1. Management of Septic Shock Dr Rajath A.

2. Septic Shock Septic shock- once a uniformly fatal condition with 100% mortality. Present recovery rates are upto 50%. Significance: Frequent occurrence and high mortality.

3. Septic Shock I. Introduction. II. Pathophysiology III.Clinical Manifestations IV.Management

4. Introduction. What is shock? Shock is a state of acute disruption of circulatory function, resulting in insufficiency of tissue perfusion,oxygen utilization and cellular energy producion. Low BP is NOT sine qua non of shock.

5. Septic Shock I. Introduction. II. Pathophysiology III.Clinical Manifestations IV.Management

6. Pathophysiology The nidus of infection: –Localised infections ( otitis, pneumonia, meningitis etc.,) –Colonization of mucosal and invasion ( Hib, menigococci) –Occult bacteremia ( 3mo to 3 years ) –Nosocomial : ‘at risk patients’

7. Pathophysiology The Pathogen: Neonates: GBHS, enterobacteriacae, listeria, Staph aureus, HSV. Infants: Hib, Strep pneumoniae, Staph aureus. Children: Strep pneumoniae, N.meningitidis, S.aureus, enterobacteriacae, Hib. Immunocompromised: Enterobacteriacae,Staph, Pseudomonas, Candida. ‘Pathophysiology’Pathophysiology’

8. Pathophysiology The agent - host interaction leads to CHAOS’ ‘ CHAOS’

9. Pathophysiology What ‘type of shock’ is septic shock? Septic shock has features of : –Hypovolemic shock –Cardiac shock –Distributive shock.

10. Septic Shock I. Introduction. II. Pathophysiology III.Clinical Manifestations IV.Management

11. Clinical Manifestations. The Continuum of infection to MODS and Death (Clinical Definitions)

12. Clinical Manifestations. Recognition of Septic Shock: Inflammatory triad- –Fever –Tachycardia –flushed skin Warm Shock Hypoperfusion –Altered sensorium – Urine output –>CFT –Wide pulse pressure.......bounding pulses

13. Clinical Manifestations. Hypotension –Cold and clammy skin –Mottling –Tachycardia Cold shock –Cyanosis –Narrow pulse pressure –Hypoxemia –Acidosis.

14. Clinical Manifestations. Staging of Septic Shock: I.Compensated / Preshock / Hyperdynamic II.Decompensated / Organ hypoperfusion III. End organ failure / Irreversible

15. Septic Shock I. Introduction. II. Pathophysiology III.Clinical Manifestations IV.Management

16. Management Prevention: 1.Immunisation 2.Prompt treatment of local infections 3.Hospitalized patient: look out for nidus of infection- IV lines, catheters, E.tubes

17. Management Recognise septic shock early: Remember- Inflammatory triad Signs of hypoperfusion Do not wait for the BP to fall ! Lower limit for systolic BP = 70 +( age x 2)

18. Management. Two means of death: 1.Shock. 2.Multi organ failure. Aims of treatment: 1.Assure perfusion of critical vascular beds. ( cerebral, coronary, renal) 2.Rx underlying cause.

19. Management STEPS 1. Prevent / correct hypoxemia: Supplement oxygen 95-100%. 2. IV access: peripheral vein. 3. If IV access fails: Intraosseous line. 4. Fluid resuscitation: 20mL/Kg NS or RL as bolus, repeat upto 60 mL/Kg. End point : Improved perfusion.

20. Management STEPS Improved perfusion => a. CFT b. Warmth c. Strong pulses d. mental status e. Tachycardia f. BP (ideal = 90 + age x 2; Min = 70+ age x 2) g. Urine output.

21. Management STEPS 5. Establish a 2nd IV line for Dopamine infusion (Draw blood for culture)Dopamine infusion 6. Administer IV antibiotics <2 mo:Ampicillin + gentamicin or Ampicillin+ceftriaxone/cefataxime >2mo: Ceftriaxone or Cefotaxime alone or Ampicillin + Chloramphenicol

22. Management STEPS 7. Correct metabolic derangement: –Metabolic acidosis.Metabolic acidosis. –Hyper or hypoglycemia : always correct hypoglycemia.

23. Management STEPS 8. DIC: Restoration of normovolemia reverses abnormal activation. ‘Component replacement’ (Goal - Normal PT, PTT, fibrinogen, PC = 40,000 to 1 Lakh/cumm.) a. FFP - most beneficial in early stages. b. Cryo- consider 1 unit/3 units of FFP transfused. c. Platelet concentrate

24. Management STEPS 9. Recognize and manage organ failure: a. Cardiovascular support: Rate & rythm- correct 0 2, acidosis, Ca, Mg, K variations Stroke volume - fluid correction & replace losses Ionotrope support.

25. Management STEPS 9. Recognize and manage organ failure: b. Renal: Volume replacement Low dose dopamine ?diuretic with vol expansion Indications for dialysis: Hyperkalemia refractory metabolic acidosis Anuria despite diuresis BUN>100mg%

26. Management STEPS 9. Recognize and manage organ failure: c. Respiratory support: Supplement 0 2, Early intubation and PPV ( PEEP) d. GI: Antacids, sucralfate, early enteral nutrition.

27. Monitoring a Child With Septic Shock. Frequent monitoring is MOST IMPORTANT to recognise and Rx complications. 1. Pulse5. Urine output. 2. BP6. ABG 3. Level of consciousness7. PT/PTT/PC 4. 0 2 saturation8. CVP

28. Management- summary. Five important points 1. ABC, supplement 0 2 always. 2. IV or IO access and fluid resuscitation upto 60 mL/Kg. 3. Early dopamine infusion @10µg/Kg/min 4. Empirical antibiotic. 5. Frequent monitoring.

29. References 1.Nelson TB of Pediatrics. 16th edn. 2.Medical Emergencies in Children- Meharban singh 3.PALS: 1997, AAP & AHA. 4.PCNA: Intensive Care. 1987. 5.TB of Pediatric Critical Care- P.R.Holbrook 6.Handbook of PIC- Rogers & Hefaler 7.Various Speakers: Critical Care CME, May 2002