EGDT - PICU-NICU-Bandung-2016-DadangH

Early Goal Directed Therapy
Management of Pediatric
Sepsis and Septic Shock
2016
Dadang Hudaya Somasetia
Pediatric Emergency and Intensive Care Working Group
Indonesian Pediatric Society
(UKK Emergensi dan Rawat Intensif Anak [ERIA] PP IDAI)
PICU-NICU8 Bandung, 20/4 16 1

DISCLOSURE STATEMENT
Dr. Dadang Hudaya Somasetia has documented that:
he has nothing else to disclose.
His clinical practice presentation involves discussion of
Pediatric Early Goal Directed Therapy 2016
No Disclosures or conflicts of interest

What Defines Shock?
• Shock is a syndrome that results from inadequate
oxygen delivery to meet metabolic demands
• Sequelae of shock are metabolic acidosis, organ
dysfunction and death
Abnormal Perfusion
Flash Capillary Refill
Capillary Refill > 2 seconds (early phase)
OR
Cold Clammy Extremity
Hypotension (late phase)
Shock: Basic Relationships of Cardiovascular Parameters
EARLY SHOCK (compensated ): Compensated shock
Decompensated shock
Tachycardia and
Irreversible shock
Prolonged capillary refill time
(↑ HR & SVR ) Preload - Hypovolemic
Detected ASAP
Stroke Myocardial - Cardiogenic
CO = HR x SV Volume Contractility
Cardiac Afterload - Obstructive
Output Heart
Rate
Blood
Pressure
Systemic Adequate Systemic Perfusion
Vascular Should be Maintained
Resistance
- Distributive (Septic) Shock: Preload, MC and SVR

General Consequences of Sepsis:
Vasodilation + hypotension
• liberation of bacterial endotoxin (cell-wall lipopolysaccharide)
that reduces vascular tone and ↑capillary permeability with
loss of fluid into the extravascular space resulting in
hypovolemia
Increased capillary permeability + interstitial edema
Capillary endothelium damaged by a number of factors:
• DIC, microemboli
• release of vasoactive compounds
• complement activation
• adhesion and extravascular migration of leucocytes
Fluid leaks into the interstitial compartment causing edema
• pulmonary edema + ARDS
• due to ↑permeability of the alveolar capillary endothelium
resulting in impaired gas exchange and hypoxia
Metabolic Consequences of Sepsis:
Gluconeogenesis
•Endocrine, Metabolism & Exercise
•formation of glycogen from noncarbohydrates, such as protein or fat,
by conversion of the latter to glucose
•stimulated by increased glucagon and catecholamine levels
associated with insulin resistance
Anaerobic metabolism
•insufficient O2 delivery to the tissues (tissue hypoxia) results in ↑anaerobic metabolism
through glycolysis with the formation of lactic acid from pyruvate
•this is an energy inefficient process that results in the formation of large amounts of lactic acid
•hepatic hypo-perfusion means that lactic acid is unable to enter the Cori cycle to convert the
lactic acid back to glucose
Metabolic acidosis
•↓pH through the depletion of HCO3 from ↑metabolic acid compensated by:
chemical buffering (mins → hrs)
respiratory compensation (hrs → days)
renal correction (days → weeks)
Catabolism
•is a general catabolic state
•associated with hypermetabolism and fever
By Michael Wirth
Stage of Shock
1. Compensated (early stage)
2. Decompensated (late stage)
Type of Shock
3. Irreversible (terminal stage) 1. Hypovolemic
Progressive Process 2. Distributive
3. Cardiogenic
4. Obstructive
5. Dissociative
Where are SEVERE SEPSIS and SEPTIC SHOCK?

Therapy Across the Sepsis Continuum
Infection SIRS Sepsis Severe Sepsis Septic Shock
Microorganism A clinical SIRS with Sepsis with Refractory

invading response arising a
from a nonspecific organ failure hypotension
sterile tissue presumed
•
insult, with 2 of Vascular
or
the following: collapse
T >38oC or <36oC confirmed
infectious • Renal
HR >90 beats/min
RR >20/min process • Hemostasis
WBC • Lung
>12,000/mm3 or
<4,000/mm3 or
>10% bands
PICU-NICU8 Bandung, 20/4 16 Chest 1992;101:1644 8

The Sepsis Continuum
Goldstein B, Giroir B, Randolph A.
Definitions for sepsis and organ
dysfunction in pediatrics.
Pediatr Crit Care Med 2005;6:2-8.
Sir, always remember this:

SIRS always present before Shock
Infection/Burns,
Trauma SIRS Sepsis Severe Sepsis
SIRSor
At least 2 of the following (temp. SIRS with a Sepsis + > 1 system
At least should
leucocyte 2 of the following (temp.presumed
be present): or
confirmed
or
leucocyte should
organ be present):
failure.
1. Core temp. > 38.5°C or < 36°C Persistent
infectious
2. Tachycardia, a mean HR > 2SD hypotension
1. Core temp. >
above normal for age38.5°C or < 36°C
process
2.
3. Tachycardia,
Mean RespiratoryaRate mean> 2SDHR > 2SD above normal for age
above normal for age
Septic Shock
3. Mean Respiratory Rate > 2SD above normal for ageHypotension
Refractory
4. Leucocyte count or  for age or
4. >10%
Leucocyte
immaturecount or  for age or >10% immature neutrophils
neutrophils
PICU-NICU8 Bandung, 20/4 16
Death 9
Pediatric Assessment Triangle (PAT)
SHOCK
Wo
e
rk
nc
Abnormal Normal
of
ara
Br
pe
UKK
ea
Ap
thi
ERIA
ng
Circulation to Skin
Abnormal

Initial Evaluation in Early Septic Shock:
Physical Exam Findings
• Neurological: Altered mental status,

• Skin and extremities: Cool, pale, mottling,
cyanosis, poor cap refill/CRT, weak/bounding
pulses, poor muscle tone
• Cardio-pulmonary: Tachycardia, tachypnea,
BP is maintained by homeostatic regulatory
• Renal: Scant, concentrated urine

Management of Septic Shock-EGDT
Early goals are: Target: good perfusion

Normal heart rate a. CRT < 2 sec.
Capillary refill < 2 secs b. Warmth
Normal blood pressure c. Strong pulses
(Normal lactate) d. Mental status ~ N
A time-sensitive manner - GCS/AVPU
e. Tachycardia ~ N
f. BP: Ideal = 90 + age x 2;
Minimum = 70+ age x 2
g. Urine output >1mL/kg/hr.
Clinical Manifestations of Septic Shock
Recognition of Septic Shock:
Inflammatory triad
– Fever
– Tachycardia
– flushed skin
Early
Hypoperfusion
Warm Shock
– Altered mental status
– Urine output
– CRT >2 sec
– Wide pulse pressure.......
bounding pulses
Clinical Manifestations of Septic Shock
Recognition of Septic Shock:
Hypotension
– Cold and clammy skin
– Mottling
– Tachycardia Late
– Cyanosis Cold Shock
– Narrow pulse pressure
– Hypoxemia
– Acidosis.
What if I work in Office/Praktek Dokter Perorangan,
PUSKESMAS or RSUD type D or PPK1 ?
Early goal directed therapy (EGDT) in the community
is also associated with improved outcome
Goal-Directed Management of Pediatric Shock in the Emergency Department.
Joseph A. Carcillo, MD, Kato Han, MD, John Lin, MD, Richard Orr, MD
Early recognition of tachycardia, prolonged capillary refill, and hypotension at triage. Sets
out a time-sensitive 3-step process: establishment of emergency vascular access, goal-
directed stepwise administration of fluid therapy, and infusion of epinephrine (in some cases
with hydrocortisone) for reversal of shock within the first hour of arriving in the emergency
department (and community health care).
Goals: reversal of prolonged capillary refill, hypotension and improved shock index.
Clin Ped Emerg Med 8:165-175 C 2007 .
Early inotropes & vasopressors?
Early recognition & Intervention Early hypoglicemia correction?
Early fluid resuscitation Early hypocalcemia correction?
Early antibiotic Early blood transfusion?
Early steroid? (Early transfer?)
SEPTIC SHOCK
Aggressive treatment by optimizing O2 delivery
Supplemental O2 and/or ventilation

Optimal HgB or O2 carrying capacity
Optimal cardiac output
Preload - volume resuscitation
Afterload - vasoactive treatment
Contractility - inotropic support
(And early antibiotic for septic shock)
EARLY FLUID RESUSCITATION IS ESSENTIAL
IN SEPTIC SHOCK
Type of Fluids
Colloids Crystalloids Others
x
Albumin NaCl 0.9% Glucose 5-10%
Natural
NaCl 3%
RL Mannitol 20%
Dextran
Semisynthetic RA Electrolyte
Gelatin concentrates
Balanced
HES Fluid Etc.
(Hydroxyethyl starch)
Ringerfundin®
consist of : Hypertonic
electrolytes Saline Lactate
May consist of :
& high
macro molecule consist of : concentration of
electrolytes
PICU-NICU8 Bandung, 20/4 16 electrolytes 17
EARLY FLUID RESUSCITATION IS ESSENTIAL
IN SEPTIC SHOCK
• Optimize preload
• NS, RL, RA, Balanced Fluid, Colloids,
(Hypertonic Sodium)
• Rapid bolus 20mL/kg BW every 5-10 minutes
Reassess after every bolus (2-3 times).
• At 60mL/kg BW consider: fluid overload,
ongoing losses, adrenal insufficiency,
intestinal ischemia, obstructive shock.
Get CXR, place CVC (if available).
• May need inotropes in fluid resistant shock.
CRITICAL CARE IN
LOW INCOME COUNTRIES
Early Goal Directed Therapy (EGDT) for

Severe Sepsis and Septic Shock
Triage and emergency care
– Move away from ‘first-come-first-served’ approach
– Quick identification of sickest patients
– Protocols for emergency treatments
– Nurses or clinical officers
– Some evidence for this approach in pediatrics
Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson
RS, Westerman ME, et al.
Early reversal of pediatric-neonatal septic shock by
community physicians is associated with improved
outcome. Pediatrics. 2003;112:793-9.
Small action
Big impact

Pediatr Crit Care Med 2009; 10:597– 600
Pediatr Crit Care Med 2009; 10:597– 600
Study assuring quality with the usage of guidelines

(Pediatr Crit Care Med 2011; 12:494–503)
World Federation of Pediatric Intensive Care and
Critical Care Societies: Global Sepsis Initiative*
Niranjan Kissoon, MD; Joseph A. Carcillo, MD; Victor Espinosa, MSc;
Andrew Argent, MD, PhD; Denis Devictor, MD, PhD; Maureen Madden, RN,
MSN; Sunit Singhi, MD; Edwin van der Voort, MD; Jos Latour, RN, PhD; and
the Global Sepsis Initiative Vanguard Center Contributors
• Conclusions: Niranjan Kissoon
• Success in reducing pediatric mortality and morbidity,

evaluated yearly as a measure of global child health care
quality improvement, requires ongoing active recruitment
of international participant centers. Please join us at
http://www.pediatricsepsis.org or http://www.wfpiccs.org.
(Pediatr Crit Care Med 2011; 12:494–503)
Critical care and illness in the world’s least
developed countries: a systematic review
Dhillon et al, ATS 2010
• Limited literature describing critical illness and

care from the world’s least developed countries
despite a great burden of illness and high early
mortality rate
• Unfunded
• Infections

EGDT, ProCESS, ARISE, ProMISe
ProCESS: Protocolized Care for Early Septic Shock

ARISE: Australasian Resuscitation in Sepsis Evaluation
ProMISe:
PICU-NICU8Protocolized
Bandung, 20/4 16 Management in Sepsis 27
Kumar et al. (24 centers in Canada and the US)
Early recognition and treatment save lives
1_ The ProCESS Investigators: A randomized Trial of Protocol-Based Care for Early
Septic Shock. N Engl J Med: March 18, 2014 //
2_ The ARISE Investigators and the ANZICS Clinical Trials Group: Goal-Directed
Resuscitation for Patients with Early Septic Shock. N Engl J Med: October 1, 2014. //
3_ Kumar A, Roberts D, Wood KE, et al.: Duration of hypotension before initiation of
effective antimicrobial therapy is the critical determinant of survival in human septic
shock. Crit Care Med, 34: 1589-1596, 2006.
STOP SEPSIS
SAVE LIVES

28
ProCESS

Septic shock definition and guidelines
Pediatric
sepsis
Recommendations guidelines:
for sepsis summary
2007 update management in for
from resource limited resource-
Surviving American settings limited
Sepsis College countries
Campaign Critical Care
2012 Medicine
• Studies testing shock septic guidelines
• Differences and benefits of each shock septic guidelines
Septic Shock Definition
• Despite administration of isotonic intravenous fluid bolus 40
mL/kg in 1 hr:
– Decrease in BP (hypotension) 5th percentile for age or systolic
BP 2 SD below normal for age
» OR
– Need for vasoactive drug to maintain BP in normal range
(dopamine 5 g/kg/min or dobutamine, epinephrine, or norepinephrine
at any dose)
» OR
– Two of the following:
• Unexplained metabolic acidosis: base deficit 5.0 mEq/L
• Increased arterial lactate 2 times upper limit of normal
• Oliguria: urine output 0.5 mL/kg/hr
• Prolonged capillary refill: 5 secs
• Core to peripheral temperature gap 3°C
Goldstein B, dkk. International pediatric sepsis consensus conference: definitions for sepsis and
organ dysfunction in pedaitrics. Pediatr Crit CareBandung,
PICU-NICU8 Med. 2005
20/4 16 31
Dellinger RP, dkk. Surviving sepsis campaign: international guidelines form management of severe
sepsis and septic shock: 2012. Crit Care Med. 2013
Surviving Sepsis Campaign 2012
3 HOURS BUNDLES
–SEVERE SEPSIS
6 HOURS BUNDLES
– SEPTIC SHOCK
Dellinger RP, dkk. Surviving sepsis campaign: international guidelines form

management of severe sepsis and septic shock: 2012. Crit Care Med. 2013
PEDIATRIC
CONSIDERATION
Adopted from 2007 Update

from American College of
Critical Care Medicine
Joe Brierley et al 2009 PICU-NICU8 Bandung, 20/4 16 34
Children blood volume = 80 mL/kg BW
25/100 x 80 mL/kg BW = 20 mL/kg BW
Figure 1 Systemic vasoconstriction can maintain MAP and perfusion pressure

despite hypovolemia and reduced CO, so shock must be recognized as
tachycardia and prolonged capillary refill before hypotension occurs.
JA Carcillo et al. Management of pediatirc shock in the ED. Clin Ped Emerg Med 8:165-175 C 2007
2007 Update from American College of Critical Care Medicine
Therapeutic End Points Therapeutic End Points

(within 1 hour of
resuscitation) (within stabilization)
• Capillary refill ≤2 secs • Capillary refill ≤2 secs
• Normal pulses with no • Threshold HRs
differential between peripheral • Normal pulses with no differential
and central pulses, between peripheral and central pulses
• Warm extremities
• Warm extremities,
• Urine output >1 mL/kg/h
• Urine output >1 mL/kg/h
• Normal mental status,
• Normal mental status • CI 3.3 6.0 L/min/m2 with normal
• Normal blood pressure for perfusion pressure for age,
age • ScvO2 >70%
• Normal glucose concentration • Maximize preload to maximize CI,
• Normal ionized calcium MAPCVP
concentration. (Level III) • Normal INR, anion gap, and lactate.
(Level III)
Clinical practise parameters for hemodynamic support of

PICU-NICU8 pediatric
Bandung, 20/4and
16 neonatal septic shock: 2007 update36from
the American College of Critical Care Medicine. Crit Care Med. 2009
Recommendations for Sepsis Management in
Resource-Limited Settings
Dunser MW, et al. Recommendations for sepsis

PICU-NICU8 management
Bandung, 20/4 16 in resource-limited settings. 37
Intensive Care Med. 2012
Recommendations for Sepsis Management in Resource-
Limited Settings: Acute Interventions

Limited Settings: Post Acute Interventions

Limited Settings: Post Acute Interventions
• Clinical indicators of adequate tissue perfusion
Normal capillary refill time
Absence of skin mottling
Warm and dry extremities
Well felt peripheral pulses (e.g., radial or dorsalis pedis pulses)
Return to baseline mental status before sepsis onset
Urine output 0.5 mL/kg/hour (adults) or 1 mL/kg/hour (children)

Recommendations for Sepsis Management in
Resource-Limited Settings
Suggested therapies to be avoided
DO NOT use hypotonic fluids (e.g., glucose solutions) for fluid resuscitation
DO NOT use fluid balance as a guide to administer or withhold further volume loading
DO NOT use high dose steroids
DO NOT use muscle relaxants except for endotracheal intubation and in
mechanically ventilated patients with severe respiratory distress
DO NOT use succinylcholine in patients immobilized >3 days or with neuromuscular
diseases
DO NOT use furosemide unless hypervolemia, hyperkalemia and/or renal acidosis
are/is present
DO NOT use dopamine in an attempt to improve renal function
DO NOT use sodium bicarbonate to treat metabolic acidosis arising from tissue
hypoperfusion
DO NOT use non-steroidal anti-inflammatory analgesics
DO NOT restrict oxygen because of considerations to reduce respiratory drive
DO NOT diagnose ‘‘fever of unknown origin’’
DO NOT use insulin if blood sugar cannot be measured regularly
• The guidelines was formulated by the Indian Academy of
Pediatrics (IAP) in order to publish a guidelines applicable
to resource-limited countries with options based on levels
of resource limitations and feasibility of interventions
• Guidelines are divided into 4 steps according to clinical
condition, time and available resources
• Grading of level of recommendations are based of
American College of Critical Care Medicine (ACCM) 2007
Khilnani P, dkk. Pediatric sepsis guidelines: summary for resource-limited countries.
Indian J Crit Care Med. 2010
Guidelines: Pediatric Sepsis Guidelines:
Summary for Resource-Limited Countries
STEP 1: 0-5 minutes
• Recognize depressed mental status and decreased perfusion by rapid
cardiopulmonary assessment
• Begin high flow oxygen (level 3)
• Establish intravenous/intraosseous access (level 2)
• Venturi masks or non-rebreating mask may be used for high flow
oxygen therapy (level 3)
• If airway is unstable op patient is lethargic or unresponsive and
adequate oxygenation and ventilation is not achieved, bag-valave mask
ventilation should be started and early endotracheal intubation and
mechanical ventilation should be planned (level 3). Other indications for
intubation are hypotension on arrival or during therapy, convulsive
seizures refractory to 2 doses of benzodiazepine, GCS <8, dan signs of
increased intracranial pressure.

Indian J Crit Care Med. 2010 PICU-NICU8 Bandung, 20/4 16 43
STEP 2: 540 min
 Initial fluid resuscitation: rapid infusion 20 mL/kg isotonic salin up to 60 mL/kg
titrated toward achievement of the therapeutic goals of shock resolution or
unless rales or hepatomegaly develop (level 3). Choice of fluid for volume
replacement is isotonic crystalloid such as Ringers lactatte or normal saline
(level 1). We suggest fluids are given in boluses of 20 mL/kg as rapidly as
possible by pull-push method using the three-way stop-cock (level 1), by
gravity method over 1520 min (level 2). Infusion pump are ideal but nt always
available.
 Second peripheral IV/cetral line should be established if feasible (level 2)
 Antibiotic should be started (third generation cephalopsporin and an
aminoglycoside) (level 2). Antibiotic should be administered within 1 hour of the
identification of severe sepsis, if possible, after appropriate cultures have been
obtained (level 1).
 Hypoglycemia shoud be checked for and corrected (level 2). Hyperglycemia
should be avoided (level 2).
 Ionized
Khilnani P,hypocalcemia that might
dkk. Pediatric sepsis impair
guidelines: cardiacforperformances
summary resource-limitedshould be
countries.
corrected (level 3).
STEP 3: 4060 min
 Recognize fluid refractory shock: begin inotrope by

intravenous or intraosseuss (IO) route; dopamin up to
10 µg/kg/minute (level 2).
 Obtain central venous access and airway if needed and
feasible (level 1).

STEP 4: >60 min

 Recognize dopamine resistant shock
 Transfer to PICU
 If possible, monitor CVP, echocardiography, and MAP (level 2)
 Titrate fluid and vasoactive drugs to resole shock based on CVP,
echocardiography to achieve therapeutic goals.
 Reverse cold-shock resistant to dopamine (normal or low blood
pressure) titrate central epinephrine (level 2)
 Reverse warm shock with wide pulse pressure and/low blood pressure
by titrating central norepinephrin (level 2)
 Begin hydrocortisone (50 mg/m2/24 hr) if child is at risk for absolute
adrenal insufficiency (level 2)
Khilnani P, et al. Pediatric sepsis guidelines: summary for resource-limited countries.
Khilnani P, et al. Pediatric
sepsis guidelines: summary for
resource-limited countries.

Khilnani P, et al. Pediatric sepsis guidelines: summary for resource-limited countries.

• Therapeutic endpoints of resuscitation of septic shock
1. Normalization of heart rate
2. Capillary refill <2 second
3. Well felt dorsalis pedis pulses with no different between peripheral
and central pulses
4. Warm extremities
5. Normal range of systolic pressure and pulse pressure
6. Urin output >1 mL/kg/hour
7. Return to baseline mental status tone and posture
8. Normal range respiratory rate
Other end-points that have been widely used in adults and may apply to
children include CVP 812 mmHg
Khilnani P, dkk. Pediatric sepsis guidelines: summary for resource-limited countries. Indian J 49
Crit
Care Med. 2010
• Several unresolved issues:
– Time to avhieve various therapeutics endpoints may be
variable
– Arterial blood gas (ABG) and lactate estimations are
available in few centers. Use of ScVO2 is still beyond reach
of most centers
– Ability to place central lines is still limited
– Echocardiography for determining cardiac filling is not
practical in many centers
– Precise therapeutic end-points for severely malnourished
children are unknown

Study emphasizing the usage of
guidelines
• The Campaign was associated with sustained,

continuous quality improvement in sepsis care. A
reduction in hospital mortality rates was reported.

Other Studies ...
Pediatrics. 2012.
• 79% patients were recognized within 5 minutes of meeting the
septic shock criteria.
• About 67% had IV access within 5 minutes.
• 37% had adequate IVF adherence, receiving 60 mL/kg of IVFs
within 60 minutes. PICU-NICU8 Bandung, 20/4 16 53
Adherence to PALS sepsis guidelines
and hospital length of stay
• 11% had perfect IVF adherence, receiving 60 mL/kg
within 15 minutes.
• Of the 47% with fluid refractory shock, 35% received an
inotrope at 60 minutes from definition
• 70% received an antibiotic within 60 minutes
• 3.2% had hypocalcemia and 0% of these had
correction within the recommended 60 minutes of
meeting the definition.
Overall adherence to PALS sepsis guidelines was low;

however, when patients were managed within the guideline’s
recommendations, patients had significantly shorter duration
of hospitalization
Paul R, et al. Adherence to PALS sepsis guidelines and hospital length of stay. Pediatrics. 2012;130.
Other studies..
Inwald DP, et al. Emergency management of children with severe sepsis in the United Kingdom:
the results of the Paediatric Intensive Care Society sepsis audit. Arch Dis Child. 2009
Emergency management of children with
severe sepsis in the United Kingdom
• Overall, 62% of shocked children did not received

fluid and inotrope management suggested by
PALS
• Failure to reverse shock by the time of PICU

admission was independently asociated with
mortality
Inwald DP, et al. Emergency management of children with severe sepsis in the United Kingdom:
the results of the Paediatric Intensive Care Society sepsis audit. Arch Dis Child. 2009
SEPSIS SIX
To be delivered within 1 hour:

1. Deliver high-flow oxygen
2. Take blood cultures and other cultures, consider
source control
3. Administer empirical intravenous antibiotic
4. Measure serum lactate
5. Start IV fluid resuscitation
6. Commence accurate urin output measurement
Daniels R. Surviving the first hours in sepsis: getting the basic right (an intensivist’s perspective).
J Antimicrob Chemother 2011 PICU-NICU8 Bandung, 20/4 16 58
THE BASIC MANAGEMENT OF SHOCK . . .
 Stabilize the respiration
 Assess perfusion
 Access vascular: IV or IO
 Fluid resuscitation
(crystalloids and/or colloids)
– which one?
 Inotropes and Vasopressors
 Transfusion: RBC
 Electrolyte and Metabolic: hypoglycemia,
hypocalcemia
 Steroid
Take home points
• Your job as an emergency physician
– Recognition!
– Early antibiotics!
– EGDT!
– ARDS ventilator settings
• Good to know, but MUCH less important to us

– Steroids
– Insulin
– APC

Conclusion
• The themes of the currently accepted guidelines for
SEVERE SEPSIS and SEPTIC SHOCK: Goal-
directed, early and aggressive fluid resuscitation;
early administration of effective antibiotics; rapid
escalation of cardiovascular support (inotropes and/or
vasopressors) if fluid resuscitation does not have the
desired effect; and corticosteroid if adrenal
insufficiency suspected/proven. ECMO is the last
step.
• Management of septic shock in the resource limited
countries are more complex and still need further
studies and special efforts.
Thank you
Think of you
Thank you
Think of you

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Early Goal Directed Therapy

PICU-NICU8 Bandung, 20/4 16 1

His clinical practice presentation involves discussion of

Pediatric Early Goal Directed Therapy 2016

No Disclosures or conflicts of interest

PICU-NICU8 Bandung, 20/4 16 2

- Distributive (Septic) Shock: Preload, MC and SVR

Where are SEVERE SEPSIS and SEPTIC SHOCK?

Infection SIRS Sepsis Severe Sepsis Septic Shock

Microorganism A clinical SIRS with Sepsis with Refractory

PICU-NICU8 Bandung, 20/4 16 Chest 1992;101:1644 8

Sir, always remember this:

PICU-NICU8 Bandung, 20/4 16 10

• Neurological: Altered mental status,

PICU-NICU8 Bandung, 20/4 16 11

Early goals are: Target: good perfusion

Aggressive treatment by optimizing O2 delivery

Supplemental O2 and/or ventilation

Early Goal Directed Therapy (EGDT) for

PICU-NICU8 Bandung, 20/4 16 20

PICU-NICU8 Bandung, 20/4 16 23

• Conclusions: Niranjan Kissoon

• Success in reducing pediatric mortality and morbidity,

• Limited literature describing critical illness and

PICU-NICU8 Bandung, 20/4 16 26

ProCESS: Protocolized Care for Early Septic Shock

PICU-NICU8 Bandung, 20/4 16

PICU-NICU8 Bandung, 20/4 16 29

Dellinger RP, dkk. Surviving sepsis campaign: international guidelines form

Adopted from 2007 Update

25/100 x 80 mL/kg BW = 20 mL/kg BW

Figure 1 Systemic vasoconstriction can maintain MAP and perfusion pressure

Therapeutic End Points Therapeutic End Points

Clinical practise parameters for hemodynamic support of

Dunser MW, et al. Recommendations for sepsis

Dunser MW, et al. Recommendations for sepsis

Dunser MW, et al. Recommendations for sepsis

• Clinical indicators of adequate tissue perfusion

Normal capillary refill time

Absence of skin mottling

Warm and dry extremities

Well felt peripheral pulses (e.g., radial or dorsalis pedis pulses)

Return to baseline mental status before sepsis onset

Urine output 0.5 mL/kg/hour (adults) or 1 mL/kg/hour (children)

Dunser MW, et al. Recommendations for sepsis

Khilnani P, dkk. Pediatric sepsis guidelines: summary for resource-limited countries.

STEP 3: 4060 min

 Recognize fluid refractory shock: begin inotrope by

Khilnani P, dkk. Pediatric sepsis guidelines: summary for resource-limited countries.

STEP 4: >60 min

PICU-NICU8 Bandung, 20/4 16 47

Khilnani P, et al. Pediatric sepsis guidelines: summary for resource-limited countries.

Khilnani P, dkk. Pediatric sepsis guidelines: summary for resource-limited countries.

• The Campaign was associated with sustained,

PICU-NICU8 Bandung, 20/4 16 52

Overall adherence to PALS sepsis guidelines was low;

• Overall, 62% of shocked children did not received

• Failure to reverse shock by the time of PICU

To be delivered within 1 hour:

• Good to know, but MUCH less important to us

PICU-NICU8 Bandung, 20/4 16 60

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