1. Pediatric Septic Shock
PICU Resident Talk
Stanford School of Medicine
Pediatric Critical Care Medicine
(Updated June 2014)

2. Learning Objectives 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)- Sepsis-
The presence of at least two of the following one of which must be abnormal temperature or leukocyte count.
- Temperature. >38.5 or <36.
- Tachycardia (or bradycardia for children <1yo)
- Tachypnea
- Leukocyte count increased or decreased or > 10% bands.
Sepsis-
SIRS in the presence of suspected or proven infection.
Severe sepsis-
Sepsis plus end organ dysfunction (cardiovascular organ dysfunction OR ARDS OR 2 or more other organ dysfunction)
Septic shock-
Sepsis plus 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. SIRS PRO-inflammatory response IL-1 TNF-alpha
ANTI-inflammatory response
IL-10

7. CARS ANTI-inflammatory response IL-10 PRO-inflammatory response IL-1
TNF-alpha
ANTI-inflammatory response
IL-10

8. Immunologic Dissonance
PRO-inflammatory response
IL-1
TNF-alpha
ANTI-inflammatory response
IL-10

9. What is our goal?

10. Deliver oxygen to end organs!
[1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q

11. Therapeutic Endpoints
capillary refill of < 2 s
normal blood pressure for age
normal pulses with no differential between peripheral and central pulses
warm extremities
urine output ≥1 mL/kg/hr
normal mental status
ScvO2 saturation ≥70%
cardiac index between 3.3 and 6.0 L/min/m2 should be targeted
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.

12. Give oxygen [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q NC Non rebreather
HFNC
CPAP

13. [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q Volume
isotonic crystalloids or albumin boluses of up to 20 mL/kg over 5–10 minutes without inducing hepatomegaly or rales.
If hepatomegaly or rales exist then inotropic support should be implemented, not fluid resuscitation
Surviving Sepsis Campaign 2012

14. [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q
Inotropes/vasopressors/vasodilators
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.

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

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

17. [1.39 x Hb x SaO2 + (0.003 x PaO2)] x Q Transfuse
During resuscitation of low superior vena cava oxygen saturation shock (≤ 70 %), hemoglobin levels of 10 g/dL are targeted
After stabilization and recovery from shock and hypoxemia then a lower target ≥ 7.0 g/dL can be considered reasonable
Surviving Sepsis Campaign 2012
The optimal hemoglobin for a critically ill
child with severe sepsis is not known. A recent multicenter
trial reported no difference in mortality in
hemodynamically stable critically ill children managed
with a transfusion threshold of 7 g/dL compared with
those managed with a transfusion threshold of 9.5 g/dL;
however, the severe sepsis subgroup had an increase in
nosocomial sepsis and lacked clear evidence of equivalence
in outcomes with the restrictive strategy [584, 585].
Blood transfusion is recommended by the World Health
Organization for severe anemia, hemoglobin value\5 g/
dL, and acidosis. A RCT of early goal-directed therapy for
203
pediatric septic shock using the threshold hemoglobin of
10 g/dL for patientswith a SvcO2 saturation less than 70 %in
the first 72 h of pediatric ICU admission showed improved
survival in the multimodal intervention arm

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

19. 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

20. But is it?? ProCESS group, NEJM, 2014
Randomized control, multi institutional study
~1300 adult patients
No difference in protocolized early goal directed therapy (EGDT), protocolized standard therapy and usual care at 60 or 90 day mortality

21. 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

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

23. Take Home Points
Septic shock is due to an imbalance in pro and anti inflammatory response
Therapeutic goal is to deliver enough oxygen to end organs
Early goal directed therapy improves survival (maybe?)