PEDIATRIC SHOCK

Patricia Abboud M.D.

Department of Critical Care Medicine
Resident Core Conference
August 18, 2010

Aitaneet, Lebanon

Findings consistent with Necrotizing fascitis

Carson Bruner
4 year old male diagnosed and
treated for strep toxic shock in the
PICU in January of 2008.

Carson Bruner
playing soccer in April 2009

SEPSIS with not such a happy ending.

SEPSIS with not such a happy ending.

3 year old presents to ED
with cc of vomiting, fever,
Medical Decision Making
minimal cough
Labs: ((1010))
ROS: denies diarrhea,, abd
8.9
10
424
pain, ST
32
Vitals: 40.7 R/ 176/28/ 120/p
14B 50S 26L 10M
PE: alert, non toxic,
139 106 17 112
interactive, playful, normal
3.7 22 0.6 9.2
exam, no petichiae or
purpura
Blood Culture sent
CXR: Normal

SEPSIS with not such a happy ending.

Tolerated PO
Given zofran
d/c vitals: 38
38.9
9 R / 140/ 36
Sent home with instructions
d/c diagnosis: Acute Febrile Illness with
most likely viral etiology

SEPSIS with not such a happy ending.

Vitals: 38.4/148/48/ 82/p
Labs: (2007)
PE: listless
Widespread purpuric and
ecchymotic
y
lesions with
dark punctate areas on:
Face, trunk, extremities,
ears, palate

10
120
31
17B 13S 67L 3M
2.2

141 106 24 136

3.9 11 1.2 8.6
PT 18 PTT 63 INR 1.75

SEPSIS with not such a happy ending.

Returns that evening at 1915 with
concern for increased fussiness,
sleepiness
p
and bruise-like rash that
suddenly appeared
Blood culture from 1010 is growing
something

SEPSIS with not such a happy ending.

Interestingly: blood culture from 2050
grew NOTHING
Rocephin documented as given at 2038
Lactic acid = 12.4
LP
CSF WBC 6 RBC 14 PRO 30 GLU 86
Neutrophils 82 Mono10 Lymp 8
Gram stain showed.

Gram Negative Diplococci

NEISSERIA MENINGITIDIS

SEPSIS with not such a happy ending.

Objectives
Define sepsis and the sepsis spectrum as
it relates to the pediatric population
Understand the role of inflammation and
inflammatory mediators in sepsis
Review the management strategy for
sepsis
Understand the endpoints of resuscitation
Review recent advances and research in
the management of pediatrics sepsis
Review brain death criteria

Sepsis Epidemiology
1990
CDC
estimated
450,000
cases off
sepsis/yr
Adults and
children1
1.
2.

CDC.JAMA 1990.
Martin. NEJM.2003.

Sepsis Epidemiology

Information on children is limited

Pediatric subset of previous study
4th leading cause of death in U.S. children
behind congenital anomalies, prematurity, and
SIDS
Over 42,000 cases/yr

Sepsis Epidemiology
Half of all children
with underlying comorbidity
Mean length
g of
stay 31days
Survivors
reduced quality of
life

AM J Respir Crit Care Med. 2003.

Watson RS. Am J Resp CCM 2003:695-701.

Sepsis Epidemiology

Sepsis Definitions

Hospital mortality of 10.3%

Risk of death increases with increasing
numbers of organ failure
Mortality rate of septic shock is 40%
70%
20% of deaths occurred within 2 days of
admission
Treating patients with sepsis costs
nearly $17 billion in the United States
Watson R, et al. Am J Resp CCM 2003.

Sepsis Definitions

CCM. 2008; 36(1):296-327

Sepsis Definitions

Goldstein. PCCM 2005.

Sepsis is a Complex Disease

Environmental
Risk Factors

Genetic
Risk
Factors

SEPSIS

Patient
Risk
Factors

Sepsis and Inflammation

Microvascular Circulation

Complement Activation

IL-10

IL-6

Pro-Inflammatory
Responses

Anti-Inflammatory
Responses
Anti-Inflammatory
Anti
Inflammatory
Responses

Pro-Inflammatory
Responses

Sepsis

SIRS
Sepsis

Coagulation

Endothelial
Injury

Inflammation

Severe
Sepsis

Fibrinolysis

Septic Shock

Organ
Failure

Death

Pediatric Sepsis Definitions

Age Specific Vital Signs and

Laboratory Values
Age Group

SIRS

Sepsis

Clinical response with 2 of

the following:
T > 38.5C or < 36C
HR > 2 SD above nl or in
children <1 yr bradycardia
RR > 2 SD above nl or mech
vent
WBC or for age or > 10%
bands

Severe Sepsis

SIRS in
presence of
suspected
or proven
infection

Tachycardia Bradycardia

RR

WBC Count

SBP

Septic Shock

0-7 days

>180

<100

>34

>34

<65

SEVERITY

7-30 days

>180

<100

>40

>19.5 or <5

<75

1 mo- 1 yr

>180

<90

>34

>17.5 OR <5

<100

2-5 years

>140

NA

>22

>15.5 OR <5

<94

6-12 years

>130

NA

>18

>13.5 OR
<4.5

<105

13-18 years

>110

NA

>14

>11 OR <4.5

<117

Sepsis + one
of the
following:
CV organ
dysfunction
ARDS
2 organ
dysfunctions

Sepsis + CV
dysfunction
(despite fluid
resuscitation)

PCCM:2005;Vol. 6, No. 1 pp 2-8

PCCM:2005;Vol. 6, No. 1 pp 2-8

What is the problem in shock?

Shock is a syndrome that

results from inadequate
oxygen delivery to meet
metabolic demands

P
Poor
Oxygen
O
Delivery
D li

Oxygen Delivery
= PUMP x

blood O2 content

Cardiac Output
Heart Rate x Stroke Volume

Preload

Cardiac Output

(volume)
Hypovolemic or Hemorrhagic Shock

HR x SV

preload

contractility
afterload

NS
LR
Blood
Albumin
FFP

Afterload

Contractility

(resistance)
Distributive Shock

Cardiogenic Shock

Dopamine
Epinephrine
Norepinephrine
Phenylephrine
Vasopressin

Inotropic agents

Dopamine
D b t i
Dobutamine
Milrinone
Epinephrine

Calcium

The Role of the Community Physician

Septic Shock
a dysfunction of preload,
afterload and contractility
y

It

is likely that the initial resuscitation that community hospital

physicians provide will have the greatest impact on determining
the survival outcome for children who present with septic shock.

WARM Septic Shock

Early, compensated, hyperdynamic
Clinical Signs

COLD Septic Shock

Late, uncompensated with decreased CO
Clinical Signs

-confusion

-Warm extremities

bounding pulses, TACHYCARDIA,

tachypnea

Cyanosis, cold, clammy

Rapid, thready pulses with
shallow respirations

Physiologic Parameters
Wide pulse pressure, increased CO
decreased SVR

Thrombocytopenia, oliguria, myocardial

dysfunction, capillary leak

Management
GOAL:

Management

oxygen delivery
oxygen demand

Aggressive fluid resuscitation with

crystalloid or colloids is of fundamental
importance to survival of septic shock
i children.
in
hild

ABC
Fluid
Temperature control
Broad spectrum antibiotics after
cultures sent
Correct metabolic abnormalities
Inotropes

Parker, M. et al. Pediatric Considerations. CCM. 2004; 32 (11)S591-S594.

Management
Volume Expansion
Optimize preload
NS or LR
Use 10-20
10 20 cc/kg q 2
2-10
10 minutes
At 40-60 cc/kg reassess and consider
ongoing losses
adrenal insufficiency
intestinal ischemia

Have I improved oxygen

delivery?
Good oxygen delivery translates
i t good
into
d end
d organ perfusion.
f i

How do I know if Im doing a good

job?

Therapeutic Endpoints

Normal Mental Status

Heart Rate normal for age
Capillary refill < 2 sec
Strong pulses
Warm extremities
Good urine output
Decreased lactate

Coming SoonSepsis Bundle

GOLDEN HOUR SEPTIC SHOCK BUNDLE
Dx: Severe Sepsis
Continuous Cardiac Monitoring
Continuous Pulse Oximeter Monitoring
Vital Signs (Q15 minutes x 2 hours)
Diet: NPO
Labs:
;
;

CBC with diff

CMP

Blood Culture: Aerobic

STAT Blood Glucose

Blood Gas: Capillary

;

Lactic Acid
Tracheal Culture
Urinalysis

Urine Culture

Cortisol Level

Type and Screen

PT/PTT

Fibrinogen

Anaerobic
Venous

Fungal

Arterial

D-Dimer

IV Fluid Bolus:
;

Normal Saline bolus IV (20 ml/kg within 10 minutes and repeat as necessary)

Albumin 5% 10 ml/kg IV over 30 minutes

Inotropic Agents:

Dopamine Drip 800 mcg/ml in D5W at initial rate of 10 mcg/kg/min IV

Epinephrine Drip 30 mcg/ml in NS at initial rate of 0.1 mcg/kg/min IV

Norepinephrine Drip 16 mcg/ml in D5W at initial rate of 0.1 mcg/kg/min IV

Antibiotics:
;

Ceftriaxone 100 mg/kg/dose IV (max 2 gram/dose)

Vancomycin 15 mg/kg/dose IV (max 1 gram/dose)

Neutropenic patient Cefepime 50 mg/kg/dose IV (max 2 gram/dose)

Ensures fidelity and is a mechanism of adaptation

Why your DNA is not your destiny?

Genome
Static
Alters DNA
g seen over millions
Changes
of years
Natural selection
Inherited
Irreversible

Epigenome
Dynamic
No change in DNA
g
Seen in NEXT generation
Biological response to
environmental stressors
Acquired
Reversible

10

Epigenetics: genes and environment

Epigenetic Regulation of
Immunoparalysis

interacting

Cancers
Imprint disorders (Anglemans Syndrome)
Immunity related disorders
p y
disorders
Neuropsychiatric
Pediatric Syndromes (Retts, Muscular
Dystrophy)
Inutero exposure (origin)
Adult disease

Macrophage activation/deactivation (Dr.

Cornell, Motts Childrens, MI)

Are there any long term effects of

sepsis?

Brain Death:
Definition
Irreversible loss of function of the brain,
including the brainstem
Diagnosis is made by clinical history
and examination
It is EQUIVALENT to death just like the
person who has irreversible cessation of
cardiac and respiratory function

Brain Death:
Criteria

Criteria for brain death include absent

cerebral function, absent brainstem function,
and a known cause of the childs coma.
Prerequisites for the diagnosis are absence
of all the following:
Hypothermia
cardiovascular shock
coincident metabolic derangement predisposing to
coma
drug or toxin leading to excessive sedating

Brain Death:
Clinical Exam
Cerebral Response: Painful Stimuli
Brainstem Response

Pupillary response
Corneal reflex
Oculocephalic reflex (dolls eyes)
Oculovestibular reflex
Gag reflex
Cough reflex
Spontaneous respirations
Apnea test

11

Brain Death:
age dependent requirements
Once the child meets the previous noted
criteria, examination findings must remain
consistent with brain death for a defined
period:
48 hours for children 7 days to 2 months of age
24 hours for those 2 mo to 1 year of age
6-12 hours in patients older than 1 year of age

Confirmatory testing may be completed to

expedite the brain death diagnosis (cerebral
angiograms, flow study)

Final Thoughts
Sepsis is a disease spectrum and patients
can present anywhere in the process.
Inflammation and inflammatory mediators, for the
most part, are responsible for the tissue injury seen
in sepsis.
Management involves increasing oxygen
delivery and minimizing oxygen demand.
Management is basic: ABC, antibiotics, fluids,
and supportive measures to maintain adequate
perfusion
Brain death is equivalent to irreversible cardiac or
respiratory function.

My OFFSPRING

Final Thoughts
Before you drink that beer,
Over indulge

stay up too late partying,

think about the implications
for you AND your offspring!!
It may come back to haunt YOU!

George, Joseph, and Sophia

abboudp@childrensdayton.org

What happens in late stages sepsis?

Injury
Compensatory anti-inflammatory
response

Deactivation of moncytes
T-cell dysfunction
Dysfunction of adaptive immunity

Infection
Multi-system organ dysfunction
Death

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