MANAGEMENT OF SEPTIC SHOCK with full details

More concise and conceptual

1. MANAGEMENT OF
SEPTIC SHOCK
Dr. Saurav Suman
JR2
Department of
Pediatrics, PMCH

2. “Sepsis At Its Inception Is Difficult
To Recognize But Easy To Treat;
Left Unattended It Becomes Easy To
Recognize But Difficult To Treat”

3. Early Recognition Of Septic
Shock
Mortalityreduction
Reduction of organ dysfunction
Morbidity reduction
Reduction in duration of hospitilisation
Reduction in ventilation duration

4. How To Identify Early?
High index of suspicion
Signs and Symptoms
Clinical examination
I.PAT( pediatric assessment triangle)
II.Primrary assessment
Frequent assessment
Lab investigations

5. Signs of Septic Shock
Cardiac
I.Tachycardia
II.Low pulse pressure
III.Low pulse volume
IV.Low B.P.
V.Prolonged CRT
Respiratory
VI.Tachypnea
VII.oxygenation
CNS
I.Altered sensorium
II.Low GCS
Renal
III.Urinary output

preload)
Hypothermia/
Hyperthermia

6. Clinical Criteria of Septic Shock
Septic shock is defined as sepsis with
cardiovascular organ dysfunction or presence of:
1.Hypotension(systolic B.P. <70mmhg in infants; <[70+(2*age)] after 1 year
of age depite >40ml/kg of isotonic i.v. fluid in 1hr or
2.Need of vasoactive drug to maintain B.P. above 5
th

and sex, or
3.Signs of hypoperfusion- (any 3 of the following)
iv.Decreased pulse volume(weak or absent dorsalis pedis pulse)
v.CRT>3sec
vi.Tachycardia
vii.Core (rectal/oral) to peripheral(skin/toe) temperature gap >3C
viii.Urine output < 1ml/kg/hr

7. Clinical Triad of Septic Shock

8. The importance of accurate interpretation of Heart Rate and
Respiratory Rate in early identification of pediatric shock
•Because of their high sympathetic tone,children can maintain a seemingly
normal B.P. longer than the adult would, making hypotension a very late
finding in critically ill child.
•This can make early recognition of shock more challenging in children.
•So, the key to early identification of pediatric sepsis lies in the H.R. and
R.R., both of which will increase disproportatioly to the fever in sepsis.
•While individual vitals signs are sensetive but not specific, multiple
abnormal vital signs taken together have an improved specificity for
sepsis.

9. Red flag signs for Severe Sepsis and
Shock
Hyper/hypothermia
Abnormal CRT > 5 sec
Pale/mottled/ashen/ blue skin or purpuric rash
Oxygen needed to maintain SpO2>92%
Tachypnea or grunting
Lactate > 2mmol/l
AVPU= verbal or pain responsive or unresponsive
Parents reporting decreased urine output, decreased activity or weak, high
pitched or continous cry

10. Clinical Examination
Pediatric Assesment Triangle
Primary Assessment
Pentagon

11. Initial management after receiving the patient
in ER
Assessment and Intervention simultaneously.
A: Airway
oPosition
oOxygen
oAirway protection
B: Breathing
oSpontaneous
o
C: Circulation
o90secs or 2 attempts
oInterosseous line
oBolus and I.V. Fluid
Investigations:
oCulture, blood gas with lactate, RBS, other 1
st

Interosseous cannulation
technique

12. First Hour Management of Septic
shock
•The Surviving Sepsis guideline for septic shock in
children. PCCM. Feb,2020 recommends BUNDLE
APPROACH for management of septic shock.
•Bundles are a group of “therapies” built around
the best evidence based guidelines, which, when
implemented together, produce greater benefit in
terms of outcome than the individual theraputic
interventions.

13. Red flag signs or evidence of sepsis:
Initiate Sepsis-6
Give 3 :
•Give oxygen(high flow)
•Gives fluid boluses(10-20ml/kg isotonic
crystalloids)
•Give broad spectrum antibiotics
Take 3 :
•Take blood and other cultures, gram
stains
•Take blood gas with lactates
•Take urine measurment – foleys
catheter

14. Any point of time features suggestive of fluid overload then stop boluses and start ionotropes.

15. Recent
Guidelines for 1
st
hour Bundle
Therapy
PCCM. Feb,2020

16. Lactate levels:
•The committee was unable to issue a recommendation about using
blood lactate values to stratify children with suspected septic shock or
other sepsis-associated organ dysfunction into low- versus high-risk of
having septic shock or sepsis.
•
vasopressors with lactate greater than 2 mmol/L was 32.0% compared with 16.1%
if lactate was less than or equal to 2 mmol/L. (Intensive Care Med2017; 43:1085–1096)
•Other studies have shown that lactate levels greater than 4 mmol/L are
consistently associated with mortality.(Bai Z, Zhu X, Li M, et al: Effectiveness of predicting in-
hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatr2014;
14:83)
•
presentation was associated with decreased risk of persistent organ
dysfunction.(Lactate clearance and normalization and prolonged organ dysfunction in pediatric
sepsis. J Pediatr2016; 170:149–155.e1)
•Lactate levels should therefore be interpreted as part of a more comprehensive
assessment of clinical status and perfusion.

17. Blood culture
•It recommends obtaining blood cultures before
initiating antimicrobial therapy in situations where
this does not substantially delay antimicrobial
administration.
•Whenever possible, blood cultures should be obtained prior to initiation
of antimicrobial therapy in children with severe sepsis or septic shock.
•
antimicrobial therapy to the patient, then administration of
antimicrobials should take precedence.
•At least two sets of blood cultures should be obtained
before starting antibiotics, with atleast one drawn
percutaneously and one drawn through each vascular
access device, unless the device was recently(<48hrs)
inserted.

18. Fluid therapy
•
administering up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per bolus) over
the first hour, titrated to clinical markers of cardiac output and discontinued
if signs of fluid overload develop, for the initial resuscitation of children with
septic shock or other sepsis-associated organ dysfunction.
•
absence of hypotension, it recommend against bolus fluid administration
while starting maintenance fluids (strong recommendation)
•
present, it suggest administering up to 40 mL/kg in bolus fluid (10–20 mL/kg
per bolus) over the first hour with titration to clinical markers of cardiac
output and discontinued if signs of fluid overload develop

19. Choice of fluid
•Use Crystalloid vs 5% albumin.
•Balanced and buffered crystalloid(RL/Plasmalyte) vs NS.(
less chance of hyperchloremia and acidosis)
•Although no pediatric RCTs compare balanced/buffered crystalloids to 0.9% saline, there are two large observational studies
in children with sepsis. They included a total of 30,532 children with sepsis, 2,100 of whom received only balanced/buffered
crystalloids for the first 72 hours of hospital admission, and 28,432 who received 0.9% saline.
•These studies showed that use of balanced/buffered crystalloids was associated with lower mortality.
•Taken together, these data support that the desirable consequences of balanced/buffered crystalloids
probably outweigh the undesirable consequences (including cost), especially in those who require large
volume of fluid resuscitation.
•No starch/ gelatine containing fluid.

20. Clinical assessment after each bolous
•Airway: look for frothing, cough
•Breathing : look for increasing respiratory rate, grunt,
desaturtion, crepts
•Circulation : look for gallop, tachycardia, hepatomegaly,
hypotension
•Disability : agitation, combativeness
•Others : jugular venous distension, heart size on CXR

21. Guide to further fluid therapy
One of the most important concepts in resuscitation is volume
responsiveness i.e. ability of the C.O. to increase in response
to a fluid challenge.
It is Based on assumptions that increased cardiac output will
increase oxygen delivery and increase tissue oxygenation.
Fluid therapy can be guided with:
1.Transthoracic echocardiography guided IVC variability
during respiration:
•Volume status in a spontaneously breathing patient can be measured by assessing
the IVC diameter and IVC collapsibility.
•In spontaneously breathing patients, a diameter of <1.5cm indicates hypovolemia.
•This is not same as fluid fluid responsiveness.

22. •For assessing fluid responsiveness, the difference between maximum and minimum
IVC diameter divided by the maximum diameter is used.
•This is the Collapsibility index
•In contrast , an IVC diameter of >2.5cm suggests an overhydrated state and a
Collapsibility index of <50% may suggest that the patient is unlikely to respond
to the fluid.
2. Assessment of ventricular filling and ejection fraction by
echocardiography :
•Dilated or filled cardiac chambers suggest enough or more preload and giving
bolouses in these patients might not help.
3. Passive leg raisisng test (PLRT) :
•The change in cardiac output during passive leg raisisng test can be measured by
various parameters like change in aortic blood flow velocity (measured by doppler).
•A change in cardiac output by > 10% predicts fluid responsiveness.

23. Passive leg raisisng test
With PLRT we check change in cardiac output (CO), which will menifest
with improvement in B.P. and reduction in H.R.

24. Theraputic End Points of Resuscitation
Circulation
•Normalization of the heart rate.
•Capillary refill time of <2sec
•Well felt peripheral pulsed with no difference between peripheral and central pulses.
•Warm extremities.
•Normal range of systolic and pulse pressure.
Metabolic
•Normal glucose concentration.
•Normal ionised calcium concentration.
Renal
•Urine output > 1ml/kg/hr
Respiration
•Normal rate of breathing.
CNS
•Normal sensorium

25. Maintainance Fluids
Isotonic Fluid
80% maintenance is generally considered appropriate.
Maintan RBS below 180mg/dl
“We were unable to issue a recommendation regarding what blood glucose range to
target for children with septic shock or other sepsis-associated organ dysfunction.
However, in our practice, there was consensus to target blood glucose levels below 180
mg/dL (10 mmol/L) but there was not consensus about the lower limit of the target
range.” [Surviving Sepsis guideline for septic shock in children. PCCM. Feb,2020 ]
Target normal calcium levels for children with septic shock
requiring vasoactive infusion support.

26. Antibiotics

as possible, within 1 hour of recognition.
In children with sepsis-associated organ dysfunction but without
shock, start antimicrobial therapy as soon as possible after
appropriate evaluation, within 3 hours of recognition.

more antimicrobials to cover all likely pathogens.
but
Once the pathogen(s) and sensitivities are available, it
recommends narrowing/de-escalation empiric antibiotic therapy
coverage.

28. Choice of Antibiotics
1
st
Vancomycin + Ceftriaxone/cefotaxime
Genito-urinary infections Aminoglycoside (Amikacin/Gentamycin)
GI infections Piperacillin-tazobactum + clindamycin/
metronidazole
Resistant cases Meropenem
Fungal infections Amphotericin B
Rickettsial fever Doxycillin

29. After successful complition of 1
st

30. 1
st

1.CBC with differential
2.Serum electrolyte
3.Serum creatinine
4.Liver function test
5.ABG
6.Lactate
7.PT/INR
8.Blood culture and sensitivity
These are baseline
investigations for
diagnosing and monitoring
sepsis and its
complications.

31. If Shock and Perfusion
Still Abnormal After
Initial Resuscitation or
Signs of Fluid
Overload?

32. Shift the patient to an ICU with invasive monitoring facility and
personnel experienced in sepsis care.
Frequent clinical examination and assessment is crucial.
Continous monitoring of H.R. , B.P. , and Sp02.
B.P. monitoring via invasive arterial line is very important.
Central line to facilitate reliable delivery of ionotropes that may
cause extravasation injury.
Cardiopulmonary monitoring using bedside ECHOCARDIOGRAPHY.
Consider respiratory support/ Mechanical ventilation.

33. Multi modality monitoring?
Why?

34. Management of Fluid Refractory
Shock

35. Cold Shock Vs Warm Shock
Variables Warm Shock Cold shock
Heart Rate Tachycardia Tachycardia
Pulses Bounding peripheral pulsesPoor peripheral pulses
CRT Flush capillary refill timeProlong capillary refill time
Peripheries Warm Cold
Blood Pressure Hypotension or
normotension
Hypotension or
normotension
Pulse pressure Wide Narrow
Sensorium Altered or restlessnessAltered or restlessness
Urine output Oligouria Oligouria
Skin Warm/normal/ petechial
or purpuric rash
Pale or ashen grey skin,
core and peripheral temp
gradient > 3c

36. Choice of Inotropes
IF DECREASED SVR USE DRUG WITH α ACTION (i.e. NorAdr)
A general preference for epinephrine to treat myocardial dysfunction and low cardiac
output and for norepinephrine to increase systemic vascular resistance.

37. 
resuscitation if the patient continues to have evidence of abnormal perfusion, or
sooner if fluid overload develops or other concerns for fluid administration are
present.
SSCG suggests using epinephrine, rather than dopamine, in
children with septic shock.
It suggests using norepinephrine, rather than dopamine, in
children with septic shock.
They were unable to issue a recommendation for a specific
first-line vasoactive infusion for children with septic shock.
“We were unable to issue a recommendation for a specific first-line
vasoactive infusion for children with septic shock. However, in our
practice, we select either epinephrine or norepinephrine as the first-line
vasoactive infusion guided by clinician preference, individual patient
physiology, and local system factors.” [Surviving Sepsis guideline for
septic shock in children. PCCM. Feb,2020 ]

38. Dopamine in Septic shock
Higher incidence of hospital acquired
infections and mortality with
dopamine versus epinephrine in
pediatric shock.

40. Mechanical Ventilation

children with fluid-refractory, catecholamine-resistant septic shock.
However, in our practice, we commonly intubate children with fluid-
refractory, catecholamine-resistant septic shock without respiratory
failure.” [Surviving Sepsis guideline for septic shock in children. PCCM. Feb,2020 ]
Rationale :
oIt is well understood that a high metabolic demand from
refractory shock typically indicated by progressive lactic
acidemia and end-organ dysfunction can be, at least in part,
mitigated by early invasive mechanical ventilation even
without clinical symptoms of acute pulmonary edema or
respiratory failure.

41. oIn children with septic shock, work of breathing (WOB) may represent 15%
to 30% of oxygen consumption and therefore contributes to the
development of lactic acidosis.
oThe early use of mechanical ventilation reduces WOB and allows for
redistribution of limited cardiac output to vital organs.
oIt improves oxygenation and decreases left ventricular afterload.
oLung protective ventilation strategy should be implemented
while ventilating patients with fluid refractory shock to
prevent lung injury and/or limit injury in ARDS.

42. Lung protective ventilation strategy

43. Source Control
•All patients presenting with severe sepsis should be evaluated for the presence of
focous of infection amenable to source control measures within 6 hours.
•
remove the source of infection or to prevent spread of the infection
systemically or to adjacent tissues.
•It may include percutaneous or deep abscess drainage, drainage of an empyema,
septic joint, or subperiosteal abscess, removal of infected hardware or CVCs, or
debridement of necrotizing soft-tissue infection.
•
antimicrobials and contribute to direct and hematogenous spread, ongoing
inflammation, and organ dysfunction.
•Waiting for patients to clinically stabilize prior to intervention is not recommended, as
delaying adequate source control may lead to further clinical deterioration.

44. Desired Blood Pressure
•There is no such recommendation about whether to target Mean
Arterial Pressure at 5
th

th

shock and other sepsis associated organ dysfunction.
•However, we need to target MAP between 5
th

th

greater than 50
th

•In settings where direct measurement of MAP is less reliable, systolic
blood pressure provides reasonable alternative.

45. Catecholamine Resistant Shock?

46. Role of Corticosteroids
•Upto 50% of critically ill patients may have absolute or relative adrenal
insufficiency.
•Patients at risk of adrenal insufficiency include those with CAH, abnormalities
of hypothalmic pitutary axis and recent therapy with corticosteroids (asthma,
rheumatic disease, inflammatory bowel disease, nephrotic syndrome etc.).
•These patients are at high risk for adrenal dysfunction and should receive
stress dose of hydrocortisone.[50mg/sq m/24hrs, followed by 50mg/sq
m/day in 4 divided doses i.v. for 5-7days]
•In summary no high quality investigations and RCTs currently
support or refute the routine use of adjuvent corticosteroid for
pediatric septic shock or other sepsis associated organ
dysfunction. [Surviving Sepsis guideline for septic shock in children. PCCM. Feb,2020 ]

47. Blood Products
Optimum Hb for a critically ill child with severe sepsis during resuscitation phase of
septic shock is 10gm/dl.
A hemoglobin level of greater than or equal to 7gm/dl is acceptable in
hemodynamically stabilized children with septic shock or other sepsis associated
organ dysfunction.
No prophylactic platelet transfusion based solely on platelet levels in nonbleeding
children with septic shock or other sepsis-associated organ dysfunction and
thrombocytopenia.

high risk of bleeding as in patients with oncological diagnoses or those receiving
ECMO, prophylactic platelet transfusion can be given.
No prophylactic plasma transfusion in nonbleeding children with septic shock or other
sepsis associated organ dysfunction and coagulation abnormalities.

48. Other Supportive Treatment options
1.Renal Replacement Therapy
children with septic shock or other sepsis-associated organ dysfunction
who are unresponsive to fluid restriction and diuretic therapy.
2.ECMO- As a rescue therapy in children with septic shock only if
refractory to all other treatments.
3.IMMUNOGLOBULIN No routine use of IV immune globulin (IVIG)
in children with septic shock or other sepsis associated organ
dysfunction.

49. 4. Stress ulcer prophylaxis – No routine use of stress ulcer
prophylaxis in critically ill children with septic shock or other sepsis-
associated organ dysfunction, except for high risk patients. [Risk
factors of clinically important gastrointestinal bleeding include multiple organ
dysfunction, prolonged mechanical ventilation (> 48 hr), coagulopathy,
persistent shock, and treatment with corticosteroids and nonsteroidal anti-
inflammatory agents].
5. DVT prophylaxis – No routine deep vein thrombosis (DVT)
prophylaxis (mechanical or pharmacologic) in critically ill children with
septic shock or other sepsis-associated organ dysfunction. [Systematic review found
the quality of evidence to be low and that the efficacy of low molecular weight heparin in preventing CVC-associated
thrombosis is unknown (Brandao LR, Shah N, Shah PS: Low molecular weight heparin for prevention of central venous
catheterization-related thrombosis in children. Cochrane Database Syst Rev2014; (3):CD005982.)]

50. Nutrition
•Preference to commence early enteral nutrition within 48 hours of
admission in children with septic shock or sepsis-associated organ
dysfunction who have no contraindications to enteral nutrition and to
increase enteral nutrition in a stepwise fashion until nutritional goals are
met.
•Enteral feeding is not contraindicated in children with septic shock after
adequate hemodynamic resuscitation who no longer require escalating
doses of vasoactive agents or in whom weaning of vasoactive agents has
started.
•Enteral nutrition is the preferred method of feeding and administering
enteral feeds through a gastric tube, rather than a postpyloric feeding tube,
to children with septic shock or other sepsis-associated organ dysfunction
who have no contraindications to enteral feeding is suggested. [Surviving Sepsis
guideline for septic shock in children. PCCM. Feb,2020 ]

51. Recent Advances
HAT(Hydrocortisone, Thiamine, Vit C )Therapy
•Metabolic resuscitation and mitochondrial restoration.
•Scavenging free radicals.
•Inhibition of NADPH oxidase.
•Inhibition of Xanthine oxidase.
•Decrease activation of NF-κB
•
•Rapid resolution of shock was seen with HAT Vs placebo in adults.
•No mortality benefit was seen.
•Not much evidence in children.
•SSC Guidelines on septic shock management in children – NOT TO USE HAT
•DOSE : Vit. C:- 30mg/kg/dose i.v. Q6H * 4days,
thiamine 4mg/kg/day* 4days, hydrocortisone 50/sq.m/ 4divided dose/day

52. Multisystem Inflammatory Syndrome- Children
•35 children with MIS-C
•31/35 confirmed COVID
•PCR poitive – 14
•30/35 had antibody
POSITIVE(mostly IgG)
•28/35 vasoactive
medication needed
•25/35 IVIG given
•10/35 needed ECMO
•No mortality till now.
•3/35 recieced ANAKINRA(
IL-1receptor antagonist)

53. Hyperinflammatory Shock In COVID
•CLINICAL
FEATURES:
i.High grade fever
ii.Variable rash
iii.Conjunctivitis
iv.Peripheral edema
v.Significant GI symptoms
vi.No significant respiratory
involvement
•MANAGEMENT
i.High index of suspicion to diagnose
early
ii.Mostly PCR negative in BAL/NPA
iii.Antibody test positive
iv.IVIG 2gm/kg within 24hrs
v.Antibiotics- clindamycin +
ceftriaxone
vi.Fluid refractory/ vasoactive
responsive shock
vii.Methyl prednisolone was used in
some patients.

54. SUMMARY
•Early clinical diagnosis.
•Vascular access – 5 mins.
•1
st

•Antibiotics and blood culture in 1
st

•De-escalation of antibiotics once culture sensitivity reports available.
•Continous and intensive monitoring after each intervention.
•Inotropes in case of fluid refractory shock or if signs of fluid overload.
•Balanced buffered crystalloids over NS.
•Warm shock- Nor-epinephrine
•Cold shock – Epinephrine
•Lung protective ventilation strategy.
•Early enteral nutrition if pt. hemodynamically stable.