Dr David Inwald's presentation at Meningitis Research Foundation's 2013 conference, Meningitis and Septicaemia in Children and Adults

1. Give fluids!
Dr David Inwald
Consultant in PICU
St Mary’s Hospital and CATS

2. Two pathophysiological reasons
to give fluids in septic shock
• Fluid is in the wrong place
• The pump is not working

3. Increased capillary permeability

4. Dysregulation of vascular tone
Sepsis
Warm shock
High CO
vasodilation
Cold shock
Low CO
vasoconstriction

5. Depression of myocardial
contractility

6. Shock
• A clinical syndrome of inadequate
tissue perfusion
• DO2 < VO2

7. Increasing DO2

8. Therapeutic implications
GIVE FLUIDS

9. Frank-Starling curve
inotropes
fluids

10. How much fluid?

11. Up to and over
60 ml/kg by
15 minutes
Brierley J et al, Crit Care Med 2009; 37:666–688

12. Early reversal of shock
Every hour without resuscitation and
restoration of CRT < 2 s and normal BP
increases mortality by 40%!
Han YY et al Pediatrics. 2003;112:793-9
10
9
8
7
6
5
4
3
2
1
1 Hour
2 Hours
3 hours

13. Fluid resuscitation of hypovolemic shock:
acute medicine's great triumph for
children
Carcillo JA and Tasker RC, ICM 2006;32:958-61

15. Time (h)
Mortality

16. FEAST management
• C - Circulation

17. Developed world management
• A - Airway
• B - Breathing
• C - Circulation…

18. Other therapies?
• Haemofiltration
• ECMO
• Modulators of coagulation
• rh-APC
• Protein C
• Protein S
• AT III
• r-tPA
• Anti-endotoxin strategies
• Polymixin
• Anti-endotoxin antibodies (HA-1A)
• rBPI21
• Prostacyclin

19. Therapeutic implications
GIVE FLUIDS

23. GIVE FLUIDS