SEVERE SEPSIS&SEPTIC SHOCK SEVERE SEPSIS&SEPTIC SHOCK IN PEDIATRICS IN PEDIATRICS . . Abdel Razzaq Abu Mayaleh, MD Abdel Razzaq Abu Mayaleh, MD PRCS _ New Hospital - Hebron PRCS _ New Hospital - Hebron Based partially on Based partially on www.picucourse.org
Abdel Razzaq Abu Mayaleh, MD PRCS _ New Hospital - Hebron Based partially on www.picucourse.org. SEVERE SEPSIS&SEPTIC SHOCK IN PEDIATRICS. INTRODUCTION. SEPSIS :- it’s an infection plus systemic manifestation of infection. - PowerPoint PPT Presentation
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SEVERE SEPSIS&SEPTIC SHOCK SEVERE SEPSIS&SEPTIC SHOCK IN PEDIATRICSIN PEDIATRICS..
Abdel Razzaq Abu Mayaleh, MDAbdel Razzaq Abu Mayaleh, MD PRCS _ New Hospital - HebronPRCS _ New Hospital - Hebron
Based partially onBased partially on
www.picucourse.org
INTRODUCTIONINTRODUCTION
SEPSIS:- it’s an infection plus systemic manifestation of infection.
SEVERE SEPSIS :- Sepsis plus sepsis-induced organ dysfunction or tissue hypo perfusion.
A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. Crit Care Med 2004; 320(Suppl):S595-S597
Septic Shock Epidemiology
During the last 2 decades the incidence of sepsis & septic shock has increased across all age groups. This is thought to be due to:
- ↑ use of invasive procedures
- ↑ use of immunosuppressive drugs
- ↑ microbacterial ressistance
Child mortality improved dramatically from 97% → 9% due to
the advance in critical care technology.
Septic Shock: “Warm Shock”
Early, compensated, hyperdynamic state Clinical signs
Warm extremities with bounding pulses, tachycardia, tachypnea, confusion.
Titrate epinephrine for cold shock, norepinephrine for warm shock to normal clinical endpoints and ScvO2 saturation ≥70% .
15 min
Fluid responsive *
Observe in PICU
0 min
5 min
Catecholamine-resistant shock
Begin hydrocortisone if at risk for absolute adrenal insufficiency
Normal Blood Pressure
Cold Shock
ScvO2 Sat <70%
Low Blood Pressure
Cold Shock
ScvO2 Sat < 70%
Low Blood pressure
Warm Shock
ScvO2 Sat ≥ 70%
Add Vasodilator or type III phosphodiesgerase inhibitor with volume
loading
Titrate volume and epinephrine
Titrate volume and norepinephrine
Persistent Catecholamine- resistant shock
Start Cardiac output measurement and direct fluid, inotrope, vasopressor, vasodilator, and hormonal therapies to attain CL>3.3 and <6.0 L/min/m²
60 min
Refractory shock
Consider ECMO
VENTILATOR MANAGEMENT
Assist control mode-volume ventilation Reduce tidal volume to 6ml/kg predicted body wt. Keep Pplat <30cm H2O Maintain SaO2 / pO2 88-95%
Anticipated PEEP setting at various FiO2 requirements
FiO2 0.3 0.4 0.5 0.5 0.6 0.7 0.8 0.9 1.0
PEEP 5 5 8 10 12 14 16 18 20
Sedation and Analgesia in Sepsis
Sedation protocol for mechanically ventilated patients with standardized subjective sedation scale target.• Intermittent bolus• Continuous infusion with daily
awakening/retitrationGrade B
Kollef, et al. Chest 1998; 114:541-548Brook, et al. CCM 1999; 27:2609-2615Kress, et al. NEJM 2000; 342:1471-1477
Neuromuscular Blockers
Avoid if possible Used longer than 2-3 hrs
PRN bolus Continuous infusion with twitch monitor
Grade E
The Role of IntensiveInsulin Therapy in the Critically Ill
At 12 months, intensive insulin therapy reduced mortality by 3.4% (P<0.04)
Adapted from Figure 1B, page 1363, with permission from van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-67
In-h
osp
ital
su
rviv
al (
%)
100
00
Intensive treatment
Conventional treatment
Days after admission
80
84
88
92
96
50 100 150 200 250
P=0.01
Glucose Control
After initial stabilization Glucose < 150 mg/dL Continuous infusion insulin and glucose
or feeding (enteral preferred) Monitoring
Initially q30–60 mins After stabilization q4hGrade D
Bicarbonate therapy not recommended to improve hemodynamics in patients with lactate induced pH >7.15
Grade C
Cooper, et al. Ann Intern Med 1990; 112:492-498Mathieu, et al. CCM 1991; 19:1352-1356
Bicarbonate Therapy
Primary Stress Ulcer Risk Factors Frequently Present in Severe Sepsis
Mechanical ventilation Coagulopathy Hypotension
Choice of Agents forStress Ulcer Prophylaxis
H2 receptor blockers
Role of proton pump inhibitors
Grade C
Cook DJ, et al. Am J Med 1991; 91:519-527
Blood Product AdministrationRed Blood Cells
Tissue hypoperfusion resolved
No extenuating circumstances Coronary artery disease Acute hemorrhage Lactic acidosis
Transfuse < 7.0 g/dl to maintain 7.0-9.0 g/dL
Grade B
Blood Product Administration
Do not use erythropoietin to treat sepsis-related anemia. Erythropoietin may be used for other accepted reasons.
Grade B
Blood Product Administration
Fresh frozen plasma
• Bleeding
• Planned invasive procedures.
Grade E
Blood Product Administration
• Do not use antithrombin therapy.
Grade B
Warren et al. JAMA 2001; 1869-1878
Blood Product Administration
Platelet administration Transfuse for < 5000/mm3 -
Transfuse for 5000/mm3 – 30,000/mm3 with significant bleeding risk
Transfuse < 50,000/mm3 for invasive procedures or bleeding