case presentation of septic shock

1. Dr Abdullah alzahrani

2. 
 5 year's old girl k/c of SCA on folic acid and ospen.
 Came with fever for one day, received paracetamol
then vomited 2 times and have convulsion
generalized tonic colonic with up rolling of eye for
the last 2 hours.
 the family took her to nearby clinic, received one
dose rectal diazepam and cold compression was
applied, discharged against medical advice and
arrived to KKUH.
History

3. 
 Upon arrival to ER patient was not conscious
 Airway: not maintainable
 Breathing: RR 9 ,gasping , equal air entry, O2 sat
undetectable .
 Circulation: . looks pale, cyanotic, mottled skin and cold
extremity, HR 137 , BP not detectable ,peripheral pulses
were not palpable , CRT >3 seconds.
 Disability: GCS 3/15 , fixed dilated pupils , HGT low .
 Exposure: T 37.1 .no skin rash or signs of trauma .
Examination

4. uncompensated septic shock
Impression

5. 
 Ambo bagging, Patient intubated size 4.5 at 12 cm ,
connected to ventilation SIMV PRVC rate 30 FIO2
100% TV 100 ml PEEP 5 .
 PICU team came at time of intubation.
 Peripheral line was not detectable, IO line in RT and
LT tibia .
 midazolam 1.3 mg one dose , fentanyl infusion 2
mcg/kg.
Management

6. 
 Initially BP was not detectable but started to
increased with 3 boluses NS, 20 ml/kg and
dopamine infusion 10 mcg/kg/min than BP started
to increased 39/12mmgh – 66/38mmgh –
88/58mmgh – high BP then dopamine infusion
decrease to 5mcg/kg/min.
 BP 104/44mmgh when patient transfer to PICU. 100
ml/hour NS as maintenance
Management

7. 
 2 times 50 ml D10 due to low HGT.
 Initially pupils were dilated and not reactive but
with resuscitation started to be concentrated and
reactive.
 After resuscitation ,NGT , urine catheter inserted
draining 50 ml.
 ceftriaxone 1.3 gram , tazocin , gentamycin.
 Blood sample was taken from femoral vein.
Management

8. 
Investigation

9. 
Investigation
 Ph 6.762
 PCO2 35.4
 HCO3 5
 WBC 6.5 Neut 76%
Lymp 22.5%
 HGB 48
 PLT 87
 coagulation profile: High
 RBS < 2
 urea 4.5
 Creatinine 59
 Na 143
 K 3.4
 Cl 121
 HCO3 5.4
 Ca 1.10 corrected Ca 1.56
 Mg 1
 albumin 34
 Patient was transferred to PICU before getting lab result

10. 
Investigation
 Ammonia 268
 Lactate 10.1
 Blood c/s
 Haemophilus influenzae
repeated –ve
 Urine analysis :
 WBC 11
 RBC 23
 hyaline cast
 nitrate –ve
 blood +3
 haemoglobin +3
 Urine c/s –ve

11. 
 Patient received more inotrope medication, she was
on dopamine and epinephrine for 3 days.
 Developed hypertonic in lower limps, AKI and DIC.
 Brain CT was unremarkable.
 Extubated after one week.
 Now, breathing on RA, feeding orally ,on CRR, still
has hypertonic LL.
PICU course

12. 
 Failure of delivery oxygen and substrates to meet the
metabolic demands of the tissue .
 Failure to remove metabolic end-products.
 Result of inadequate blood flow and/or oxygen
delivery.
 5-30% of pediatric patients with sepsis will develop
septic shock.
 Mortality rates in septic shock are 20-30% (up to 50%
in some countries).
Shock

13. 
• Temp instability
• Tachycardia
• Tachypnea
• WBC ↓ or ↑,
bands
SIRS
• SIRS
•evidence of
infection
Sepsis • Sepsis
• Hypotension
• End organ
dysfunction renal
failure, liver
dysfunction,
changes in mental
status, or
elevated
serum lactate
Severe
Sepsis
• Sepsis
•refractory hypotension
• Pressor requirement
• Further evidence of low perfusion
(lactate, oliguria)
Septic
Shock

14. 
 < 1 year of age
 Very low birth weight infants
 Prematurity
 Presence of underlying illness
 Co-morbidities
Risk factors for Sepsis in
Children

15. 
 Fever
 Increased HR
 Increased RR
 Altered mental state
 Skin:
 Hypoperfusion
 Decreased capillary refill
 Petechiae, purpura
 Cool vs warm.
Clinical Manifestations

16. 
Cold Shock Warm Shock
HR Tachycardia Tachycardia
Peripheries Cool Warm
Pulses Difficult to palpate Bounding
Skin Mottled, pale Flushed
Capillary refill Prolonged Blushing
Mental state Altered Altered
Urine Oliguria Oliguria

17. 
 This is main difference with adults.
 Blood pressure does not fall in septic shock until very late.
 CO= HR x SV
 HR in children much higher therefore BP falling is late.
 Hypotension formula : 70+(age× 2)mmgh
Blood Pressure in Children

18. 
 Recognize early
 Resuscitation must be done in a proactive time
sensitive manner.
 Every minute counts – “golden hour”
 Every hour without appropriate resuscitation
increases mortality risk by 40%.
Management

19. Recognize decreased mental status and perfusion
Maintain airway and establish access
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalcemia
Fluid Responsiveness Fluid Refractory shock
O min
5 min
15 min
Observe in PICU

20. Fluid Refractory Shock15min
Begin dopamine or peripheral adrenaline
Establish central venous access
Establish arterial access
Titrate Adrenaline for cold shock and noradrenaline for
warm shock to normal MAP-CVP and SVC sats>70%
Catecholamine resistant shock60 min

21. Catecholamine Resistant Shock
At Risk of adrenal insufficiency – give
hydrocortisone
Not at Risk - don’t give
hydrocortisone
Normal Blood Pressure
Cold Shock
SVC < 70%
Low Blood Pressure
Cold Shock
SVC < 70%
Low Blood
Pressure
Warm Shock
Add vasodilator or
Type III PDE inhibitor
Titrate volume and
adrenaline
Titrate volume &
Noradrenaline
Consider
Vasopressin
ECMO

22. 
 Heart Rate normalized for age
 Capillary refill < 2sec
 Normal pulse quality
 No difference in central and peripheral pulses
 Warm extremities
 Blood pressure normal for age
 Urine output >1 mL/kg/h
 Normal mental status
 CVP >8 mmHg
 Decreased lactate and base deficits
Therapeutic endpoints

23. 
 Early Recognition
 Early goal directed therapy
 Remember golden hour
 Early and Empiric antimicrobials
 Early source control and aggressive therapy
Take home points….