Debate on aggressive vs restricted fluid resuscitation in childhood sepsis

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Dr David Inwald's presentation at Meningitis Research Foundation's 2013 conference, Meningitis and Septicaemia in Children and Adults

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Debate on aggressive vs restricted fluid resuscitation in childhood sepsis

  1. 1. Give fluids! Dr David Inwald Consultant in PICU St Mary’s Hospital and CATS
  2. 2. Two pathophysiological reasons to give fluids in septic shock • Fluid is in the wrong place • The pump is not working
  3. 3. Increased capillary permeability
  4. 4. Dysregulation of vascular tone Sepsis Warm shock High CO vasodilation Cold shock Low CO vasoconstriction
  5. 5. Depression of myocardial contractility
  6. 6. Shock • A clinical syndrome of inadequate tissue perfusion • DO2 < VO2
  7. 7. Increasing DO2
  8. 8. Therapeutic implications GIVE FLUIDS
  9. 9. Frank-Starling curve inotropes fluids
  10. 10. How much fluid?
  11. 11. Up to and over 60 ml/kg by 15 minutes Brierley J et al, Crit Care Med 2009; 37:666–688
  12. 12. Early reversal of shock Every hour without resuscitation and restoration of CRT < 2 s and normal BP increases mortality by 40%! Han YY et al Pediatrics. 2003;112:793-9 10 9 8 7 6 5 4 3 2 1 1 Hour 2 Hours 3 hours
  13. 13. Fluid resuscitation of hypovolemic shock: acute medicine's great triumph for children Carcillo JA and Tasker RC, ICM 2006;32:958-61
  14. 14. Time (h) Mortality
  15. 15. FEAST management • C - Circulation
  16. 16. Developed world management • A - Airway • B - Breathing • C - Circulation…
  17. 17. 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
  18. 18. Therapeutic implications GIVE FLUIDS
  19. 19. GIVE FLUIDS

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