New concept of Pediatric Septic

Shock: Initial resuscitation

Novik Budiwardhana
*Pediatric cardiac intensive care
Objectives
• To discuss about Pediatric septic shock: what
is the magnitude
• To discuss about the current concept which
will be applied as “guideline”
• The Algorythm
Objectives
• To discuss about Pediatric septic shock: what
is the magnitude
– Is it really that big?
• To discuss about the current concept which
will be applied as “guideline”
• The Algorythm
Quick answer: YES
• Carolin Fleischmann et al: Hospital treated
sepsis 148/100000 person years with
mortality up to 17%
• Still unacceptable
Am J Respir Crit Care Med. 2016 Feb 1;193(3):259-72
Quick answer: Yes (2)
• Indonesia:
– RSCM, as national refferal center records the
incidence of 19,3% out of 502 patients admitted
to that hospital
– Mortality 54%
• Other centers revealed mortality 50 – 80%
Quick answer: Yes (3)
• Indonesia:
– Limited epidemiology literature in Indonesia
– If any.. use different terminology and different approach
making it difficult to evaluate the efficacy of a guideline
• Shock  dengue
– making it clear that septic shock is a big challenge

“
“
Jurnal of Pediatric infectious disease 2009 (4)
Quick answer: Yes (4)

Pre-post protocol study (Aggressive vs WHO group)

Lower mortality in aggressive group (16,6% vs 6,3%)
Aggressive group means ACCM/ PALS algorythm
Septic shock Vs Dengue shock
syndrome
Septic shock Dengue shock syndrome
Fever is always be a presenting symptom Aphyrexial at onset of shock
Tachycardia Relatively bradicardic
Vasodilatation or vasoconstrictive Predominantly vasoconstrictive at
admission
SIRS Less SIRS
Normal or wider of pulse pressure Pulse pressure is usually narrow

• Shock  dengue
• “Viral” pediatric septic shock is a different entity but aggressive
management as in ACCM/PALS guideline is beneficial
• making it clear that septic shock is a big challenge
Is Pediatric septic shock a big
problem?
• Pediatric septic shock is a big challenge
• Mortality hospital treated sepsis is improving
• Management of pediatric septic shock
requires significant effort in order to lower
mortality rate A GUIDELINES
Objectives
• To discuss about Pediatric septic shock: what
is the magnitude
• To discuss about the current concept which
will be applied as “guideline”
• To discuss the current practice of Pediatric
septic shock. Which will be most feasible?
 Latest definition
• Sepsis is now a term that refers to the term of
severe sepsis in 2012 guidelines
• Sepsis is now defined as life-threatening organ
dysfunction caused by a dysregulated host
response to infection (SEPSIS 3)
• Septic shock is a subset of sepsis with
circulatory and cellular/metabolic
dysfunction associated with a higher risk of
mortality
Diagnosis armametarium
• Shock should be clinically diagnosed before
hypotension occurs
• The earlier the founding  determine outcome
• Carcillo et.all: specific hemodynamic instability in
ED determine the progressive mortality:
– Eucardia (1%), Tachycardia or bradycardia(3%) <
Hipotensive + capillary refill time < 3 secs (5%) <
normotensive + capillary refill time >3 secs (7%) <
hypotension + capillary refill time >3 secs (33%)
Hypotension
Septic shock
• The American Heart Association, in the course
on pediatric advanced life support (PALS),
defines infants with fifth–percentile systolic
blood pressure as follows:
• Newborn - 60 mm Hg
• Infant (1 mo to 1 y) - 70 mm Hg
• Child (>1 y) - 70 + 2 X age (in y)

Do not wait until

hypotension occurs!!
 Tricky parameters in
Pediatrics septic shock
• SIRS should have abnormal leukocyte count and
temperature.
• Pediatric sepsis involves newborn LCOS could be
caused by
– Remember PPHN or Duct dependent systemic
circulation
• Different age-groups different norm liter of
hemodynamic profile
• Requires significant effort to measure cardiac
index
 Tricky lab parameter
in pediatric septic shock
• Evidence of Infection
– Blood culture to guide antibiotic therapy 3 days
– Procalcitonin and other surrogates
• Surrogates marker to detect LCOS:
– Mixed vein saturation or SCVO2
– Lactate level
– PiCCO, USCOM
SSC 2016 No Pediatric consideration
• First hour goal: Restore and maintain HR threshold, capillary
refill ≤2 secs and normal BP in emergency department.
Support oxygenation and ventilation as appropriate
• Subsequent ICU goal: Intervene to restore and maintain
normal perfusion pressure, SCVO2 >70% and CI. 3,3
L/min/m2)
IDAI Recommendation
 What is new in initial resuscitation?
• We recommend that, following initial fluid resuscitation, additional
fluids be guided by frequent reassessment of hemodynamic status.
– Remarks: Reassessment should include a thorough clinical
examinaon and evaluaon of available physiologic variables (heart
rate, blood pressure, arterial oxygen saturation, respiratory rate,
temperature, urine output, and others,as available) as well as other
noninvasive or invasive monitoring,as available.
• We recommend further hemodynamic assessment (such as assessing
cardiac function) to determine the type of shock
– if the clinical examination does not lead to a clear diagnosis (BPS).
• We suggest that dynamic over static variables be used to predict fluid
responsiveness, where available (weak recommendaon, low quality of
evidence).
Challenges
• Providing PGE1 in neonatal septic shock with
duct dependent lesion
• Dynamic hemodynamic monitoring not just
static
– Passive leg raising
– Pulse pressure variation
– Echo study
– USCOM study
– Lactate
Challenges
• Vasoactive agent in new guidelines first
choice is norepinephrine
– In pediatrics SSC 2012 and IDAI
recommendation
– Dobutamine iv periphery is recommended since
2007
Crit Care Med 2009; 37:666-688
Challenges
– The needs of central venous line
• The important:
– Delivery of drug which is incompatible with peripheral line
– Measure SCVO2

• Timing:
– Fluid refractory shock
– The need of other vasoactive drugs
Objectives
• To discuss about Pediatric septic shock: what
is the magnitude
• To discuss about the current concept which
will be applied as “guideline”
• The algorythm
PGE1
IDAI Recommendation
Implementing the guidelines
CVP line Level 3 CVP line, mechanical Arterial and CVP
ventilation, monitoring,
Continuous ECG Multi
optimization of fluid, measurement of
discipline
monitoring, vasoactive drugs and
Invasive Academic SCvO2, blood
Oxygen delivery
monitoring Hospital gases and lactate

Rapid fluid infusion, Continuos ECG and

O2, IO lines, Culture, source infection pulse oxymetri
urine SpA, control, dopamine,
catheter, Blood pressure,
dobutamin, inodilator (?),
antibiotics , B type intubation and manual
urine output,
ETT, dopamin- hospital ventilation. Correction of
dobutamin hypoglicemia

Intubation, rapid fluid Physical

challenge, Dopamine, examination, non
correction hyp- invasive BP
O2, IV Puskesmas, general oglycemia
line Practitioner

Feasible management Feasible monitoring

First thing first
• Registering the cases
• Using definition in IDAI recommendation on
Pediatric sepsis  the literature will be
structurally well-defined
• Pre and post protocol study will lead us to
better protocols
• Pediatric sepsis initiative at
www.pediatricsepsis.org
What is feasible
• Basically everything in the guidelines
• Standardized Emergency department and its
equipment
• Standardized PICU and its equipment
• PICU  skilled personel
Summary
• Pediatric septic shock is still a big problem
• Epidemiology studies with standard definition
is required
• The feasibility to implement the guideline
should be a continuing effort
Thank you