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Corrine Balit
1:15am: 3 year old female arrives at Triage with HR 180,
RR 35, looks tired. Has had URTI symptoms for past couple
of days.
Infection
Sepsis
Severe Sepsis
Septic Shock
Systemic Inflammatory Response
Syndrome
Presence of 2 of the following criteria:
If < 1yr old: bradycardia HR < 10th centile for age
Leucocyte abnormality
SEPSIS
SIRS in presence of suspected or proven infection
Severe Sepsis
Sepsis + one of the following
CV organ dysfunction
ARDS
2 or more organ dysfunction
Septic Shock
Sepsis + CV organ dysfunction
Cardiovascular dysfunction
Despite >40ml/kg Isotonic fluid bolus in 1 hour:
Decrease in BP <5th centile for age
Need for vasoactive drug to maintain BP
2 of the following:
Unexplained metabolic acidosis
Increase lactate
Oliguria
Prolonged cap refill > 5 seconds
Core-peripheral temp gap >3 degrees
Risk factors for Sepsis in Children
< 1 year of age
Very low birthweight infants
Prematurity
Presence of underlying illness eg chronic lung, cardiac
conditions, malignancy
Co-morbidities
Boys
Genetic factors
What makes you suspect shock?
Clinical Manifestations
Fever
Increased HR
Increased RR
Altered mental state
Skin:
Hypoperfusion
Decreased capillary refill
Petechiae, purpura
Cool vs warm.
Cold Shock Warm Shock
HR Tachycardia Tachycardia
CO= HR x SV
Goals:
Capillary refill < 2 seconds
Urine ouptut > 1ml/kg/hr
Normal pulses
Improved mental state
Decreased lactate and base deficits
Perfusion pressures appropriate for age
Recognise decreased mental status and perfusion
O min
Maintain airway and establish access
Observe in PICU
Recognise decreased mental status and perfusion
Maintain airway and establish access
Vascular Access:
•Only few minutes to be spent on obtaining IV access
•Need to use IO if cant get access
•May need to put 2 x IO in
Intubation + Ventilation
•Clinical assessment of work of breathing , hypoventilation or
impaired mental state
•Up to 40% of cardiac output is used for work of breathing
•Volume loading and inotrope support is recommended before and
during intubation
•Recommended: Ketamine, atropine and short acting neuromuscular
blocking agent.
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Antimicrobials, Correct hypoglycemia and hypocalemia
Fluid Resuscitation:
•Needs to be given as push
•May need to give up to 200mls/kg
•Give fluid until perfusion improves.
Which Fluids
•Isotonic vs collloid
•Most evidence extrapolated from adults
•Wills et al
• RCT of cystalloid vs colloid in children with dengue fever
• No difference between the two groups.
15min Fluid Refractory Shock
ECMO
Drug Dose Comments
Dopamine 2-20mcg/kg/min Historically 1st choice in kids
Alpha, beta and dopamine receptor
activation
Can be given peripherally
Dobutamine 5-10mcg/kg/min Chronotropic as well as inotropic
Afterload reduction
Adrenaline 0.05- 1mcg/kg/min Initially increases contractility/heart
rate
High doses increase PVR
Noradrenaline 0.05 – 1 mcg/kg/min Vasopressor
Increases PVR
Milrinone 0.25-0.75mcg/kg/ Phosphodiesterase inhibitor
min Afterload reduction
Rivers et al, NEJM 2001
Single Centre , RCT in Emergency Department
New changes :
Inotrope via peripheral access
Fluid removal considered early
What about Hydrocortisone?
Controversial
Current recommendations:
If child is at risk of adrenal insufficency and remains in
shock should receive hydrocortisone
At risk defined as purpura fulminans, congenital adrenal
hyperplasia, recent steroid exposure,
hypothalamic/pituitary abnormality
Evidence – Controversial
Annane D JAMA 2002
Multicentre , RCT looked at use of hydrocortisone and
fludrocortisone in septic shock.
Nutrition
GI protection
Early CVVH
Activated Protein C
Inhibits factors Va and VIIIa – prevent generation of
thrombin
96% had at least 3 organ failure and 35% had a cardiac arrest
prior to ECMO