debate on aggressive vs restricted fluid resuscitation in childhood sepsis
DESCRIPTION
Dr David Inwald's presentation at Meningitis Research Foundation's 2013 conference, Meningitis and Septicaemia in Children and AdultsTRANSCRIPT
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