Septic shock

Management of septic shock

1. MANAGEMENT OF SEPTIC SHOCK

2. Severe sepsis and septic shock are the two major causes of death in children with sepsis. The incidence of septic shock is 2 – 4% of admissions in western PICUs & 40% - 67% for Indian PICUs.

3. Sepsis is the systemic response to infection with bacteria, viruses, fungi , protozoa, or rickettsiae . Severe sepsis is defined as sepsis plus one of the following – Cardiovascular organ dysfunction or; Acute respiratory distress syndrome or; Two or more other organ dysfunctions. Septic shock in a child with sepsis is defined by the presence of – Hypotension (systolic BP < 70 mm Hg in infant); (< 70 + 2 × age after one year) or; Need for any vasoactive drug to maintain BP above 5 th centile range or; Signs of hypo-perfusion (any three of the following) or; 1. decreased pulse volume 2. capillary refilling time > 3 sec 3. tachycardia ( > 190/min in newborn; >160 in infants; >110 in a 10 yr child) 4. difference in core to peripheral temp. > 3°C 5. urine output < 1 ml/kg/hr 6. Tache Cerebrale - stroke skin with a blunt instrument -> 30-60 sec -> raised red rash Sepsis and cardiovascular organ dysfunction.

4. Early Recognition of Septic shock The first hours following the diagnosis of severe sepsis and septic shock are known as the “golden hour” as it is during this period that aggressive hemodynamic resuscitation has been shown to be associated with higher survival rates & reduced organ dysfunctions. The major cause of loss of “golden hours” in our country may be due to – Delay in recognition Delay in transport Delay in initiating treatment

5. The clinical diagnosis of early septic shock is possible with presence of the following in a case of suspected infection – Hypothermia or hyperthermia Decreased mental status Prolonged CRT Diminished or bounding pulses Mottled cool extremities Decreased urine output <1 ml/kg/hr BP drops only in late shock & its presence in a child with suspected infection is confirmatory. The shock is further classified as – Cold shock – characterized by signs of decreased perfusion with diminished peripheral pulses. Warm shock – characterized by signs of decreased perfusion with bounding peripheral pulses.

6. PRINCIPLES OF MANAGEMENT Initial treatment of child with septic shock – This includes aggressive fluid resuscitation of up to 60 ml/kg as boluses of 20 ml/kg of isotonic crystalloid such as Ringer lactate or Normal saline by I/V push in 10 to 15 mins to achieve desired heart rate and blood pressure. Colloids (starch, gelatins) produce greater & more sustained increase in plasma volume, but they may not be readily available. Fluid overload should be assessed by – Jugular venous distension Increasing liver span Puffy eyelids Signs of pulmonary edema & congestion on chest radiograph

7. If a patient does not respond to aggressive fluid therapy, vasoactive drugs should be started. Dopamine is recommended as the first line agent in a fluid refractory shock, started at a infusion rate of 10 µg/kg/min. Dobutamine is to be used as the first choice in children with normal BP & low cardiac output. Mixing of more than one vasoactive drug in the same infusion set is not recommended. Infusion should be prepared in D5% or D5% with NS

8. Management in Intensive care setting – In case of fluid refractory shock, central venous line should be inserted & vasoactive drugs like dopamine and dobutamine be started. In case of shock refractory to these above drugs, epinephrine & nor-epinephrine can be used depending on whether the child has cold shock or warm shock, respectively. If there is no response to the above catecholamines , then ScvO2 can be monitored & vasodilators/ PDE inhibitors can be added in children with normal BP & cold shock with ScvO2 <70%. In children with low BP, either epi . or nor- epi . can be titrated depending on whether it is cold shock or warm shock.

9. Early initiation of Appropriate Antimicrobial Therapy Administration of broad spectrum antibiotic to cover the likely pathogens (including gram + ve and gram - ve ) within 1 h of dx of septic shock as well as reassessment after microbiologic data is available, to narrow the coverage, is recommended. Blood culture should be obtained before starting antibiotic. Source control- All pts. should be evaluated for presence of focus of infection amenable to source control measures like abscess drainage, debridement of necrotic tissue, or removal of infective device.

10. Use of adjuvant therapy like steroid Steroid are to be used only in children with suspected or proven adrenal insufficiency which shows high prevalence in septic shock, especially catecholamine refractory shock. Mechanical Ventilation Due to low functional residual capacity young infants and neonates with severe sepsis may require early intubation. The early use of mechanical ventilation aided by sedation reduces the work of breathing and allows for redistribution of limited cardiac output to vital organs, improves oxygenation and decreases PVR & left ventricular afterload .

11. Blood products Hb conc. Should be maintained at a minimal level of 10 g/ dL . Platelet transfusion should be done when PC < 5000/mm³ regardless of apparent bleeding. PC 5000-30,000/mm³ with significant risk of bleeding. Higher PC > 50,000/mm³ are typically required for surgery or invasive procedure. FFP is indicated in- Active bleeding Before surgery Before invasive procedure Reverse warfarin effect

12. Other supportive care Avoid hypoglycemia Prophylaxis for DVT in post-pubertal children Correction of symptomatic hypocalcemia Renal replacement therapy Done for ARF which includes peritoneal dialysis, intermittent hemodialysis , cont. renal replacement therapies IV immunoglobulin IVIg has shown to reduce mortality and length of PICU stay and less progression to complications, esp. DIC.

13. Therapeutic end points of resuscitation of septic shock Normalization of HR CRT ≤ 2 sec. Palpable peripheral pulses with no difference b/w peripheral and central pulses Warm extremities Normal BP and PP UO > 1 ml/kg/hr Return to baseline mental status, tone and posture Normal RR

14. Algorithm

15. Recognize depressed mental status and poor perfusion in a febrile child with or without foci of infection O2 by non- rebreathing mask if effortless tachypnea and septic shock BMV if arirway unstable, bradypnea , apnea; plan early intubation Establish IV/IO access Start saline/RL 20 ml/kg over 15-20 min(BP N/High); more rapidly by pull-push if BP is low. First dose of antibiotics, correct documented hypoglycemia and hypocalcemia Monitor for clinical therapeutic goals after each bolus till all goals are achieved; viz RR, work of breathing, HR, CRT, BP, peripheral temp., UO, sensorium , liver span 0 min 5 min

16. 20 min 40 min Therapeutic goals attained No PE/ hepatomegaly Goals not attained No PE/ hepatomegaly Goals not attained PE/ hepatomegaly 2 nd bolus 3 rd bolus, if needed Goals not attained PE/ hepatomegaly Goals not attained after 60 ml/kg No PE/ hepatomegaly Fluid refractory shock Start dopamine, interrupt fluids briefly, intubate , catheterize Start PPV

17. 20 min 40 min Goals not attained PE/ hepatomegaly Goals not attained after 60 ml/kg No PE/ hepatomegaly Fluid refractory shock Start dopamine, interrupt fluids briefly, intubate , catheterize Start PPV Dopamine @ 10-20 microgram/kg/min Consider intubation Catheterize for UO monitoring Cont. fluids in smaller amount, till goals attained or PE/ hepatomegaly occur PE and hepatomegaly resolve Goals not attained Titrate 10-20 ml/kg @ 10-20 min until goals achieved PE/ hepatomegaly recur Or PE/ hepatomegaly not resolved, No further fluids Fluid refractory dopamine resistant shock Continue monitoring Goals achieved Shift to ICU 60 min

18. Fluid refractory, Dopamine/ Dobutamine resistant shock Reassess clinical status, and Wherever possible, monitor BP, CVP, perform echocardiography, check ScVO2 And Hb and PCCV Cold shock Warm shock BP >5 th centile Hypotensive Low pulse pressure ≤ 20 mm Hg Start epinephrine < 0.3 µg/kg/min Epinephrine resistant low CO If BP normal add nitroso vasidilator or add milrinone after volume loading If PP is low- milrinone If PP is N-titrate NE+dobutamine Hydrocortisone 50 mg/m²/dose Hypotensive Wide pulse pressure, Target-PP < 40 mm Hg Titrate NE up @ 0.1-1 µg/kg/min and fluids Catecholamine Resistant Shock Consider vasopressin

19. Thank You