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.

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