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Case Study - Pediatric - Septic Shock
A 3-year-old boy with septic shock presented on the basis of persistent fever and respiratory distress, requiring transfer to the PICU where he underwent mechanical ventilation and treatment with fluid boluses and medications. His condition showed initial improvements but worsened after six hours necessitating additional interventions, including milrinone administration. The document outlines the dynamic nature of septic shock management and emphasizes the importance of monitoring hemodynamic changes for timely treatment decisions.
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Case Study - Pediatric - Septic Shock
- 1. Septic Shock -Pediatric History 3 year old boy. Taken to Pediatrician with fever and cough. Started on Paracetamol and oral antibiotics. One week later still low grade fever, tachypnea. Referred to hospital. www.uscom.com.au The Measure of Life
- 2. Septic Shock -Pediatric Presentation Pale, irritable, respiratory distress Temperature 37.2o C CVS: HR 120 bpm, BP 96/40 mmHg Capillary refill time 2 sec RS: RR 50, rapid shallow breaths SaO2 100% in oxygen NS: Agitated, no neck stiffness Altered chest X-ray www.uscom.com.au The Measure of Life
- 3. Septic Shock -Pediatric Chest X-RAY – 4 cm thickness fluid collection in the pleural cavity www.uscom.com.au The Measure of Life
- 4. Septic Shock -Pediatric Treatment On Presentation Started on antibiotics Electively scheduled for intercostal drainage Transferred to PICU after procedure Still on mechanical ventilation (was intubated for the procedure and unable to extubate) PICU Admission Pale, irritable, respiratory distress Temperature 37.2o C CVS: HR 120 - 160 bpm, BP 96/40 - 100/36 mmHg Capillary refill time 2 - < 2 sec Warm extremities, bounding pulses RS: Mechanical ventilation www.uscom.com.au The Measure of Life
- 5. Septic Shock -Pediatric PICU Admission Now what? A) fluid bolus B) fluid + vasopressor C) fluid + inotrope D) only vasopressor E) only inotrope F) I don’t know www.uscom.com.au The Measure of Life
- 6. Septic Shock -Pediatric Parameter PICU Age wise Admission norms MD (m/min) 40 18-30 SVI (ml/m2) 58 40-55 Hyperdynamic SV (ml/kg) 3.0 1.5-2.4 SVV (%) 35 <15 Hypovolemia / FTc (ms) 350 300-375 Fluid responsive HR 168 85-115 Low Systemic SVRI (d.s.cm/m2) 650 1000-1600 Vascular Resistance SVR (d.s.cm) 1200 1500-2000 CI (l/min/m2) 5.1 3.5-5.0 Elevated Cardiac Index CO (l/min) 4.2 2.5-4.0 and Stroke Volume Vpk (ms) 1.5 1.1-1.6 www.uscom.com.au The Measure of Life
- 7. Septic Shock -Pediatric Treatment at PICU Admission Fluid bolus 60 ml/kg Norepinephrine 0.2 mcg/kg/min A) fluid bolus B) fluid + vasopressor C) fluid + inotrope D) only vasopressor E) only inotrope F) Now I know www.uscom.com.au The Measure of Life
- 8. Septic Shock -Pediatric 60 minutes Sedated, mechanical ventilation Afebrile CVS: HR 160 - 132 bpm, BP 100/36 - 100/48 mmHg Capillary refill time <2 - 2 sec www.uscom.com.au The Measure of Life
- 9. Septic Shock -Pediatric 60 minutes Now what? A) fluid bolus B) fluid + vasopressor C) fluid + inotrope D) only vasopressor E) only inotrope F) Go have a coffee www.uscom.com.au The Measure of Life
- 10. Septic Shock -Pediatric Parameter Base 60 min Age wise norms MD (m/min) 40 32 18-30 Mild Hyperdynamic SVI (ml/m2) 58 54 40-55 SV (ml/kg) 3.0 2.8 1.5-2.4 Mild Hypovolemia / SVV (%) 35 23 <15 Fluid responsive FTc (ms) 350 340 300-375 HR 168 140 85-115 Improving SVRI (d.s.cm/m2) 650 1050 1000-1600 Systemic Vascular SVR (d.s.cm) 1200 1700 1500-2000 Resistance CI (l/min/m2) 5.1 3.9 3.5-5.0 Adequate Cardiac CO (l/min) 4.2 2.8 2.5-4.0 Index Vpk (ms) 1.5 1.4 1.1-1.6 www.uscom.com.au The Measure of Life
- 11. Septic Shock -Pediatric Treatment at 60 Minutes Fluid bolus 20 ml/kg A) fluid bolus B) fluid + vasopressor C) fluid + inotrope D) only vasopressor E) only inotrope F) Go have a coffee www.uscom.com.au The Measure of Life
- 12. Septic Shock -Pediatric 6 hours Worsening tachycardia 130 - 170 bpm, no fever. BP 100/48 - 80/46 Capillary refill time 2 - 3 sec Decreased urine output www.uscom.com.au The Measure of Life
- 13. Septic Shock -Pediatric 6 hours Treatment Fluid bolus 20 ml/kg but without improvement Now what? A) fluid bolus B) fluid + vasopressor C) fluid + inotrope D) only vasopressor E) only inotrope F) Forget about the coffee www.uscom.com.au The Measure of Life
- 14. Septic Shock -Pediatric Parameter Base 60 6 Age wise min hours norms MD (m/min) 40 32 22 18-30 SVI (ml/m2) 58 54 38 40-55 SV (ml/kg) 3.0 2.8 1.3 1.5-2.4 SVV (%) 35 23 13 <15 FTc (ms) 350 340 280 300-375 HR 168 140 178 85-115 SVRI (d.s.cm/m2) 650 1050 1230 1000-1600 SVR (d.s.cm) 1200 1700 1900 1500-2000 CI (l/min/m2) 5.1 3.9 3.3 3.5-5.0 Sepsis-induced CO (l/min) 4.2 2.8 2.2 2.5-4.0 Myocardial Depression Vpk (ms) 1.5 1.4 0.9 1.1-1.6 www.uscom.com.au The Measure of Life
- 15. Septic Shock -Pediatric Treatment at 6 hours Started on milrinone 0.5 mcg/kg/min A) fluid bolus B) fluid + vasopressor C) fluid + inotrope D) only vasopressor E) only inotrope F) Forget about the coffee www.uscom.com.au The Measure of Life
- 16. Septic Shock -Pediatric Parameter Base 60 min 6 hour Post Age wise norms inotrope MD (m/min) 40 32 22 25 18-30 SVI (ml/m2) 58 54 38 46 40-55 SV (ml/kg) 3.0 2.8 1.3 1.7 1.5-2.4 SVV (%) 35 23 13 10 <15 FTc (ms) 350 340 280 310 300-375 HR 168 140 178 150 85-115 SVRI (d.s.cm/m2) 650 1050 1230 1100 1000-1600 SVR (d.s.cm) 1200 1700 1900 1878 1500-2000 CI (l/min/m2) 5.1 3.9 3.3 3.8 3.5-5.0 CO (l/min) 4.2 2.8 2.2 2.9 2.5-4.0 Vpk (ms) 1.5 1.4 0.9 1.2 1.1-1.6 www.uscom.com.au The Measure of Life
- 17. Septic Shock -Pediatric Summary “…septic shock represents a dynamic process so that the agents selected and their infusion dose may have to be changed over time based on the need to maintain adequate organ perfusion.” Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine* Joe Brierley, MD; Joseph A. Carcillo, MD; Karen Choong, MD et al. Crit Care Med 2009 Vol. 37, No. 2 Conclusion Monitoring non-invasively with USCOM aided the physician to make timely management decisions by early recognition of the hemodynamic changes. www.uscom.com.au The Measure of Life
Editor's Notes
- #7 Hyperdynamic circulation with relative hypovolemia.High MD – 40 (Typical 18-30)High SVI - 58 (Typical 40-55)High SVV – 35 (Typical <15)Normal FTc - 350 (Typical 300-375)Low SVRI – 650 (Typical 1000-1600)Normal Vpk -1.5 (Typical 1.1-1.6)High CI - 5.1 (Typical 3.5-5.0)
- #9 Heart rate reducedNo change to BP or Cap refill time.
- #11 On the right track.Hyperdynamic circulation with relative hypovolemia.Heart rate contributing to the COHigh MD – 32 (Typical 18-30)High SVI - 54 (Typical 40-55)High SVV – 23 (Typical <15)Normal FTc - 340 (Typical 300-375)Low SVRI – 1050 (Typical 1000-1600)Normal Vpk -1.4 (Typical 1.1-1.6)Normal CI – 3.9 (Typical 3.5-5.0)
- #15 Hypodynamic circulationLow volume or Low contractility?Heart failure - Low Vpk - 0.9 (Typical 1.1-1.6)Low-NormalMD – 22 (Typical 18-30)High HR - 178Very low SVI - 38 (Typical 40-55)Normal SVV – 13 (Typical <15)Normal FTc - 280 (Typical 300-375)Normal SVRI – 1230 (Typical 1000-1600)Low Vpk - 0.9 (Typical 1.1-1.6)Low CI – 3.3 (Typical 3.5-5.0)FTc affected by large changes in inotrope, so not helpful in this situation!
- #17 Normodynamic circulationNormalMD – 25 (Typical 18-30)High HR - 150Normal SVI - 46 (Typical 40-55)Normal SVV – 10 (Typical <15)Normal FTc - 310 (Typical 300-375)Low SVRI – 1110 (Typical 1000-1600)Normal Vpk – 1.2 (Typical 1.1-1.6)Normal CI – 3.8 (Typical 3.5-5.0)