The Role Of Cardiac Index and

Oxygen Delivery in Septic Shock

Indra Saputra
Divisi
Emergensi Rawat Intensif Anak
Bagian Ilmu Kesehatan Anak RSMH/FK UNSRI
• No conflict of interest
Outline
• Background
• Fluid bolus therapy
• Hemodynamic parameters
• Cardiac Index in septic shock
• DO2 in septic shock
• The global burden of sepsis and septic shock is high in pediatric
intensive care units (PICUs) with prevalence studies suggesting
mortality rates ranging from 6 to 25%
• Septic shock is a syndrome characterized by abnormal oxygen
utilization
• Fluid bolus therapy (FBT) is the central component of resuscitation of
children with sepsis
• FBT improve the circulating volume, cardiac output and mitigate
circulatory dysfunction and organ hypoperfusion.
• Data supporting current pediatric sepsis guidelines are limited
Carcillo JA, Fields AI,. Crit Care Med. (2002) 30:1365–78.

Boeddha NP, Schlapbach LJ, Driessen GJ, Herberg JA, Rivero-Calle I, CebeyLópez M, et al. Crit Care (2018) 22:143.

Weiss SL, Fitzgerald JC, Pappachan J, Wheeler D, Jaramillo-Bustamante JC, Salloo A, et al. Am J Respir Crit Care Med. (2015) 191:1147–57.
Tan et al.JAMA Pediatrics April 2019 Volume 173, Number 4
Dellinger et al.Surviving Sepsis Campaign Guideline. Intensive Care Med (2013) 39:165–228 DOI 10.1007/s00134-012-2769-8
Kumar et al.Critical Care Med. 2006
• The pathophysiology and haemodynamic patterns in septic shock are
complex, dynamic and not easily determined clinically.
• The pathophysiological hallmarks of septic shock are cytokine and
nitric oxide mediated inflammation, activation of the coagulation
cascade, manifesting as myocardial, endothelial, and organ
dysfunction.
• Therapeutic targets in the acute management of septic shock are
fundamentally aimed at matching oxygen delivery to demand by
improving cardiac output for which the key targets are macrovascular.

Greer JR. Pathophysiology of cardiovascular dysfunction in sepsis. BJA Educ. (2015) 15:316–21
• The goal in the treatment of shock is, therefore, to increase oxygen
delivery (DO2) to meet oxygen demand in order to resolve the global
tissue hypoperfusion
• Resuscitation of shock at the bedside is dependent on optimizing the
components of CO and CaO2: Preload, afterload, contractility,
hemoglobin, and oxygen saturation
• No single marker guarantees adequate oxygen delivery or organ
perfusion
• A multimodal approach that combines different parameters
Heffner AC, Robinson MT: Fluid management. In: Critical Care.Emergency Medicine, edited by Farcy DA, Chiu WC, Flaxman A, Marshall JP, New York, The McGraw-Hill Companies,2012, chapter 47
 Hemoglobin
(Hb)

Arterial Oxygen Oxygen Saturation

Content (CaO2) (SaO2)

Partial Pressure
DO2 Of Oxygen (PaO2)

Heart rate

Cardiac Output
Preload
(CO)

Stroke Volume Contractility

Afterload
Greer JR. Pathophysiology of cardiovascular dysfunction in sepsis. BJA Educ. (2015) 15:316–21
 EVLW
SV

Large increase in EVLW

Sepsis
Smal increase in CO

Large increase in CO
Small increase in EVLW

Preload

Marik P. The Physiology of Volume Resuscitation.Curr Anesthesiol Rep (2014) 4:353–359

 ARDS, Sepsis
Normal
Critical delivery
Critical delivery
treshold point

O2 Consumption ( VO2)

t
en
Supply independent

nd
pe
de
pl y
p
Su

Systemic oxygen delivery ( Cardiac Output x CaO2)

Roberts K.AnnalsATS Volume 12 Number 6| June 2015

Oxygen delivery is responsive to (patho-)physiological changes in any of the 3 components of
DO2 (Hb,oxygenation, and CO) and changes in VO2

H.S. Lim.Clin. Cardiol. 39, 8, 477–483 (2016)

• Fluid bolus therapy resulted in a transient increase in CI in children with sepsis and
acute circulatory failure.
• Fluid responsiveness was not sustained in the majority of cases
Long et al.Cardiac Index Changes With Fluid Bolus Therapy in Children With Sepsis—An Observational Study. Pediatric Critical Care Medicine. 2018
Kaufman,Rackow, Felk.The Relationship Between Oxygen Delivery and Consumption during Fluid Resuscitation of Hypovolemic and Septic Shock. CHEST I 85 I 3 I MARCH. 1884
 Pre FBT Post FBT Hemodilution

Fluid bolus therapy make hemodilution and cause decresing of Hemoglobin concentration

Saputra I,Pudjiadi AH, Yuniar I.Cardiac Index and delivery oxygen change in pediatric septic shock.Children's Health Care (Submitted)
Take home message
• Early recognize and early treatment can reduce the mortality of sepsis
• Septic shock is complicated that need multimodal monitoring
• End of resuscitation is rapid restoration of perfusion
• No single marker guarantees adequate oxygen delivery or organ
perfusion
 Thank You

CERIA

CEGAH SEPSIS SEDARI AWAL