1. Pediatric Septic Shock
PICU Resident Talk
Stanford School of Medicine
Pediatric Critical Care Medicine
June 2010

2. Learning Objectives
After this lesson, the participant will be able to:
Distinguish the terms SIRS, sepsis & septic shock.
List physiologic changes that occur in sepsis and explain how each factor affects O2 demand/ delivery.
Understand the rationale for goal directed therapy in septic shock

3. Septic Shock
Systemic inflammatory response syndrome (SIRS)- The presence of at least two of the following one of which must be abnormal temperature or leukocyte count.
- Temperature. >38 or <36.
- Tachycardia
- Tachypnea
- Leukocyte count increased or decreased or > 10% bands.
Sepsis- SIRS in the presence of infection.
Severe sepsis- Sepsis plus end organ dysfunction i.e. ARDS, renal dysfunction, coagulopathy.
Septic shock- Sepsis plush cardiovascular organ dysfunction.
Goldstein et al. Pediatr Crit Care Med 2005

4. American College of Critical Care Medicine Hemodynamic Definitions of Shock
Brierley, Carcillo et al. Pediatr Crit Care Med 2009

5. Sepsis leads to micro-vascular occlusion, vascular instability, and organ failure through complex interactions between pathogens, immune cells, and the endothelium.
Cohen, Nature 2002

6. The predominant cause of mortality in adult sepsis is vasomotor paralysis.
Parker, et al. Crit Care Med. 1987

7. Contrary to adults low cardiac output not low SVR is associated with mortality in septic shock in children.
Pollack et al. Crit Care Med 1984, 1985

8. Early Intervention in the treatment of septic shock is vital: The first hour in the ED
Maintain and restore airway, oxygenation, and ventilaton
Therapeutic endpoints
Monitoring
Goals- Maintain or restore airway, oxygenation and ventilation.
Therapeutic endpoints-
Capillary refill less than or equal to 2 seconds
Normal pulses, blood pressure
Warm extremities
UOP > 1 cc/kg/hr
Normal mental status
Normal glucose and ionized calcium
Monitoring- Pulse oximeter, Continous HR montior, blood pressure, tempurature, urine output, glucose and calcium.

9. Therapeutic Endpoints
Fluid Resuscitation & Hemodynamic Support
Threshold heart-rates
Age appropriate perfusion pressure
UOP > 1 cc/kg/hr
CI> 3.3 and less than 6 L/min/m2
Scvo2 >70%
Normal perfusion
CRT< 2 seconds
Normal INR, anion gap, lactate
Goals/Therapeutic endpoints-
Normal perfusion
capillary refill ≤ 2 sec
threshold heart rates
perfusion pressure (MAP-CVP, MAP-IAP)
Scvo2 >70%
CI> 3.3 and less than 6 L/min/m2
UOP > 1 cc/kg/hr
Normal INR, anion gap, lactate
Monitoring- Pulse oximetry, EKG, Arterial line, temperature, Foley, CVP, Svo2, PA, CO, glucose , calcium, INR, lactate, and Ion gap.

10. Hemodynamic Support Hydrocortisone therapy-
In the fluid refractory patient begin a peripheral inotrope while establishing central access.
If dopamine refractory start epinephrine in cold shock.
If dopamine refractory start norepinephrine in warm shock.
Goal is normal perfusion and blood pressure.
Hydrocortisone therapy-
Start hydrocortizone in at risk patients.
Purpura fulminans
CAH
Recent steroid exposure
Hypothalamic/pituitary abnormality
Refractory shock
Try to obtain a baseline cortisol level
Intermittent or continuous infusion.
Dose ranges from 1-2 mg/kg/day for stress coverage to 50 mg/kg/day titrated to the reversal of shock.

11. Consider CI, BP, and SVR when implementing CV support.
Low CI
Normal blood pressure
High SVR
Afterload reduction may improve blood flow by increasing ventricular emptying.
Nitroprusside
(Beware of Cyanide toxicity)
Milrinone.
Low CI,
Low blood pressure
Low SVR
Norepinephrine can be added to epinephrine to increase DBP and SVR.
Once adequate BP is reached dobutamine, or Milrinone can be added to improve CI and Scvo2.
Hemodynamic support-
May be required for several days in children with fluid refractory and dopamine resistant shock.
May present with low CO/high SVR, high CO/low SVR, low CO/low SVR.
Hemodynamic states may change with time.
CO can be monitored with pulmonary artery catheter, femoral artery thermodilution catheter, or doppler ultrasound when poor perfusion persists in spite of therapy guided by clinical exam.
High CI
Low or normal
Blood Pressure
Low SVR
Norepinephrine, fluid
If shock persists consider Vasopressin

12. Pediatric Septic Shock Algorithm
Brierley, Carcillo et al. Pediatr Crit Care Med 2009

13. Refractory Shock?? ? ? ? ? Immune? Mechanical Problem?
Pericardial effusion
Pneumothorax
Increased abdominal
Pressure.
Necrotic tissue.
Ongoing blood loss
Excessive immunosuppression
Uncontrolled infection ? ? ?
Endocrine? ?
Hypothyroid
Hypoadrenal

14. Early Goal directed therapy resulted in a 40% reduction in mortality compared to control in adult patients with septic shock.
Rivers et al. NEJM 2001

15. Early Shock REVERSAL resulted in 96% survival versus 63% survival among patients who remained in persistent shock state
Every hour that went by with out restoration of normal blood pressure was associated with with a two-fold increase in adjusted mortality odds ratio.
Han, Y. Y. et al. Pediatrics 2003

16. Goal directed therapy causes a significant reduction in 28 day mortality in children with septic shock
Oliveira et al. Intensive care med 2008

17. Summary of Key Points
Early goal directed therapy can improve outcomes in septic shock
Pediatric septic shock is different from adult septic shock