maria lyn quintos-alagheband, md associate director ... · associate director pediatric critical...
TRANSCRIPT
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Maria Lyn Quintos-Alagheband, MDAssociate Director Pediatric Critical Care
The Children’s Medical Center at Winthrop University
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ObjectivesDiscuss pathogenesis of sepsis
Discuss pathogenesis of sepsis induced AKI
Explore potential strategies to limit renal damage in severe sepsis and septic shock
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Septic Shock
Hypovolemic
Distributive
Cardiogenic
Cytotoxic
sometimes Obstructive
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Pediatric Septic ShockAssociated with severe Hypovolemia – usually children respond well to volume
Contrary to adult usually low CO, not low SVR is associated w/ mortality
Children with fluid refractory shock have diverse hemodynamic profile (lowCO/highSVR; lowCO/lowSVR)
Shock is a dynamic process
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Acute Renal Failure in Sepsis19% in patients with moderate sepsis23% with severe Sepsis51% with septic ShockAcute Renal failure + Sepsis = 70% mortalityAcute Renal Failure not related to Sepsis = 45.2%
Can We Help It?
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Pathogenesis of Sepsis Related AKI
Ronco C et al. CJASN 2008:3
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Improve Renal HemodynamicsGoal: Maintain Renal Blood Flow
Primary threats are reduced cardiac output and renal perfusion pressure
Rivers, NEJM – MODS, SAPS II and APACHE II scores significantly lower with Early goal directed therapy in patients with severe sepsis (p<0.001)
Surviving Sepsis Campaign guidelines
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Fluid ResuscitationRestore effective circulating blood volume
NQF bundle for Septic Shock – fluid resuscitation > 30cc /kgFluid resuscitation >40 ml/kg in the 1st hour conferred survival advantage to children with septic shock
Saline versus Albumin (SAFE study) Finfer S. et al NEJM 350, 2004
What is the end‐point ? CVP 8‐12, MAP >65, Urine output > 0.5 cc/kg/hr Cardiac output or pulse‐pressure variationFluid resuscitation should stop when patient no longer fluid responsive
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Maintaining Renal Perfusion PressureNorepinephrine – improve MAPProspective observational trial 97 pts with septic shock NE confers survival advantage Martin C et al. CritCareMed 28,2000
Augments UO and GFR Schetz M. Blood Purif 2002.
Randomized trial 32 pts. with septic shock NE higher BP, SVR and diuresis than dopamine Martin C etal. Chest 103,1993
Arginine Vasopressin improve UO and creatinine clearance in septic shock pts. refractory to NE
Patel et al. Anesthesiology 96, 2002.
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Lung Protective Strategy
Low‐tidal‐volume ventilation
Animal model of ARDS injurious ventilator strategy led to increase epithelial cell apoptosis in the kidneys with evidence of renal dysfunction
Fas ligand as possible mediator of organ cross‐talk
Improved lung function and oxygenation beneficial to kidneys and other organs
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Metabolic ControlTight glycemic control with aggressive insulin therapy
Surgical ICU patients with septic focus dramatic reduction in ARF requiring RRT Reduction in risk of AKI (RIFLE) in medical ICU pts.
Hyperglycemia induces oxidative stress‐mediated apoptosis in tubular epithelial cellsInsulin anti‐inflammatory and anti‐apoptotic effect
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Experimental AgentsAnti‐Tumor Necrosis Factor αPlatelet‐activating factor inhibitorNitric Oxide Synthase inhibitionEndothelin antagonismInhibitors of arachidonic acid metabolismExogenous Atrial Natriuretic peptideInhibition of Leukocyte adhesionInhibitors of Coagulation
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Renal Replacement Therapy
CRRT versus IHDTiming ? Technique ?? Dose???
Extracorporeal Inflammatory Mediator Removal
Homeostasis
SIRS
CARS
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Renal Repair80% of survivors of severe AKI will recover renal functionNGALGrowth factors – IGF, VEGF, hepatocyte growth factorBone morphogenic protein‐7 (BMP‐7)Erythropoietin
Best strategy is to Keep Patient Alive
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