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MANAGEMENTOFSEPTICSHOCK
Severe sepsis and septic shock are the two
major causes of death in children with sepsis.
The incidence of septic shock is 2 ā€“ 4% of
admissions in western PICUs & 40% - 67% for
Indian PICUs.
Sepsis is the systemic response to infection with bacteria, viruses,
fungi, protozoa, or rickettsiae.
Severe sepsis is defined as sepsis plus one of the following ā€“
ā€¢ Cardiovascular organ dysfunction or;
ā€¢ Acute respiratory distress syndrome or;
ā€¢ Two or more other organ dysfunctions.
Septic shock in a child with sepsis is defined by the presence of ā€“
ā€¢ Hypotension (systolic BP < 70 mm Hg in infant); (< 70 + 2 Ɨ age after one
year) or;
ā€¢ Need for any vasoactive drug to maintain BP above 5th centile range or;
ā€¢ Signs of hypo-perfusion (any three of the following) or;
1. decreased pulse volume
2. capillary refilling time > 3 sec
3. tachycardia ( > 190/min in newborn; >160 in infants; >110 in a 10 yr
child)
4. difference in core to peripheral temp. > 3Ā°C
5. urine output < 1 ml/kg/hr
6. Tache Cerebrale - stroke skin with a blunt instrument -> 30-60 sec ->
raised red rash
ā€¢ Sepsis and cardiovascular organ dysfunction.
Early Recognition of Septic shock
The first hours following the diagnosis of severe sepsis and septic
shock are known as the ā€œgolden hourā€ as it is during this
period that aggressive hemodynamic resuscitation has been
shown to be associated with higher survival rates & reduced
organ dysfunctions.
The major cause of loss of ā€œgolden hoursā€ in our country may be
due to ā€“
ā€¢ Delay in recognition
ā€¢ Delay in transport
ā€¢ Delay in initiating treatment
The clinical diagnosis of early septic shock is possible with presence of the
following in a case of suspected infection ā€“
ā€¢ Hypothermia or hyperthermia
ā€¢ Decreased mental status
ā€¢ Prolonged CRT
ā€¢ Diminished or bounding pulses
ā€¢ Mottled cool extremities
ā€¢ Decreased urine output <1 ml/kg/hr
BP drops only in late shock & its presence in a child with suspected infection
is confirmatory.
The shock is further classified as ā€“
Cold shock ā€“ characterized by signs of decreased perfusion with diminished
peripheral pulses.
Warm shock ā€“ characterized by signs of decreased perfusion with bounding
peripheral pulses.
PRINCIPLES OF MANAGEMENT
Initial treatment of child with septic shock ā€“
This includes aggressive fluid resuscitation of up to
60 ml/kg as boluses of 20 ml/kg of isotonic crystalloid such as
Ringer lactate or Normal saline by I/V push in 10 to 15 mins to
achieve desired heart rate and blood pressure.
Colloids (starch, gelatins) produce greater & more sustained
increase in plasma volume, but they may not be readily
available.
Fluid overload should be assessed by ā€“
ā€¢ Jugular venous distension
ā€¢ Increasing liver span
ā€¢ Puffy eyelids
ā€¢ Signs of pulmonary edema & congestion on chest radiograph
If a patient does not respond to aggressive fluid therapy,
vasoactive drugs should be started.
ā€¢ Dopamine is recommended as the first line agent in a
fluid refractory shock, started at a infusion rate of 10
Āµg/kg/min.
ā€¢ Dobutamine is to be used as the first choice in children
with normal BP & low cardiac output.
ā€¢ Mixing of more than one vasoactive drug in the same
infusion set is not recommended.
ā€¢ Infusion should be prepared in D5% or D5% with NS
Management in Intensive care setting ā€“
In case of fluid refractory shock, central venous line should be
inserted & vasoactive drugs like dopamine and dobutamine be
started.
In case of shock refractory to these above drugs, epinephrine & nor-
epinephrine can be used depending on whether the child has
cold shock or warm shock, respectively.
If there is no response to the above catecholamines, then ScvO2
can be monitored & vasodilators/ PDE inhibitors can be added in
children with normal BP & cold shock with ScvO2 <70%.
In children with low BP, either epi. or nor-epi. can be titrated
depending on whether it is cold shock or warm shock.
Early initiation of Appropriate Antimicrobial
Therapy
Administration of broad spectrum antibiotic to cover the likely
pathogens (including gram +ve and gram -ve) within 1 h of dx
of septic shock as well as reassessment after microbiologic
data is available, to narrow the coverage, is recommended.
Blood culture should be obtained before starting antibiotic.
Source control- All pts. should be evaluated for presence of focus
of infection amenable to source control measures like abscess
drainage, debridement of necrotic tissue, or removal of
infective device.
Use of adjuvant therapy like steroid
Steroid are to be used only in children with suspected or
proven adrenal insufficiency which shows high prevalence
in septic shock, especially catecholamine refractory shock.
Mechanical Ventilation
ā€¢ Due to low functional residual capacity young infants and
neonates with severe sepsis may require early intubation.
ā€¢ The early use of mechanical ventilation aided by sedation
reduces the work of breathing and allows for redistribution
of limited cardiac output to vital organs, improves
oxygenation and decreases PVR & left ventricular afterload.
Blood products
Hb conc. Should be maintained at a minimal level of 10 g/dL.
Platelet transfusion should be done when
PC < 5000/mmĀ³ regardless of apparent bleeding.
PC 5000-30,000/mmĀ³ with significant risk of bleeding.
Higher PC > 50,000/mmĀ³ are typically required for surgery or
invasive procedure.
FFP is indicated in-
Active bleeding
Before surgery
Before invasive procedure
Reverse warfarin effect
Other supportive care
Avoid hypoglycemia
Prophylaxis for DVT in post-pubertal children
Correction of symptomatic hypocalcemia
Renal replacement therapy
Done for ARF which includes peritoneal dialysis, intermittent
hemodialysis, cont. renal replacement therapies
IV immunoglobulin
IVIg has shown to reduce mortality and length of PICU stay and
less progression to complications, esp. DIC.
Therapeutic end points of
resuscitation of septic shock
ā€¢ Normalization of HR
ā€¢ CRT ā‰¤ 2 sec.
ā€¢ Palpable peripheral pulses with no difference b/w
peripheral and central pulses
ā€¢ Warm extremities
ā€¢ Normal BP and PP
ā€¢ UO > 1 ml/kg/hr
ā€¢ Return to baseline mental status, tone and posture
ā€¢ Normal RR
Algorithm
ā€¢Recognize depressed mental status and poor perfusion in a febrile
child with or without foci of infection
ā€¢O2 by non-rebreathing mask if effortless tachypnea and septic
shock
ā€¢BMV if arirway unstable, bradypnea, apnea; plan early intubation
ā€¢Establish IV/IO access
ā€¢Start saline/RL 20 ml/kg over 15-20 min(BP N/High); more rapidly
by pull-push if BP is low.
ā€¢First dose of antibiotics, correct documented hypoglycemia and
hypocalcemia
ā€¢Monitor for clinical therapeutic goals after each bolus till all goals
are achieved; viz RR, work of breathing, HR, CRT, BP, peripheral
temp., UO, sensorium, liver span
0 min
5 min
20 min
40 min
Therapeutic goals
attained
No PE/hepatomegaly
Goals not attained
No PE/hepatomegaly
Goals not attained
PE/hepatomegaly
2nd bolus
3rd bolus, if needed
Goals not attained
PE/hepatomegaly
Goals not attained
after 60 ml/kg
No PE/hepatomegaly
Fluid refractory shock
Start dopamine, interrupt
fluids briefly, intubate,
catheterize
Start PPV
20 min
40 min
Goals not attained
PE/ hepatomegaly
Goals not attained
after 60 ml/kg
No PE/ hepatomegaly
Fluid refractory shock
Start dopamine, interrupt
fluids briefly, intubate,
catheterize
Start PPV
Dopamine @ 10-20 microgram/kg/min
Consider intubation
Catheterize for UO monitoring
Cont. fluids in smaller amount, till goals
attained or
PE/hepatomegaly occur
PE and hepatomegaly
resolve
Goals not attained
Titrate 10-20 ml/kg @
10-20 min until goals
achieved
PE/hepatomegaly recur
Or PE/hepatomegaly
not resolved, No further
fluids
Fluid refractory dopamine
resistant shock
Continue monitoring
Goals achieved
Shift to ICU
60 min
Fluid refractory, Dopamine/Dobutamine resistant shock
Reassess clinical status, and
Wherever possible, monitor BP, CVP, perform echocardiography, check ScVO2
And Hb and PCCV
Cold shock Warm shock
BP >5th centileHypotensive
Low pulse pressure
ā‰¤ 20 mm Hg
Start epinephrine
< 0.3 Āµg/kg/min
Epinephrine resistant low CO
If BP normal add nitroso
vasidilator or add milrinone
after volume loading
If PP is low-
milrinone
If PP is N-titrate
NE+dobutamine
Hydrocortisone
50 mg/mĀ²/dose
Hypotensive
Wide pulse pressure,
Target-PP < 40 mm Hg
Titrate NE up @
0.1-1 Āµg/kg/min
and fluids
Catecholamine
Resistant Shock
Consider
vasopressin
Thank
You

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Septic shock

  • 2. Severe sepsis and septic shock are the two major causes of death in children with sepsis. The incidence of septic shock is 2 ā€“ 4% of admissions in western PICUs & 40% - 67% for Indian PICUs.
  • 3. Sepsis is the systemic response to infection with bacteria, viruses, fungi, protozoa, or rickettsiae. Severe sepsis is defined as sepsis plus one of the following ā€“ ā€¢ Cardiovascular organ dysfunction or; ā€¢ Acute respiratory distress syndrome or; ā€¢ Two or more other organ dysfunctions. Septic shock in a child with sepsis is defined by the presence of ā€“ ā€¢ Hypotension (systolic BP < 70 mm Hg in infant); (< 70 + 2 Ɨ age after one year) or; ā€¢ Need for any vasoactive drug to maintain BP above 5th centile range or; ā€¢ Signs of hypo-perfusion (any three of the following) or; 1. decreased pulse volume 2. capillary refilling time > 3 sec 3. tachycardia ( > 190/min in newborn; >160 in infants; >110 in a 10 yr child) 4. difference in core to peripheral temp. > 3Ā°C 5. urine output < 1 ml/kg/hr 6. Tache Cerebrale - stroke skin with a blunt instrument -> 30-60 sec -> raised red rash ā€¢ Sepsis and cardiovascular organ dysfunction.
  • 4. Early Recognition of Septic shock The first hours following the diagnosis of severe sepsis and septic shock are known as the ā€œgolden hourā€ as it is during this period that aggressive hemodynamic resuscitation has been shown to be associated with higher survival rates & reduced organ dysfunctions. The major cause of loss of ā€œgolden hoursā€ in our country may be due to ā€“ ā€¢ Delay in recognition ā€¢ Delay in transport ā€¢ Delay in initiating treatment
  • 5. The clinical diagnosis of early septic shock is possible with presence of the following in a case of suspected infection ā€“ ā€¢ Hypothermia or hyperthermia ā€¢ Decreased mental status ā€¢ Prolonged CRT ā€¢ Diminished or bounding pulses ā€¢ Mottled cool extremities ā€¢ Decreased urine output <1 ml/kg/hr BP drops only in late shock & its presence in a child with suspected infection is confirmatory. The shock is further classified as ā€“ Cold shock ā€“ characterized by signs of decreased perfusion with diminished peripheral pulses. Warm shock ā€“ characterized by signs of decreased perfusion with bounding peripheral pulses.
  • 6. PRINCIPLES OF MANAGEMENT Initial treatment of child with septic shock ā€“ This includes aggressive fluid resuscitation of up to 60 ml/kg as boluses of 20 ml/kg of isotonic crystalloid such as Ringer lactate or Normal saline by I/V push in 10 to 15 mins to achieve desired heart rate and blood pressure. Colloids (starch, gelatins) produce greater & more sustained increase in plasma volume, but they may not be readily available. Fluid overload should be assessed by ā€“ ā€¢ Jugular venous distension ā€¢ Increasing liver span ā€¢ Puffy eyelids ā€¢ Signs of pulmonary edema & congestion on chest radiograph
  • 7. If a patient does not respond to aggressive fluid therapy, vasoactive drugs should be started. ā€¢ Dopamine is recommended as the first line agent in a fluid refractory shock, started at a infusion rate of 10 Āµg/kg/min. ā€¢ Dobutamine is to be used as the first choice in children with normal BP & low cardiac output. ā€¢ Mixing of more than one vasoactive drug in the same infusion set is not recommended. ā€¢ Infusion should be prepared in D5% or D5% with NS
  • 8. Management in Intensive care setting ā€“ In case of fluid refractory shock, central venous line should be inserted & vasoactive drugs like dopamine and dobutamine be started. In case of shock refractory to these above drugs, epinephrine & nor- epinephrine can be used depending on whether the child has cold shock or warm shock, respectively. If there is no response to the above catecholamines, then ScvO2 can be monitored & vasodilators/ PDE inhibitors can be added in children with normal BP & cold shock with ScvO2 <70%. In children with low BP, either epi. or nor-epi. can be titrated depending on whether it is cold shock or warm shock.
  • 9. Early initiation of Appropriate Antimicrobial Therapy Administration of broad spectrum antibiotic to cover the likely pathogens (including gram +ve and gram -ve) within 1 h of dx of septic shock as well as reassessment after microbiologic data is available, to narrow the coverage, is recommended. Blood culture should be obtained before starting antibiotic. Source control- All pts. should be evaluated for presence of focus of infection amenable to source control measures like abscess drainage, debridement of necrotic tissue, or removal of infective device.
  • 10. Use of adjuvant therapy like steroid Steroid are to be used only in children with suspected or proven adrenal insufficiency which shows high prevalence in septic shock, especially catecholamine refractory shock. Mechanical Ventilation ā€¢ Due to low functional residual capacity young infants and neonates with severe sepsis may require early intubation. ā€¢ The early use of mechanical ventilation aided by sedation reduces the work of breathing and allows for redistribution of limited cardiac output to vital organs, improves oxygenation and decreases PVR & left ventricular afterload.
  • 11. Blood products Hb conc. Should be maintained at a minimal level of 10 g/dL. Platelet transfusion should be done when PC < 5000/mmĀ³ regardless of apparent bleeding. PC 5000-30,000/mmĀ³ with significant risk of bleeding. Higher PC > 50,000/mmĀ³ are typically required for surgery or invasive procedure. FFP is indicated in- Active bleeding Before surgery Before invasive procedure Reverse warfarin effect
  • 12. Other supportive care Avoid hypoglycemia Prophylaxis for DVT in post-pubertal children Correction of symptomatic hypocalcemia Renal replacement therapy Done for ARF which includes peritoneal dialysis, intermittent hemodialysis, cont. renal replacement therapies IV immunoglobulin IVIg has shown to reduce mortality and length of PICU stay and less progression to complications, esp. DIC.
  • 13. Therapeutic end points of resuscitation of septic shock ā€¢ Normalization of HR ā€¢ CRT ā‰¤ 2 sec. ā€¢ Palpable peripheral pulses with no difference b/w peripheral and central pulses ā€¢ Warm extremities ā€¢ Normal BP and PP ā€¢ UO > 1 ml/kg/hr ā€¢ Return to baseline mental status, tone and posture ā€¢ Normal RR
  • 15. ā€¢Recognize depressed mental status and poor perfusion in a febrile child with or without foci of infection ā€¢O2 by non-rebreathing mask if effortless tachypnea and septic shock ā€¢BMV if arirway unstable, bradypnea, apnea; plan early intubation ā€¢Establish IV/IO access ā€¢Start saline/RL 20 ml/kg over 15-20 min(BP N/High); more rapidly by pull-push if BP is low. ā€¢First dose of antibiotics, correct documented hypoglycemia and hypocalcemia ā€¢Monitor for clinical therapeutic goals after each bolus till all goals are achieved; viz RR, work of breathing, HR, CRT, BP, peripheral temp., UO, sensorium, liver span 0 min 5 min
  • 16. 20 min 40 min Therapeutic goals attained No PE/hepatomegaly Goals not attained No PE/hepatomegaly Goals not attained PE/hepatomegaly 2nd bolus 3rd bolus, if needed Goals not attained PE/hepatomegaly Goals not attained after 60 ml/kg No PE/hepatomegaly Fluid refractory shock Start dopamine, interrupt fluids briefly, intubate, catheterize Start PPV
  • 17. 20 min 40 min Goals not attained PE/ hepatomegaly Goals not attained after 60 ml/kg No PE/ hepatomegaly Fluid refractory shock Start dopamine, interrupt fluids briefly, intubate, catheterize Start PPV Dopamine @ 10-20 microgram/kg/min Consider intubation Catheterize for UO monitoring Cont. fluids in smaller amount, till goals attained or PE/hepatomegaly occur PE and hepatomegaly resolve Goals not attained Titrate 10-20 ml/kg @ 10-20 min until goals achieved PE/hepatomegaly recur Or PE/hepatomegaly not resolved, No further fluids Fluid refractory dopamine resistant shock Continue monitoring Goals achieved Shift to ICU 60 min
  • 18. Fluid refractory, Dopamine/Dobutamine resistant shock Reassess clinical status, and Wherever possible, monitor BP, CVP, perform echocardiography, check ScVO2 And Hb and PCCV Cold shock Warm shock BP >5th centileHypotensive Low pulse pressure ā‰¤ 20 mm Hg Start epinephrine < 0.3 Āµg/kg/min Epinephrine resistant low CO If BP normal add nitroso vasidilator or add milrinone after volume loading If PP is low- milrinone If PP is N-titrate NE+dobutamine Hydrocortisone 50 mg/mĀ²/dose Hypotensive Wide pulse pressure, Target-PP < 40 mm Hg Titrate NE up @ 0.1-1 Āµg/kg/min and fluids Catecholamine Resistant Shock Consider vasopressin