Debate on aggressive vs restricted fluid resuscitation in childhood sepsis

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Give fluids! Dr David Inwald Consultant in PICU St Mary’s Hospital and CATS

description

Dr David Inwald's presentation at Meningitis Research Foundation's 2013 conference, Meningitis and Septicaemia in Children and Adults

Transcript of Debate on aggressive vs restricted fluid resuscitation in childhood sepsis

Page 1: Debate on aggressive vs restricted fluid resuscitation in childhood sepsis

Give fluids!

Dr David Inwald

Consultant in PICU

St Mary’s Hospital and CATS

Page 2: Debate on aggressive vs restricted fluid resuscitation in childhood sepsis

Two pathophysiological reasons to give fluids in septic shock

• Fluid is in the wrong place

• The pump is not working

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Increased capillary permeability

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Sepsis

Warm shockHigh CO

vasodilation

Cold shockLow CO

vasoconstriction

Dysregulation of vascular tone

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Depression of myocardial contractility

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Shock

• A clinical syndrome of inadequate tissue perfusion

• DO2 < VO2

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Increasing DO2

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Therapeutic implications

GIVE FLUIDS

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Frank-Starling curve

fluids

inotropes

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How much fluid?

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Brierley J et al, Crit Care Med 2009; 37:666–688

Up to and over 60 ml/kg by

15 minutes

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Early reversal of shockEarly reversal of shockEvery hour without resuscitation and Every hour without resuscitation and

restoration of CRT < 2 s and normal BP restoration of CRT < 2 s and normal BP increases mortality by 40%!increases mortality by 40%!

Han YY et al Pediatrics. 2003;112:793-9

1 Hour 2 Hours 3 hours

10987654321

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Fluid resuscitation of hypovolemic shock: acute medicine's great triumph for

children

Carcillo JA and Tasker RC, ICM 2006;32:958-61

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Time (h)

Mor

talit

y

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FEAST management

• C - Circulation

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Developed world management

• A - Airway

• B - Breathing

• C - Circulation…

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Other therapies?• Haemofiltration• ECMO• Modulators of coagulation

• rh-APC• Protein C• Protein S• AT III• r-tPA

• Anti-endotoxin strategies• Polymixin• Anti-endotoxin antibodies (HA-1A)• rBPI21

• Prostacyclin

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Therapeutic implications

GIVE FLUIDS

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GIVE FLUIDS


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Delaney on Sepsis Resuscitation 2012

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