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1:15am: 3 year old female arrives at Triage with HR 180, RR 35, looks tired. Has had URTI symptoms for past couple of days.
1:25am: ICU/Paeds Reg called by ED doctor saying can you come and have a look 135am:You make your first assessment
HR 180 Quiet, tired, opens eyes Mod respiratory distress Cap refill 4 seconds
Mortality rates in septic shock are 20-30% (up to 50% in some countries).
Recognition
Most people dont recognise shock
Resuscitation must be done in a proactive time-sensitive manner Every minute counts golden hour Every hour without appropriate resuscitation and restoration of blood pressure increases mortality risk by 40%
How do we define it
Systemic Inflammatory Response Syndrome
Infection Sepsis
Severe Sepsis
Septic Shock
Leucocyte abnormality
SEPSIS
SIRS in presence of suspected or proven infection
Severe Sepsis
Sepsis + one of the following
CV organ dysfunction ARDS 2 or more organ dysfunction
Septic Shock
Sepsis + CV organ dysfunction
Cardiovascular dysfunction
Despite >40ml/kg Isotonic 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
Clinical Manifestations
Fever
Increased HR Increased RR Altered mental state Skin:
Hypoperfusion Decreased capillary refill Petechiae, purpura Cool vs warm.
Cold Shock
Warm Shock
HR
Peripheries Pulses
Tachycardia
Cool Difficult to palpate
Tachycardia
Warm Bounding
Investigations
Basic bloods: FBC, EUC, LFT, CMP, Coags, Glucose Inflammatory markers: PCT, CRP Acid- Base status Venous or arterial blood gas: Lactate Base deficit
Investigations
Septic Work up Urine, blood, sputum cultures Viral cultures: throat, NPA, faeces, Never do CSF in shocked patient
Imaging: CXR, CT, MRI, PET scan, ECHO, Ultrasound
Management
General Principles
Early Recognition
Early and appropriate antimicrobials Early and aggressive therapy to restore balance between oxygen delivery and demand Early and goal directed therapy
O min
Recognise decreased mental status and perfusion Maintain airway and establish access
5 min
Push 20mls/kg isotonic saline or colloid boluses up to and over 60mls/kg Antimicrobials, Correct hypoglycemia and hypocalemia
15 min
Fluid Responsiveness
Observe in PICU
Recognise decreased mental status and perfusion Maintain airway and establish access Vascular Access: Only few minutes to be spent on obtaining IV access Need to use IO if cant get access May need to put 2 x IO in Intubation + Ventilation Clinical assessment of work of breathing , hypoventilation or impaired mental state Up to 40% of cardiac output is used for work of breathing Volume loading and inotrope support is recommended before and during intubation Recommended: Ketamine, atropine and short acting neuromuscular blocking agent.
Push 20mls/kg isotonic saline or colloid boluses up to and over 60mls/kg Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Resuscitation: Needs to be given as push May need to give up to 200mls/kg Give fluid until perfusion improves. Which Fluids Isotonic vs collloid Most evidence extrapolated from adults Wills et al RCT of cystalloid vs colloid in children with dengue fever No difference between the two groups.
15min
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%
60 min
ECMO
Drug Dopamine
Dose 2-20mcg/kg/min
Comments Historically 1st choice in kids Alpha, beta and dopamine receptor activation Can be given peripherally Chronotropic as well as inotropic Afterload reduction Initially increases contractility/heart rate High doses increase PVR Vasopressor Increases PVR
Dobutamine Adrenaline
Milrinone
0.250.75mcg/kg/min
Showed significant decrease in mortality Cristisms: control group had higher mortality rate and benefits may be because group was monitored more closely
Evidence Controversial
Annane D JAMA 2002
Multicentre , RCT looked at use of hydrocortisone and fludrocortisone in septic shock.
Evidence- paediatrics
No RCT in paediatric patients with sepsis
Markovitz : PCCM 2005
Retrospective cohort study , 6000 paediatric patients Systemic steriods associated with increased mortality But no control in place for severity of illness or for dose.
Other treatment
Maintain Glucose control
Nutrition Maintain Hb > 10g/dL
GI protection
Early CVVH
Activated Protein C
Inhibits factors Va and VIIIa prevent generation of thrombin
Decreased inflammation through inhibition of platelet activation, neutrophil recruitment
ECMO
Study published this month from RCH Melbourne