update management of septic shock in children
TRANSCRIPT
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