pediatric septic shock picu resident talk stanford school of medicine pediatric critical care...
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Pediatric Septic Shock
PICU Resident TalkStanford School of Medicine
Pediatric Critical Care Medicine(Updated June 2014)
Learning Objectives
• Distinguish the terms SIRS, sepsis & septic shock
• List physiologic changes that occur in sepsis and explain how each factor affects O2 demand/ delivery
• Understand the rationale for goal directed therapy in septic shock
Septic ShockSystemic inflammatory response syndrome (SIRS)- The presence of at least two of the following one of which must be abnormal temperature or leukocyte count.
- Temperature. >38.5 or <36.- Tachycardia (or bradycardia for children <1yo)- Tachypnea - Leukocyte count increased or decreased or > 10% bands.
Sepsis- SIRS in the presence of suspected or proven infection.
Severe sepsis- Sepsis plus end organ dysfunction (cardiovascular organ dysfunction OR ARDS OR 2 or more other organ dysfunction)
Septic shock- Sepsis plus cardiovascular organ dysfunction.
Goldstein et al. Pediatr Crit Care Med 2005
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
American College of Critical Care Medicine Hemodynamic Definitions of Shock
Cohen, Nature 2002
Sepsis leads to micro-vascular occlusion, vascular instability, and organ failure through complex interactions between pathogens, immune cells, and the endothelium.
Therapeutic Endpoints• capillary refill of < 2 s• normal blood pressure for age• normal pulses with no differential between
peripheral and central pulses• warm extremities• urine output ≥1 mL/kg/hr• normal mental status• ScvO2 saturation ≥70% • cardiac index between 3.3 and 6.0 L/min/m2 should
be targeted
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Volume– isotonic crystalloids or albumin boluses of up to 20
mL/kg over 5–10 minutes without inducing hepatomegaly or rales.
– If hepatomegaly or rales exist then inotropic support should be implemented, not fluid resuscitation
Surviving Sepsis Campaign 2012
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Inotropes/vasopressors/vasodilators
In the fluid refractory
patient begin a peripheral
inotrope while establishing
central access.
If dopamine refractory start epinephrine in
cold shock.
If dopamine refractory start norepinephrine in warm shock.
Goal is normal perfusion and
blood pressure.
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
• Transfuse– During resuscitation of low superior vena cava
oxygen saturation shock (≤ 70 %), hemoglobin levels of 10 g/dL are targeted
– After stabilization and recovery from shock and hypoxemia then a lower target ≥ 7.0 g/dL can be considered reasonable
Surviving Sepsis Campaign 2012
Refractory Shock??
??? ?
Mechanical Problem?
Endocrine?
Immune?
Pericardial effusionPneumothoraxIncreased abdominalPressure.Necrotic tissue.Ongoing blood loss Hypothyroid
Hypoadrenal
Excessive immunosuppressionUncontrolled infection
Early Goal directed therapy resulted in a 40% reduction in mortality compared to control in adult patients with septic shock
Rivers et al. NEJM 2001
But is it??
• ProCESS group, NEJM, 2014– Randomized control, multi institutional study– ~1300 adult patients– No difference in protocolized early goal directed
therapy (EGDT), protocolized standard therapy and usual care at 60 or 90 day mortality
Early Shock REVERSAL resulted in 96% survival versus 63% survival among patients who remained in persistent shock state
Han, Y. Y. et al. Pediatrics 2003
Goal directed therapy causes a significant reduction in 28 day mortality in children with septic shock
Oliveira et al. Intensive care med 2008