Septilise šoki ravi vastsündinutel Mari-Liis Ilmoja SA Tallinna Lastehaigla

Diagnoos Respiratoorsed häired Teadvushäire teke või süvenemine Perifeerse mikrotsirkulatsiooni häired - perifeerne vasodilatatsioon ( = “ soe šokk “ ) - perifeerne vasokonstriktsioon ( = “ külm šokk” ) Hüpotermia või hüpertermia

From the American College of Critical Care Medicine. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock* Joseph A. Carcillo, MD; Alan I. Fields, MD; Task Force Committee Members From the American College of Critical Care Medicine. CRITICAL CARE MEDICINE 2002;30:1365-1378 Background: The Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome. Objective: To provide American College of Critical Care Medicine clinical guidelines for hemodynamic support of neonates and children with septic shock. Setting: Individual members of the Society of Critical Care Medicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001). Methods: The MEDLINE literature database was searched with the following age-specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task-force chairman modified the document until <10% of experts disagreed with the recommendations. Results: Only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicine-graded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three-fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival. Conclusion: American College of Critical Care Medicine adult guidelines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome. Crit Care Med 2002 June;30(6):1365-1378 Copyright © 2002 Lippincott Williams & Wilkins All rights reserved

Diagnoos + hingamisteed + veenitee 0 min. 5 min. Diagnoos + hingamisteed + veenitee 10 ml/kg 0,9% NaCl või kolloidi boolustena kuni 60 ml/kg. Korrigeeri hüpoglükeemia ja hüpokaltseemia. Alusta prostaglandiini infusiooni kuni duktussõltuva südamerikke väljalülitamiseni.

Vedelikravi Kristalloid või kolloid? Boolused? [c] Gill AB, Wendling AM Echocardiographic assessment of cardiac function in shocked very low birthweight infants. Arch Dis Child 1993;68(1 Spec No):17-21 Kiire infusioon võib põhjustada vere šunteerumist läbi PDA vasakult paremale kongestiivne südamepuudulikkus

CoAo Šokk Hepatomegaalia Tsüanoos ( südamekahin) Alajäsemetel madalam vererõhk ja nõrk pulss

Korrigeeri hüpoglükeemia ja hüpokaltseemia. 0 min. Diagnoos + hingamisteed + veenitee 5 min. 10 ml/kg 0,9% NaCl või kolloidi boolustena kuni 60 ml/kg. Korrigeeri hüpoglükeemia ja hüpokaltseemia. Alusta prostaglandiini infusiooni kuni duktussõltuva südamerikke väljalülitamiseni. 15 min. Vedelik – refraktaarne šokk Tsentraalveen + arter + Dopamin (Dobutrex )

Vasoaktiivne ja inotroopne ravi Dopamin on esmavalik ( kuni 8 g/kg/min) Vastsündinutel võib olla sümpaatiline süsteem välja arenemata [c] Meadows D, Edwards JD, Wilkins RG et al Reversal of intractable septic shock with norepinephrine therapy. Crit Care Med 1988;16:663-66 [c] Desjars P, Pinaud M, Potel G et al A reappraisal of norepinephrine therapy in human septic shock Crit Care Med 1987;15:134-37 Dobutrex (kuni 30g/kg/min) NB! < 1 a. võivad mitte reageerida. Lopez SL, Leighton JO, Walther FJ. Supranormal cardiac output in the dopamine- and dobutamine-dependent preterm infant. Pediatr Cardio 1997;18(4):292-6

Tsentraalveen + arter + Dopamin (Dobutrex) 15 min. Vedelik – refraktaarne šokk Tsentraalveen + arter + Dopamin (Dobutrex) Vedelik – refraktaarne Dopamin resistentne šokk Adrenalini infusioon Süsteemne alkalinisatsioon, kui püsib PPHN ja atsidoos

PPHN = persisteeruv pulmonaalne hüpertensioon Sepsisest tingitud atsidoosist ja hüpoksiast ductus arteriosus ei sulgu GBS šokk põhjustab südame väljutusmahu langust, pulmonaal-, mesenteriaal ja perifeerse vaskulaarse resistentsuse tõusu. Meadow WL, Meus PJ. Early and late hemodynamic consequences of Group B beta streptococcal sepsis in piglets: effects on systemic, pulmonary, and mesenteric circulations. Circ Shock 1986;19(4):347-56 Peevy KJ, Chartrand SA, Wiseman HJ et al. Myocardial dysfunction in group B streptococcal shock Pediatr Res 1994;19(6):511-3

Tsentraalveen + arter + Dopamin +Dobutrex ( Noradrenalin?) 15 min. Vedelik – refraktaarne šokk Tsentraalveen + arter + Dopamin +Dobutrex ( Noradrenalin?) Vedelik – refraktaarne Dopamin resistentne šokk Adrenalini infusioon Süsteemne alkalinisatsioon, kui püsib PPHN ja atsidoos 60 min. Katehhoolamiin – resistentne šokk

Katehhoolamiin – resistentne šokk Ravi vastavalt EHHO, arteriaalse ja tsentraalse venoosse rõhu näitudele: “Külm” šokk “Külm” või “soe” šokk “Soe” šokk Norm RR RR  Vas. vats. funkts  Par. vats. funkts.    Vasodilataator Inhal.NO Adrenalin või PDE I + + vedelik vedelik Refraktaarne šokk

Ravi eesmärk Teadvus Norm. vererõhk ja pulsid diurees > 1 ml/kg/h SaO2 > 95% < 5% pre- ja postduktaalse saturatsiooni vahe EHHO-s : puudub paremalt vasakule šunteerumine, trikuspidaalklapi ja parema vatsakese puudulikkus

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