MANAGEMENT OF SEPTIC SHOCK

Severe sepsis and septic shock are the two major causes of death in children with sepsis.

The incidence of septic shock is 2 – 4% of admissions in western PICUs & 40% - 67% for Indian PICUs.

Sepsis is the systemic response to infection with bacteria, viruses, fungi, protozoa, or rickettsiae.

Severe sepsis is defined as sepsis plus one of the following –• Cardiovascular organ dysfunction or;• Acute respiratory distress syndrome or;• Two or more other organ dysfunctions.

Septic shock in a child with sepsis is defined by the presence of –• Hypotension (systolic BP < 70 mm Hg in infant); (< 70 + 2 × age after one

year) or;• Need for any vasoactive drug to maintain BP above 5th centile range or;• Signs of hypo-perfusion (any three of the following) or;

1. decreased pulse volume2. capillary refilling time > 3 sec3. tachycardia ( > 190/min in newborn; >160 in infants; >110 in a 10 yr

child)4. difference in core to peripheral temp. > 3°C5. urine output < 1 ml/kg/hr 6. Tache Cerebrale - stroke skin with a blunt instrument -> 30-60 sec -> raised red rash

• Sepsis and cardiovascular organ dysfunction.

Early Recognition of Septic shock

The first hours following the diagnosis of severe sepsis and septic shock are known as the “golden hour” as it is during this period that aggressive hemodynamic resuscitation has been shown to be associated with higher survival rates & reduced organ dysfunctions.

The major cause of loss of “golden hours” in our country may be due to –

• Delay in recognition

• Delay in transport

• Delay in initiating treatment

The clinical diagnosis of early septic shock is possible with presence of the following in a case of suspected infection –

• Hypothermia or hyperthermia

• Decreased mental status

• Prolonged CRT

• Diminished or bounding pulses

• Mottled cool extremities

• Decreased urine output <1 ml/kg/hr

BP drops only in late shock & its presence in a child with suspected infection is confirmatory.

The shock is further classified as –

Cold shock – characterized by signs of decreased perfusion with diminished peripheral pulses.

Warm shock – characterized by signs of decreased perfusion with bounding peripheral pulses.

PRINCIPLES OF MANAGEMENT

Initial treatment of child with septic shock –

This includes aggressive fluid resuscitation of up to

60 ml/kg as boluses of 20 ml/kg of isotonic crystalloid such as Ringer lactate or Normal saline by I/V push in 10 to 15 mins to achieve desired heart rate and blood pressure.

Colloids (starch, gelatins) produce greater & more sustained increase in plasma volume, but they may not be readily available.

Fluid overload should be assessed by –

• Jugular venous distension

• Increasing liver span

• Puffy eyelids

• Signs of pulmonary edema & congestion on chest radiograph

If a patient does not respond to aggressive fluid therapy, vasoactive drugs should be started.

• Dopamine is recommended as the first line agent in a fluid refractory shock, started at a infusion rate of 10 µg/kg/min.

• Dobutamine is to be used as the first choice in children with normal BP & low cardiac output.

• Mixing of more than one vasoactive drug in the same infusion set is not recommended.

• Infusion should be prepared in D5% or D5% with NS

Management in Intensive care setting –In case of fluid refractory shock, central venous line should be

inserted & vasoactive drugs like dopamine and dobutamine be started.

In case of shock refractory to these above drugs, epinephrine & nor-epinephrine can be used depending on whether the child has cold shock or warm shock, respectively.

If there is no response to the above catecholamines, then ScvO2 can be monitored & vasodilators/ PDE inhibitors can be added in children with normal BP & cold shock with ScvO2 <70%.

In children with low BP, either epi. or nor-epi. can be titrated depending on whether it is cold shock or warm shock.

Early initiation of Appropriate Antimicrobial Therapy

Administration of broad spectrum antibiotic to cover the likely pathogens (including gram +ve and gram -ve) within 1 h of dxof septic shock as well as reassessment after microbiologic data is available, to narrow the coverage, is recommended.

Blood culture should be obtained before starting antibiotic.

Source control- All pts. should be evaluated for presence of focus of infection amenable to source control measures like abscess drainage, debridement of necrotic tissue, or removal of infective device.

Use of adjuvant therapy like steroid

Steroid are to be used only in children with suspected or proven adrenal insufficiency which shows high prevalence in septic shock, especially catecholamine refractory shock.

Mechanical Ventilation• Due to low functional residual capacity young infants and

neonates with severe sepsis may require early intubation.

• The early use of mechanical ventilation aided by sedation reduces the work of breathing and allows for redistribution of limited cardiac output to vital organs, improves oxygenation and decreases PVR & left ventricular afterload.

Blood products

Hb conc. Should be maintained at a minimal level of 10 g/dL.Platelet transfusion should be done when

PC < 5000/mm³ regardless of apparent bleeding.PC 5000-30,000/mm³ with significant risk of bleeding.

Higher PC > 50,000/mm³ are typically required for surgery or invasive procedure.

FFP is indicated in-Active bleedingBefore surgeryBefore invasive procedureReverse warfarin effect

Other supportive care

Avoid hypoglycemia

Prophylaxis for DVT in post-pubertal children

Correction of symptomatic hypocalcemia

Renal replacement therapy

Done for ARF which includes peritoneal dialysis, intermittent hemodialysis, cont. renal replacement therapies

IV immunoglobulinIVIg has shown to reduce mortality and length of PICU stay and

less progression to complications, esp. DIC.

Therapeutic end points of resuscitation of septic shock

• Normalization of HR

• CRT ≤ 2 sec.

• Palpable peripheral pulses with no difference b/w peripheral and central pulses

• Warm extremities

• Normal BP and PP

• UO > 1 ml/kg/hr

• Return to baseline mental status, tone and posture

• Normal RR

Algorithm

•Recognize depressed mental status and poor perfusion in a febrile child with or without foci of infection•O2 by non-rebreathing mask if effortless tachypnea and septic shock•BMV if arirway unstable, bradypnea, apnea; plan early intubation

•Establish IV/IO access

•Start saline/RL 20 ml/kg over 15-20 min(BP N/High); more rapidly by pull-push if BP is low.•First dose of antibiotics, correct documented hypoglycemia and hypocalcemia

•Monitor for clinical therapeutic goals after each bolus till all goals are achieved; viz RR, work of breathing, HR, CRT, BP, peripheral temp., UO, sensorium, liver span

0 min

5 min

20 min

40 min

Therapeutic goals attained

No PE/hepatomegaly

Goals not attainedNo PE/hepatomegaly

Goals not attainedPE/hepatomegaly

2nd bolus3rd bolus, if needed

Goals not attainedPE/hepatomegaly

Goals not attained after 60 ml/kgNo PE/hepatomegalyFluid refractory shock

Start dopamine, interrupt fluids briefly, intubate, catheterizeStart PPV

20 min

40 min

Goals not attainedPE/ hepatomegaly

Goals not attained after 60 ml/kgNo PE/ hepatomegalyFluid refractory shock

Start dopamine, interrupt fluids briefly, intubate, catheterize

Start PPV

Dopamine @ 10-20 microgram/kg/minConsider intubationCatheterize for UO monitoringCont. fluids in smaller amount, till goals attained or PE/hepatomegaly occur

PE and hepatomegalyresolve

Goals not attained

Titrate 10-20 ml/kg @ 10-20 min until goals achieved

PE/hepatomegaly recurOr PE/hepatomegalynot resolved, No further fluids

Fluid refractory dopamine resistant shock

Continue monitoring

Goals achieved

Shift to ICU

60 min

Fluid refractory, Dopamine/Dobutamine resistant shock

Reassess clinical status, andWherever possible, monitor BP, CVP, perform echocardiography, check ScVO2

And Hb and PCCV

Cold shock Warm shock

BP >5th centileHypotensiveLow pulse pressure

≤ 20 mm Hg

Start epinephrine< 0.3 µg/kg/min

Epinephrine resistant low COIf BP normal add nitrosovasidilator or add milrinoneafter volume loading

If PP is low-milrinone

If PP is N-titrate NE+dobutamine

Hydrocortisone 50 mg/m²/dose

HypotensiveWide pulse pressure, Target-PP < 40 mm Hg

Titrate NE up @ 0.1-1 µg/kg/min

and fluids

Catecholamine Resistant Shock

Consider vasopressin

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