotropes

How much fluid?

Brierley J et al, Crit Care Med 2009; 37:666–688

Up to and over 60 ml/kg by

15 minutes

Early reversal of shockEarly reversal of shockEvery hour without resuscitation and Every hour without resuscitation and

restoration of CRT < 2 s and normal BP restoration of CRT < 2 s and normal BP increases mortality by 40%!increases mortality by 40%!

Han YY et al Pediatrics. 2003;112:793-9

1 Hour 2 Hours 3 hours

10987654321

Fluid resuscitation of hypovolemic shock: acute medicine's great triumph for

children

Carcillo JA and Tasker RC, ICM 2006;32:958-61

Time (h)

Mor

talit

y

FEAST management

• C - Circulation

Developed world management

• A - Airway

• B - Breathing

• C - Circulation…

Other therapies?• Haemofiltration• ECMO• Modulators of coagulation

• rh-APC• Protein C• Protein S• AT III• r-tPA

• Anti-endotoxin strategies• Polymixin• Anti-endotoxin antibodies (HA-1A)• rBPI21

• Prostacyclin

Therapeutic implications

GIVE FLUIDS

GIVE FLUIDS