Pediatric Shock Part 6 Septic Shock

Management of Septic Shock

The clinical symptoms associated with septic shock are due to the changes  in the patient’s hemodynamic and metabolic status.  These are the result of their response to infection and the release or activation of inflammatory mediators. 

Primary Goals

·         Restoration of hemodynamic stability

·         Identification and Control of Infection

Symptoms

·         Tachypnea

·         Tachycardia

·         Bounding peripheral pulses

·         Brisk or delayed capillary refill

·         Warm flushed skin (warm shock)

·         Pale, mottled skin (cold shock)

·         Hypotension with wide pulse pressure (warm shock)

·         Hypotension with narrow pulse pressure (cold shock)

·         Changes in level of consciousness

·         Oliguria

·         Fever or Hypothermia

·         Petechial or purpuric rash

“Warm” Shock

Early in the course of septic shock a child may present with decreased systemic vascular resistance and increased blood flow to the skin.  This produces extremities that are warm to the touch with bounding peripheral pulses.

“Cold Shock”

Later in the course of septic shock, the presence of myocardial dysfunction and hypovolemia leads to a decrease in cardiac output.  As the systemic vascular resistance increases the blood flow to the skin is impaired producing cool extremities and weak peripheral pulses.

Treatment Approach

·         Oxygen support

·         Fluid resuscitation

·         Vasoactive agents

·         Diagnostic tests

·         Stress related adrenal insufficiency

Oxygen Support

·         Early intubation

·         Ventilatory support

·         Peep as needed

·         Monitor respiratory rate

·         Pulse oximetery

Fluid Resuscitation

·         Rapid fluid boluses isotonic crystalloids 20ml/kg up to 3-4 bouses

·         Frequent reassessment

·         Titrate according to hemodynamic response

·         5-10ml/kg over 20 minutes with impair myocardial function

·         Transfuse if HGB < 10

·         Monitor for symptoms of pulmonary edema and hepatomegaly

Antibiotics

·         Begin first dose of broad spectrum antibiotics as soon as possible

·         Do not delay antibiotics to wait for blood cultures or diagnostic tests

Vasoactive Agents for Fluid Refractory Shock

·         Norepinephrine  0.2-1mcg/kg/min

·         Vasopressin  0002-002 u/kg/min

·         Dobutamine  2-20mcg/kg/min

·         Dopamine  2-20mcg/kg/min

·         Epinephrine  0.1-1mcg/kg/min

·         Milrinone  50mcg/kg bolus, then 0.25-0.75mcg/kg/min

Diagnostic tests

·         CBC

·         Ionized calcium

·         Glucose

·         Lactate

·         Base deficit

·         ScvO2

·         Cultures

Stress related adrenal insufficiency

Hydrocortisone 2mg/kg IV (max dose 100mg)

Warm Shock

·         Norepinephrine

·         Vasopressin for shock refractory to norepinephrine

Normotensive Shock

·         Dopamine

·         Milrinone or nipride for patients with high SVR

Cold Shock

·         Epinephrine

·         Dobutamine and norepinephrine

Therapeutic endpoints

·         Good distal pulses

·         Adequate pressure

·         ScvO2 of ≥ 70%

·         Correction of metabolic acidosis and lactate concentration

Source

Pediatric Advanced Life Support Provider Manual by Leon, M.D. Chameides, Ricardo A., M.D. Samson, Stephen M., M.D. Schexnayder and Mary Fran, RN Hazinski (Oct 12, 2011)