Uploaded byDr.sajid Nomani
Paediatric septic-shock
An 8 year old female presented with signs of septic shock including a heart rate of 180, respiratory rate of 35, and hypotension. Initial assessments found a temperature of 39.9°F, respiratory rate of 32 breaths/min, blood pressure of 70/50 mmHg, and oxygen saturation of 90% on room air. The patient appeared tired and had delayed capillary refill of 4 seconds. Paediatric septic shock remains a significant cause of morbidity and mortality worldwide. Early goal directed therapy is crucial and aims to achieve specific clinical targets within 6 hours such as a central venous pressure of 8-12 mmHg, mean arterial pressure over 65 mmHg, urine output over 0.5 ml/kg/
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- 1. Paediatric Septic Shock Dr.SajidNomani MEM (GWU)
- 2. 8 year oldfemale arrives at ED with HR 180, RR 35, looks toxic. Has had URTI symptoms for past couple of days. Paeds Reg called by ED doctor saying can you come and have a look. You make your first assessment HR 180 T 39.9f RR-32br/min BP 70/50mmhg SPO2 90% on RA Quiet, tired, opens eyes Cap refill 4 seconds Worry??????
- 3. Why are weworried about it? Still remains significant cause of morbidity and mortality 19 milln. Cases worldwide / year( adhikari et al) 30% of paediatric patients with sepsis will develop septic shock. Mortality rates in septic shock are 20-30% (up to 50% in some countries).
- 4. Risk factors forSepsis in Children < 1 year of age Very low birthweight infants Prematurity Presence of underlying illness Co-morbidities Boys Genetic factors
- 5. So What is SEPSIS….. ..???????????? Sepsis is a life threatening response to infection. It represents a continuum through SIRS, sepsis, and septic shock
- 6. How do wedefine it Systemic Inflammatory Response Syndrome Infection Sepsis Severe Sepsis Septic Shock
- 7. SIRS…in peds Core Temp>38.5 or < 36 degrees Mean HR > 2SD for age or persitant elevation over 0.5-4hrs If < 1yr old: bradycardia HR < 10th centile for age Mean RR > 2 SD above normal for age Leucocyte abnormality. ≥2 criteria should be present ≥ 2 SIRS criteria but no infection : SIRS ≥ 2 SIRS criteria + sign of acute organ failure : severe SIRS
- 8. Sepsis SIRS + suspectedor proven infection Severe Sepsis Sepsis + sepsis induced organ dysfunction, / tissue hypo perfusion Septic Shock Sepsis + Hypotnsn /CV organ dysfunction
- 9. Cardiovascular dysfunction Despite >40ml/kgIsotonic fluid bolus in 1 hour: Decrease in BP <5th centile for age Need for vasoactive drug to maintain BP 2 of the following: Unexplained metabolic acidosis Increase lactate Oliguria Prolonged cap refill > 5 seconds Core-peripheral temp gap >3 degrees
- 10. What makes yoususpect shock??
- 11. Clinical Manifestations Variable….depends uponloads/site/pathogens/comorbidites Fever Increased HR Increased RR Altered mental state Skin: Hypoperfusion Increased capillary refill Petechiae, purpura Cool vs warm.
- 12. Cold Shock Warm Shock HR Tachycardia Tachycardia Peripheries Cool Warm Pulses Difficultto palpate Bounding Skin Mottled, pale Flushed Capillary refill Prolonged Blushing Mental state Altered Altered Urine Oliguria Oliguria
- 13. Blood Pressure inChildren 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)
- 14. Etio+ pathophysiology Pneumonia <Intraabdominal < UTI Cultures are positive in only 1/3rd cases Staph aureus and Streptococcus pneumoniae(gr +) E coli, klebsiella species,Pseudomonas aeruginosa(gr -)
- 15. PATHOPHYSIOLOGY Infectious organism/ endotoxin activates immune system Their interaction c infectioning organism stimulates Cytokines Cytokines produce vasodilation & damage endothelium of vessles ↑cap.permiablity→cap.leakage Inhibits anticoag.properties + ↑ Antifibrinolysis → microvascular thrombosis →MOD & DIC Specific inflam.mediator→ impaired cardiac contractility & myocard. d/f Adrenal gland are prone to microvascular thrombosis & hemorrhage in septic shock ↓ ↓ SVR & myocardial d/f
- 16. Management…. Recognise early Resuscitation mustbe done in a proactive time-sensitive manner. Every minute counts – “golden hour” Every hour without appropriate resuscitation increases mortality risk by 40%
- 17. Coming back toour patient…. HR 180 Initial management T 39.9f BP 70/50mmhg SPO2 90% on RA Quiet, tired, opens eyes Mod respiratory distress Cap refill 4 seconds + Symptoms of URTI WHAT NEXT???? EGDT ??????????? Blood & Imaging Source control Disposition ?????????
- 18. IV /IO-2 max.bore Monitor O2 ABCresuscitation.
- 19.
- 20. GOAL: SEPSIS INDUCEDHYPOPERFUSION IN FIRST 6 HOURS Central venous pressure 8-12 mm Hg Mean arterial pressure (MAP) ≥ 65 mm Hg Urine output ≥ 0.5 ml/kg/hr Scvo2 or Smvo2 ≥ 70% or ≥ 65%, respectively Decreased lactate Source control Better perfusion Improvement in Mental status
- 21. 0-5min: Recognise Signof poor perfusion Maintain airway and establish IV/IOaccess 5-15 min: 20mls/kg isotonic saline boluses up to and over 60mls/kg Correct hypoglycemia 0.5-1gm/kg Dx25:-2-4ml/kg Dx10:-5-10ml/kg Our pt. BP- 76/50 HR-170 CRT -≥4sec. Repeat bolus upto 60ml/kg or Sign of overload
- 22. Fluid Refractory Shock Inotrops/vasopressor to maintain Map->65 Cvp- 8-12 Svo2->70% Central line Arterial line First dose of Antibiotic Catecholamine Resistant shock Stress dose of Hydrocort 15-60 min….
- 23. O -5min 5-15m Recognise Signof poor perfusion Maintain airway and establish access Push 20mls/kg isotonic saline or colloid boluses up to and over 60mls/kg Correct hypoglycemia Antimicrobials, Correct hypoglycemia 15 -60m fluid Responsiveness Observe in PICU Fluid Refractory shock
- 24. 15min Fluid Refractory Shock Begindopamine / Norad/ Epineph. 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% 60 min Catecholamine resistant shock
- 25. Catecholamine Resistant Shock AtRisk of adrenal insufficency – give hydrocortisone-draw a baseline cortisole Evaluate Scvo2 >70% Normal BP ,poor perfusion SVC < 70% Transfuse PRBC Hb>10 Add Dopamine/NPS Milrinone Low BP,poor perfusion Cold Shock SVC < 70% Transfuse PRBC,Hb>10 Adrenaline Dobutamine+Norad. ECMO Low BP Scvo2 >70 Warm Shock Additional volume & Noradrenaline ± Vasopressin
- 26. Therapeutic endpoints Clinical HeartRate 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
- 27. During the first6 hrs, if the venous O2 saturation target not achieved with fluid resuscitation: Packed RBC transfusion to achieve a hematocrit of ≥ 30% Active source control
- 28. SOURCE CONTROL Specificanatomic site of infection should be established as rapidly as possible and within the first 6 hours of presentation Formally evaluate patient for a focus of infection amenable to source control measures (eg: abscess drainage, tissue debridement) Implement source control measures as soon as possible following successful initial resuscitation (Exception: infected pancreatic necrosis, where surgical intervention best delayed.) Choose source control measure with maximum efficacy and minimal physiologic upset. Remove intravascular access devices /cathetor if potentially infected.
- 29. Investigations Sepsis Work up Lactate , ABG , CBC PCT , CRP Metabolic Panel /Electrolyte Coagulation Profile Urine, blood, sputum ,stool, throat swab cultures Viral cultures Never do CSF in shocked patient. Imaging: CXR, CT, MRI, PET scan, ECHO, Ultrasound
- 30. Other treatment Maintain Glucosecontrol Nutrition Maintain Hb > 10g/dL No stress ulcer protection /no DVT protection before puberty age Early CVVH
- 31. Drug Dose Comments Dopamine 2-20mcg/kg/min Historically 1st choicein kids Alpha, beta and dopamine receptor activation Can be given peripherally Dobutamine 5-10mcg/kg/min Chronotropic as well as inotropic Afterload reduction Adrenaline 0.05- 1mcg/kg/min Initially increases contractility/heart rate High doses increase PVR Noradrenaline 0.05 – 1 mcg/kg/min Vasopressor Increases PVR Milrinone 0.25-0.75mcg/kg/min Phosphodiesterase inhibitor Afterload reduction
- 32. Take home points…. EarlyRecognition Early goal directed therapy Remember golden hour Early and Emperic antimicrobials Early source control and aggressive therapy
- 33.
Editor's Notes
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