Update management of septic shock in childrenKantara Lim, MD.

Division of Pulmonary and Critical careDepartment of Pediatrics

Basic concepts of shock

O X Y G E N E X T R A C T I O N O X Y G E N D E L I V E R Y

C E L L U L A R H Y P O X I A

A N A E R O B I C M E TA B O L I S M

M E TA B O L I C A C I D O S I S

Shock stage

Compensated shock

Decompensated shock

Irreversible End organ dysfunction

• Very difficult to diagnosis

• No hypotension • Organ tissue

perfusion is key

• Rapid resuscitation • Organ support

therapy

• Organ support and PICU care

• Poor prognosis and lead to cardiopulmonary failure

Septic shock Infection

Cytokine production

Host immune response

Hemodynamic response

Pro-inflammatory response Procoagulant response

Vasodilatation

Hemodynamic response

Increase cardiac output

Decrease systemic vascular resistance

Decrease cardiac output

Increase systemic vascular resistance

Early

Late

Case based discussion • Case 1-yr-old boy with hirschsprung disease S/P total

correction

• Last admission : enterocolitis with sepsis

• Present with fever and abdominal distention for 1 day

• On metronidazole (antibiotic prophylaxis)

• PE at ER : looked sick 

• BW 11.7 kg, T 38.7 c, RR 40/min, PR 170/min, BP 106/68 mmHg.

Case based discussion• Heart : tachycardia

• Abd : Soft with generalized tenderness

• Ext : pulse full

• At ER : start 5%D/N/2 IV rate 60 mL/hr

• Consultation problems : enterocolitis + mild dehydration

• Ped opinion : moderate dehydration è NSS 10mL/kg/dose and admit Ped ward I

Case based discussion• PE at ward (after NSS 10 mL/kg/hour)

• T 38.4 c, RR 44/min, HR 164/min, BP 110/69 mmHg., SpO2 100% (on cannula) 

• Capillary refill 4 secs

Problem list Enterocolitis with moderate dehydration

VS Septic shock

Approach to shock S I G N S O F S H O C K

A b n o r m a l V i t a l S i g n s

D e c r e a s e O r g a n P e r f u s i o n

B r a i n S k i n

K i d n e y G I

Normal vital signs in pediatric patient

A G E H R ( r a t e / m i n )

R R ( r a t e / m i n )

S B P ( m m H g )

0 - 1 เ ดื อน > 2 0 5 > 6 0 < 6 0

1 - 3 เ ดื อน > 2 0 5 > 6 0 < 7 0

3 - 1 2 เ ดื อน > 1 9 0 > 6 0 < 7 0

1 - 2 ปี > 1 9 0 > 4 0 < 7 0 + ( a g e X 2 )

2 - 4 ปี > 1 4 0 > 4 0 < 7 0 + ( a g e X 2 )

4 - 6 ปี > 1 4 0 > 3 5 < 7 0 + ( a g e X 2 )

6 - 1 0 ปี > 1 4 0 > 3 0 < 7 0 + ( a g e X 2 )

1 0 - 1 3 ปี > 1 0 0 > 3 0 < 9 0

> 1 3 ปี > 1 0 0 > 2 0 < 9 0

Core of management in septic shock

R a p i d R e c o g n i t i o n

E a r l y a n d A p p r o p r i a t e

R e s u s c i t a t i o n

O r g a n S u p p o r t a n d I n t e n s i v e S t a b i l i z a t i o n

ER

OPD/ward PICU

ER

OPD/ward

From the theory to practical guideline

Core of management in septic shock

R a p i d R e c o g n i t i o n

ER OPD ward

E a r l y Wa r n i n g S i g n P r o t o c o l

Sign of organ poor perfusion

Delay capillary refilled

แนวทางการวินิจฉัย Pediatric septic shock โรงพยาบาลสงขลานครินทร์

Core of management in septic shock

E a r l y a n d A p p r o p r i a t e

R e s u s c i t a t i o n

PICU ER

OPD ward

P a e d i a t r i c S e p t i c S h o c k

M a n a n g e m e n t G u i d e l i n e

Guideline manangement

Guideline manangement

Guideline manangement

Update in current guideline

• 1st line inotropic drug = epinephrine infusion

• 2nd line adjust inotropic drug follow type of shock

• Warm shock use norepinephrine

• Cold shock use epinephrine

Inotropic drug in pediatric septic shock

Organ failure–free days among survivors is higher in epinephrine group ( p=0.022)

Pediatr Crit Care Med 2016; 17:e502–e512

Core of management in septic shock

O r g a n S u p p o r t a n d I n t e n s i v e S t a b i l i z a t i o n

PICU PICU

P I C U C a r e

Crit Care Med 2017; 45:1061–1093

PICU care for septic shock

PICU care for septic shock Crit Care Med 2017; 45:1061–93.

Update in current guideline

• Target perfusion pressure as endpoint

• Perfusion pressure = MAP- CVP

Crit Care Med 2017; 45:1061–1093

PICU care for septic shock

• Hemodynamic assessment and continue resuscitation process

• Non invasive cardiac output monitoring

• Lactate level, ScVO2

• Central line insertion for medication administration and CVP monitor

PICU care for septic shock • Organ support

• Respiration : ventilator management, beware ARDS

• CNS : sedation, reduce metabolic demand

• Liver function : monitor function

• Renal function : correct electrolyte imbalance, beware fluid overload (after V/s stable consider diuretic)

• GI promote early minimal enteral feeding

• Hematology : monitor DIC, transfusion when indicated only

• Infection : follow culture result, adjust ATB appropriately

Core of management in septic shock

Tr i g g e r t o o l R a p i d c l i n i c i a n a s s e s s m e n t A c t i v a t e t r e a t m e n t b u n d l e

I O o r I V a c c e s s w i t h i n 5 m i n u t e s A p p r o p r i a t e f l u i d i n i t i a t e d w i t h i n 3 0 m i n u t e s

I n i t i a t i o n o f AT B w i t h i n 6 0 m i n u t e s B l o o d c u l t u r e i f i t d o e s n o t d e l a y AT B

A p p r o p r i a t e i n o t r o p e w i t h i n 6 0 m i n u t e s

O b t a i n n o r m a l M A P, S c V O 2 > 7 0 % A p p r o p r i a t e AT B t h e r a p y

M o n i t o r o r g a n f u n c t i o n a n d o r g a n s u p p o r t

ER, ward , OPD

PICU

Crit Care Med 2017; 45:1061–1093

ER, ward OPD

How to improve patient care

• Trigger tool as local context

• Build the system

• Early empirical antibiotics

• Rapid IV fluid resuscitation

• Build the collaboration

Thank you