Septic Shock
• Systemic inflammatory response syndrome (SIRS), when
SIRS is triggered by an infection, is defined as sepsis
• Overwhelming inflammation resulting in hypo- or hyper-
thermia, tachycardia, tachypnea, and either an elevated or
depressed white blood cell count (Table 1)
0 min Iden fy the pa ent with signs of shock Supplemental oxygen O2 and maintain airway
Access IV/IO (UVC neonates)
5 min Rapid bolus isotonic fluid 20mL/Kg up to and over 60cc/kg un l perfusion improves or unless rales or hepatomegaly develop. (10mL/Kg for neonates)
Treat hypoglycemia, hypocalcemia. Start an bio cs
Shock not reversed
15 min Fluid refractory shock: Begin dopamine, use atropine/ketamine IV/IO/IM to obtain central access and
airway if needed.
Reverse cold shock by tra ng central dopamine or if resistant, trate central epinephrine. Reverse warm shock by tra ng central norepinephrine
For neonate consider dobutamine and PGE1
Shock not reversed
60 min Catecholamine resistant shock: Begin hydrocor sone if at risk for absolute adrenal insufficiency. Monitor CVP in PICU, a ain normal MAP-CVP and ScvO2 >70%
Titrate fluids, epinephrine or norepinephrine, add vasodilators or vasopressors depending on the type of shock cold or warm, blood pressure level, and the percentage of ScvO2
Shock not reversed
Persistent catecholamine resistant shock: Rule out pericardial effusion, pneumothorax, and intra-abdominal
pressure >12mmHg, give hydrocor sone for absolute adrenal insufficiency, T3 for refractory hypothyroidism in neonates; consider further monitoring to help direct therapy
Shock not reversed Refractory shock: ECMO
Algorithm for goal-directed management of hemodynamic support in sep c shock summary. Adapted from 2007 ACCM clinical prac ce parameters for hemodynamic support
of pediatric and neonatal sep c shock. IV = intravenous, IO = intraosseous, UVC = umbilical venous catheter, IM = intramuscular, PGE1 = prostaglandin, CVP = central venous pressure, MAP = mean arterial pressure, ScvO2 = mixed venous
oxygen satura on, ECMO = extracorporeal membrane oxygena on
Algorithm for goal-directed management of hemodynamic support in septic shock summary. Adapted from 2007 ACCM clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. IV = intravenous, IO = intraos- seous, UVC = umbilical venous catheter, IM = intramuscular, PGE1 = prostaglandin, CVP = central venous pressure, MAP = mean arterial pressure, ScvO2 = mixed venous oxygen saturation, ECMO = extracorporeal membrane oxygenation
60 O. Naga
Management of Shock
Airway (Table 2)
• Regardless of the cause of shock, initial resuscitation
must be guided by the ABCs (airway, breathing, circula- tion)
• Supplemental oxygen should be administered immedi-
ately
• Intubation is indicated for the patient whose mental status
is altered, who is unable to protect his or her airway, or who has impending respiratory failure
• Positive-pressure ventilation also is a powerful tool to
decrease afterload to the left heart of the patient present- ing in cardiogenic shock
• Patients suffering shock may develop acute respiratory dis-
tress syndrome (ARDS) which usually requires protective strategy of ventilation
Access
• Obtaining rapid vascular access with at least two wide-
bore peripheral intravenous lines is critical to the timely treatment of circulatory shock
• Umbilical venous catheter (neonates only)
• Intraosseous needle (infants and children) if no other
access
• Central venous access provides more stable, long-term
access and should be obtained in patients who have fluid- refractory shock and who require titration of vasopressors and inotropes
• Sedatives and analgesics
• Fluid therapy
• Rapid volume resuscitation is the single most important
intervention to help restore adequate organ perfusion in patients presenting with various forms of hypovolemic shock
• Initial rapid bolus of 20 mL/kg of isotonic fluid followed
by immediate reassessment and titration of additional fluid administration to goals of normal BP and perfu- sion (capillary refill < 2 s, 1 mL/kg per hour urine out- put, normal mental status) or until signs of fluid overload occur (rales, increased work of breathing, gallop rhythm, hepatomegaly, CVP increases without additional hemody- namic improvement)
• Patients may require up to 200 mL/kg of isotonic fluid
within the first hour, particularly in cases of vascular paralysis, to restore adequate perfusion
Table 1 Difference between cold shock and warm shock
Cold shock Warm shock
Low cardiac output and high SVR High cardiac output and low SVR Tachycardia, mottled skin, cool extremities with prolonged capillary
refill, and diminished peripheral pulses Tachycardia, plethora, warm extremities with flash capillary refill, bounding pulses, and a widened pulse pressure
Low or normal blood pressure Low blood pressure
Dopamine with or without epinephrine may reverse the shock Dopamine with or without norepinephrine may reverse the shock
SVR systemic vascular resistance
Table 2 General evaluation of accident victim. (Adapted from: Committee on Trauma, American College of Surgeons (2008). ATLS: Advanced
Trauma Life Support Program for Doctors (8th ed.). Chicago: American College of Surgeons)
Assessment Management
A. Airway/cervical spine: Assess airway patency while immobilizing
the cervical spine 1. Open and secure airway2. Maintain cervical spine immobilization B. Breathing: Assess adequacy of oxygenation via pulse oximetry and
ventilation by observing respiratory rate and tidal volume (chest rise) 1. Provide 100 % oxygen2. Assisted ventilation as needed
3. Treat life threatening chest injuries, including: Tension pneumothorax
Open chest wound Flail chest Cardiac tamponade C. Circulation: Assess adequacy of circulation and perfusion
Measure heart rate, blood pressure, capillary refill time 1. Re-establish perfusion with fluid resuscitation (20 ml/kg 0.9 % saline fluid boluses or 10 ml/kg doses of packed red blood cells) 2. Treat significant hemorrhage
D. Disability: Assess neurologic status by examining pupil equal- ity/reactivity and level of consciousness (alert, responsive to voice, responsive to pain, unresponsive)
1. Maximize oxygenation and perfusion, normalize ventilation (no hyperventilation)
2. Consider adjunctive therapies (oncotic agents, diuretics) E. Exposure: Examine for other life-threatening injuries 1. Remove all clothes
61 The Acutely III Child
Antibiotics
• Broad-spectrum antibiotics based on age should be
administered within the first hour of presentation when sepsis is suspected
• Appropriate specimens for blood, urine, and cerebrospi-
nal fluid cultures should be obtained before antibiotic administration, although difficulty obtaining samples should not delay administration
Crystalloid versus colloid
• Isotonic crystalloid or 5 % albumin for volume resuscita-
tion in the first hour
• Beyond the first hour, the guidelines recommend crystal-
loid for patients who have Hgb values greater than 10 g/ dL (100 g/L) and packed red blood cell transfusion for those whose Hgb values are less than 10 g/dL (100 g/L)
• In addition to restoring circulating volume, packed red
blood cells also serve to increase oxygen-carrying capac- ity
• Fresh frozen plasma administered as an infusion is rec-
ommended for patients who have a prolonged Interna- tional Normalized Ratio (INR)
Cardiovascular support
• In cases of fluid-refractory shock and cardiogenic shock,
cardiovascular agents are necessary
• The choice of agent depends largely on the underlying
cause and the clinical presentation of shock
• Selection of an appropriate agent is based on its known
effects on inotropy, chronotropy, SVR, and PVR
Inotropic agents
• Dopamine, dobutamine, and epinephrine work on beta1
receptors in the myocardium increase cytoplasmic calcium concentration and enhance myocardial contractility
Vasopressors
• At higher doses, for example, dopamine and epineph-
rine have increasing alpha-adrenergic effects, leading to peripheral vasoconstriction and increased SVR
• Dobutamine, on the other hand, causes peripheral and
pulmonary vasodilation due to beta2-adrenergic effects
Vasodilators
• Nitroprusside is a pure vasodilator used to decrease after-
load and improve coronary perfusion in neonates and children who have cardiogenic shock
• Prostaglandin E1 is a potent vasodilator that relaxes
smooth muscle in the ductus arteriosus to maintain patency
• It should be initiated immediately in cases of suspected
cardiogenic shock presenting within the first 2 weeks after birth until a ductal-dependent lesion has been ruled out by echocardiography
• Inhaled nitric oxide is a selective pulmonary vasodilator
that may be considered in the treatment of cardiogenic shock involving right ventricular failure
Inodilators
• Milrinone is a phosphodiesterase III inhibitor that has
gained popularity in the treatment of cardiogenic shock due to its positive inotropic and lusitropic effects as well as its ability to reduce systemic and pulmonary afterload through vasodilation
Corticosteroids
• Hydrocortisone 50 mg/m2 per 24 h in pediatric patients
who have catecholamine-resistant septic shock and sus- pected or proven adrenal insufficiency
• Corticosteroids also should be administered to patients
who have distributive shock caused by anaphylaxis or spinal trauma
• Antihistamines may help prevent additional mast cell
degranulation in anaphylactic shock
Glycemic control
• Children presenting in shock often have a number of met-
abolic derangements, including hyper- or hyponatremia, hypocalcemia, and hypoglycemia. These disorders should be suspected and treated promptly
ECMO (Extracorporeal membrane oxygenation)
• Although ECMO has a definitive role in the treatment of
cardiogenic shock refractory to maximum pharmacologic support, its role in the treatment of refractory septic shock has been less clear