Dr. C. Kannan, Post Graduate, MGMCRI, Pudhucherry, India

1. Management of septic shock
By
Dr. C. Kannan
1st year post graduate
Department of pediatrics
MGMCRI

2. OBJECTIVES
What is septic shock?
Basic pathophysiology
Recognition of septic shock
Fluid resuscitation and therapeutic
goals
Choosing antibiotics

3. SHOCK
Shock is a syndrome that results from
• Inadequate oxygen delivery to meet metabolic demands
• Oxygen supply is less than Oxygen demand
• If untreated this leads to
Metabolic acidosis
Organ dysfunction
Death

4. SEPTIC SHOCK
• Form of distributive shock
• Invasion of microorganisms
• Exaggerated by
Immune response to infection
Release and activation of immune mediators
• Typical changes are
Vasodilation
Capillary permeability

5. PATHOPHYSIOLOGY OF SEPTIC SHOCK

6. PATTERN-RECOGNITION RECEPTORS
Four main classes
• Toll-like receptors
• C-type lectin receptors
• Retinoic acid inducible gene 1–like receptors
• Nucleotide-binding oligomerization domain–like receptor

7. SEPTIC SHOCK
• SIRS
Systemic inflammatory Response Syndrome
Seen in early stages of septic shock
Criteria
Temperature changes (>38°C or <36°C)
Tachycardia (>160/min in infants, >150/min in children)
Tachypnea (>60/min in infants, >50/min in children)
Leucocytosis/ leucopenia
• Sepsis
SIRS with suspected or proven sepsis

8. SEPTIC SHOCK
• Severe sepsis
Sepsis + CVS dysfunction/ARDS or
Sepsis with 2 or more organ failures
• Septic shock
Sepsis + CVS dysfunction despite >40ml/hr isotonic fluid in 1 hour
• CVS dysfunction
SBP < 5th centile/required vasoactive medication
CFT > 5 sec
Oliguria < 0.5 ml/kg/hr
Base deficit > 5
Lactate twice the normal

9. SEPTIC SHOCK
Warm shock
• Early compensated
• Warm peripheries
• Bounding pulses
• Increased CO
• Decreased SVR
• Widened pulse pressure
• Hypocarbia
• Hyperglycaemia
• Metabolic acidosis
Cold shock
• Late hypotensive
• Cold and clammy
• Weak thready pulses
• Decreased CO
• Increased SVR
• Narrow pulse pressure
• Hypoxia
• Hypoglycaemia
• Metabolic acidosis
• Capillary leak & Oliguria

10. RISK FACTORS
Extremes of age
Immunocompromised
Malnutrition
Asplenia
Chronic antibiotics use
Any insult (shock, trauma, burns and pancreatitis)

11. CULPRITS OF SEPSIS
Vincent J-L, Rello J, Marshall J, et al. EPIC II G roup of Investigators. International study of the prevalence
and outcomes of infection in intensive care units. JAMA 2009 ; 302 : 2323 - 9 . doi: 10 . 1001 /
jama.2009.1754 . pmid:19952319

12. EARLY RECOGNITION
• Septic shock is a clinical diagnosis
• High index of suspicion is warranted
• Altered mental status with fever
Altered alertness Lethargy
Poor eye contact Somnolence
Inconsolable cry
• Clinical triad of impending septic shock
Hyper/hypothermia Altered mental status
Peripheral vasodilation
• Any fever + irritability/ lethargy + decreased urine output- look for
tachycardia out of proportion with fever- Septic shock

13. PRIMARY RESUSCITATION
• Initial assessment of ABC
• 100% oxygen via NRM
• Early administration of broad spectrum antibiotics
• Securing minimum 2 IV lines/ intraosseous line
• Collect briefly the past history to R/O underlying cause
• Initial investigations
• ABG
• Blood sugar
• RFT and Electrolytes
• CBC
• PT/PTT
• Type and cross match
• Cultures

14. INTRAOSSEOUS TECHNIQUE
• Used in poor peripheral vascular access- 2 IV line attempts
unsuccessful- choose IO
• Sites: Tibial tuberosity, lower end of femur and lower end of
tibia
• Intraosseous needle /bone marrow aspiration needle
• Position: Fluid should infuse easily without evidence of soft-
tissue swelling
• Most successful in children younger than age six- may be
employed in older children
• Fluids, inotropes, antibiotics, transfusions

15. ANTIMICROBIALS

16. IN FIRST 3 & 6 HOURS

17. FLUID RESUCITATION
• Compensated shock
NS/RL 20 ml/kg over 1 hour
Assess the vitals and titrate the fluids accordingly
• Hypotensive shock (uncompensated shock)
Rapid boluses of NS/RL - 20 ml/kg
Until SBP/MAP normal for age
Can reach upto 60 ml/kg in 1 hour

18. FLUID RESUCITATION
General concerns in fluid therapy in any kind of shock
• Assess the vitals and CCF features
• At the end of each boluses/aliquots
• In cardiac patients start at 10-20 ml/kg over 1 hour
• Once shock is revived wean the fluid and
• Maintain according to the requirement

19. QUESTION
• Why the amount of bolus is 20 ml/kg?
• Magic number??

20. FLUID INTOLERANCE
• Features of overload or pulmonary edema
New onset/worsening of rales
Hepatomegaly
Increased oxygen requirement (WOB)
• Causes
Capillary leak into lungs
Cardiogenic pulmonary edema
ARDS
Fluid overload

21. FLUID INTOLERANCE
• Pathophysiology
Capillary leak
Uncorrected hypovolemia
Loss of crystalloids and colloids
• Management
Slow down the fluid rate
Consider colloids
Consider inotrope/pressor depending upon BP
Positive pressure ventilation( CPAP/Invasive ventilation)

22. THERAPEUTIC GOALS
• HR for age
• SBP/MAP for age
• Urine O/P > 1 ml/kg/hr
• Warm peripheries with CFT <3 sec
• Normal mental status
• Improving metabolic acidosis/reducing lactate

23. INTUBATION AND VENTILATION
• Indications
Increased work of breathing
Pulmonary edema
Hypoventilation
Altered mental status(GCS <8)
Refractory shock
Severe hypoxemia +/- hypercapnia and
Moribund state

24. INTUBATION &
VENTILATION
• Preoxygenation with 100% oxygen with NRM
• Avoid sedative drugs in moribund patients
• Select appropriate ET tube/cuffed tube
• To prevent peritubal air leaks
• Target tidal volume of 6 mL/kg
• Plateau pressure in ARDS must be ≤30 cm H2O
• PEEP on little higher side in mod/severe ARDS
• Head end elevation to 30-45 degree (aspiration / VAP)

25. BLOOD TRANSFUSIONS
Indications for RBC transfusions are
• Hb <7.0 (Target Haemoglobin is 7 to 9)
• Metabolic acidosis with base deficit > 5
• Elevated lactate
Other blood components are indicated depending upon the needs
• Platelets transfusion if counts < 100,000
• Bleeding due to DIC, consider FFP or cryoprecipitate

26. STEROIDS
Timely hydrocortisone therapy in children with
• Fluid refractory
• Catecholamine resistant shock and
• Suspected or proven absolute (classic) adrenal insufficiency
• 1-2 mg/kg of hydrocortisone bolus followed by 1mg/kg Q6-8H.

27. ACID BASE/SUGAR/ELECTROLYTES
• Hypo/hyperglycaemia both are common in SS
Periodic monitoring is warranted
In persistent hypoglycaemia consider early steroids and 10%D
Insulin infusion in persistent hyperglycaemia
• Electrolytes and RFT should be monitored
• Wide anion gap acidosis common in SS due to lactate
Bicarbonate correction is not required
Adequate fluid correction is enough

28. REFRACTORY SHOCK
If shock persists despite of
• Adequate filling
• Inotrope/ vasopressor
• Initiation of steroids
• Haematocrit >30%
Suspect
• PHTN
• Pericardial effusion
• Tension pneumothorax
• Hypoadrenalism
• Hypothyroidism
• On going blood loss
• Intraabdominal catastrophe and HTN

29. INDICATORS OF SEVERE DISEASE
• Low or falling WBC count
• Low or falling platelet count
• High requirement of fluid
• Short history(<12 hours)
• Rapid progression of multiorgan failure

30. SYMPATHETIC RECEPTORS
ALPHA
• Alpha -1 (vasoconstriction)
1-a prostatic urethra
1-b blood vessels
• Alpha -2
Presynaptic
Brake to sym system
Post synaptic
Blood vessels & brain
BETA
• Beta-1
Heart & GJ cells
• Beta-2 (vasodilation)
Bronchus, GIT, Bladder
Uterus, Liver, Skeletal muscle
Blood vessels
• Beta-3
Adipose tissue
Coronary vessels

31. CATECHOLAMINES
• Adrenaline acts on
Alpha – 1 & 2 Increases SBP & HR
Beta – 1 & 2
• Noradrenaline
Alpha – 1 & 2 Increases SBP & DBP
Beta – 1 Decreases HR

32. CATECHOLAMINES
• Dopamine
D-1 @ 1-2 mics/kg/min (Renal vasodilation)
Beta-1 @ 2-10 mics/kg/min (Increases contractility)
Alpha-1 @ >10 mics/kg/min (Vasoconstriction)
• Dobutamine
Selective beta-1 agonist increases contractility and
vasodilation

33. DOSES

34. RULE OF “6”

35. Question
• Write Dopamine orders for a 10 kg child with fluid refractory
septic shock

37. TAKE HOME MESSAGE
Septic shock is a clinical diagnosis, needs high suspicion
Early recognition and resuscitation of septic shock
Early fluid resuscitation
Early initiation/Choosing/Narrowing of antibiotics
Timely initiation of inotropes/vasopressors, if needed
Therapeutic goals in 3 & 6 hours

38. THANK YOU !!

39. CASE DEFINITION
SUSPECTED CASE
Acute febrile respiratory illness (fever ≥ 38 C)
• Within 7 days of close contact with a confirmed case or
• Within 7 days of travel to pandemic areas or
• Resides in a pandemic community.

40. Contd.,
PROBABLE CASE
Acute febrile respiratory illness who is
• Positive for influenza A
But unsubtypable for H1 and H3 by influenza RT-PCT or
• Positive for influenza A
Influenza rapid test or IFA + suspected case or
• Who died of an unexplained acute respiratory
Illness is epidemiologically linked to a probable or confirmed case.

41. Contd.,
CONFIRMED CASE
Acute febrile respiratory illness
• Found to be positive in any of following method
• Real Time PCR
• Viral culture
• Four-fold rise in H1N1 virus specific neutralizing antibodies
• Through any of WHO approved laboratory

42. • Give examples of distributive shock
Anaphylactic/Neurogenic/Septic shock

43. Important receptors of immune cells implicated in
pathophysiology of septic shock
• Toll-like receptors
• C-type lectin receptors
• Retinoic acid inducible gene 1–like receptors and
• Nucleotide-binding oligomerization domain–like receptors.

44. What is SIRS ? Criteria for SIRS ?
• Systemic inflammatory Response Syndrome
Seen in early stages of septic shock
Criteria
Temperature changes (>38°C or <36°C)
Tachycardia (>160/min in infants, >150/min in children)
Tachypnea (>60/min in infants, >50/min in children)
Leucocytosis/ leucopenia

45. • Most common organisms involved in sepsis ?
• Pseudomonas
• Klebsiella
• Acenetobacter
• E coli
• Staph aureus

46. Most common site of Intraosseous route ?
Successful upto which ?
• Lower 1/3rd of femur
• Upper 1/3rd of tibia
• Lower 1/3rd of tibia
• Age upto 6

47. Clinical features of fluid overload ? Causes ?
• Features of overload or pulmonary edema
New onset/worsening of rales
Hepatomegaly
Increased oxygen requirement (WOB)
• Causes
Capillary leak into lungs
Cardiogenic pulmonary edema
ARDS
Fluid overload

48. Therapeutic goals of septic shock ? Should achieved within ?
• All must be achieved within first 6 hours
• HR for age
• SBP/MAP for age
• Urine O/P > 1 ml/kg/hr
• Warm peripheries with CFT >3 sec
• Normal mental status
• Improving metabolic acidosis/reducing lactate

49. Role of alpha 1 and beta 2 receptors in blood vessels ?
• Alpha -1 (vasoconstriction)
• Beta-2 (vasodilation)

50. What is mixed venous oxygen saturation (called SvO2) ?
Clinical role ?
• Percentage of oxygen bound to haemoglobin in blood
returning to the right side of the heart.
• Reflects
The amount of oxygen "left over" after the tissues usage
Amount of oxygen extracted by tissues
• Helps to determine whether the cardiac output and oxygen
delivery is high enough to meet a patient's needs
• A true mixed venous sample is drawn from the tip of the
pulmonary artery catheter
• Normal SvO2 60-80%.

51. Parameters catecholamines
MAP increased by Dopamine/Adrenaline
Both CO & SVR are increased by Dopamine
Both increasing CO & decreasing SVR by Dobutamine
Most potent vasopressor Noradrenaline
DBP increased by Adre/Noradre
http://www.who.int/childgrowth/standards/weight_for_age/en/