1. Paediatric Septic Shock
Dr.Sajid Nomani
MEM (GWU)

2. 8 year old female arrives at ED with HR 180, RR 35, looks
toxic. Has had URTI symptoms for past couple of days.
Paeds Reg called by ED doctor saying can you come and
have a look.
You make your first assessment
 HR 180
 T 39.9f
 RR-32br/min
 BP 70/50mmhg
 SPO2 90% on RA
 Quiet, tired, opens eyes
 Cap refill 4 seconds
Worry??????

3. Why are we worried about it?
Still remains significant cause of morbidity and mortality
19 milln. Cases worldwide / year( adhikari et al)
30% of paediatric patients with sepsis will develop septic
shock.
Mortality rates in septic shock are 20-30% (up to 50% in
some countries).

4. Risk factors for Sepsis in Children
< 1 year of age
Very low birthweight infants
Prematurity
Presence of underlying illness
Co-morbidities
Boys
Genetic factors

5. So
What is SEPSIS ….. ..????????????
Sepsis is a life threatening response to infection.
It represents a continuum through SIRS, sepsis, and septic shock

6. How do we define it
Systemic Inflammatory Response Syndrome
Infection
Sepsis
Severe Sepsis
Septic Shock

7. SIRS…in peds
Core Temp >38.5 or < 36 degrees
Mean HR > 2SD for age or persitant elevation over 0.5-4hrs
If < 1yr old: bradycardia HR < 10th centile for age
Mean RR > 2 SD above normal for age
Leucocyte abnormality.
≥2 criteria should be present
≥ 2 SIRS criteria but no infection : SIRS
≥ 2 SIRS criteria + sign of acute organ failure : severe SIRS

8. Sepsis
SIRS + suspected or proven infection
Severe Sepsis
Sepsis + sepsis induced organ dysfunction, / tissue hypo
perfusion
Septic Shock
Sepsis + Hypotnsn /CV organ dysfunction

9. Cardiovascular dysfunction
Despite >40ml/kg Isotonic fluid bolus in 1 hour:
Decrease in BP <5th centile for age
Need for vasoactive drug to maintain BP
2 of the following:
Unexplained metabolic acidosis
 Increase lactate
 Oliguria
 Prolonged cap refill > 5 seconds
 Core-peripheral temp gap >3 degrees


10. What makes you suspect shock??

11. Clinical Manifestations
Variable….depends upon loads/site/pathogens/comorbidites
Fever
Increased HR
Increased RR
Altered mental state
Skin:
Hypoperfusion
Increased capillary refill
Petechiae, purpura
Cool vs warm.

12. Cold Shock
Warm Shock
HR
Tachycardia
Tachycardia
Peripheries
Cool
Warm
Pulses
Difficult to palpate
Bounding
Skin
Mottled, pale
Flushed
Capillary refill
Prolonged
Blushing
Mental state
Altered
Altered
Urine
Oliguria
Oliguria

13. Blood Pressure in Children
This is main difference with adults.
Blood pressure does not fall in septic shock until very
late.
CO= HR x SV
HR in children much higher therefore BP falling is late.
Hypotension formula :
70+(age× 2)

14. Etio+ pathophysiology
Pneumonia < Intraabdominal < UTI
Cultures are positive in only 1/3rd cases
Staph aureus and Streptococcus pneumoniae(gr +)
E coli, klebsiella species,Pseudomonas aeruginosa(gr -)

15. PATHOPHYSIOLOGY
Infectious organism/ endotoxin  activates immune system
Their interaction c infectioning organism stimulates  Cytokines
Cytokines
 produce vasodilation & damage endothelium of vessles 
↑cap.permiablity→cap.leakage
 Inhibits anticoag.properties + ↑ Antifibrinolysis → microvascular
thrombosis →MOD & DIC
Specific inflam.mediator→ impaired cardiac contractility & myocard. d/f
Adrenal gland are prone to microvascular thrombosis & hemorrhage in
septic shock
↓
↓ SVR & myocardial d/f

16. Management….
Recognise early
Resuscitation must be done in a proactive time-sensitive
manner.
Every minute counts – “golden hour”
Every hour without appropriate resuscitation increases
mortality risk by 40%

17. Coming back to our patient….
HR 180
Initial management
T 39.9f
BP 70/50mmhg
SPO2 90% on RA
Quiet, tired, opens eyes
Mod respiratory distress
Cap refill 4 seconds
+
Symptoms of URTI
WHAT NEXT????
EGDT ???????????
Blood & Imaging
Source control
Disposition ?????????

18. IV /IO-2 max.bore
Monitor
O2
ABC resuscitation.

19. EGDT

20. GOAL: SEPSIS INDUCED HYPOPERFUSION
IN FIRST 6 HOURS

Central venous pressure 8-12 mm Hg

Mean arterial pressure (MAP) ≥ 65 mm Hg

Urine output ≥ 0.5 ml/kg/hr

Scvo2 or Smvo2 ≥ 70% or ≥ 65%, respectively


Decreased lactate
Source control


Better perfusion

Improvement in Mental status

21. 0-5min:
 Recognise Sign of poor perfusion
 Maintain airway and establish IV/IOaccess
5-15 min:
 20mls/kg isotonic saline boluses up to and
over 60mls/kg
 Correct hypoglycemia
 0.5-1gm/kg
 Dx25:-2-4ml/kg
 Dx10:-5-10ml/kg
Our pt.
 BP- 76/50
 HR-170
 CRT -≥4sec.
Repeat bolus upto
60ml/kg
or
Sign of overload

22. Fluid Refractory Shock
Inotrops /vasopressor
to maintain
 Map->65
 Cvp- 8-12
 Svo2->70%
Central line
Arterial line
First dose of Antibiotic
Catecholamine Resistant shock
 Stress dose of Hydrocort
15-60 min….

23. O -5min
5-15m
Recognise Sign of poor perfusion
Maintain airway and establish access
Push 20mls/kg isotonic saline or colloid boluses up to and over
60mls/kg
Correct hypoglycemia
Antimicrobials, Correct hypoglycemia
15 -60m
fluid Responsiveness
Observe in PICU
Fluid Refractory shock

24. 15min
Fluid Refractory Shock
Begin dopamine / Norad/ Epineph.
Establish central venous access
Establish arterial access
Titrate Adrenaline for cold shock and noradrenaline for warm
shock to normal MAP-CVP and SVC sats>70%
60 min
Catecholamine resistant shock

25. Catecholamine Resistant Shock
At Risk of adrenal insufficency – give hydrocortisone-draw a baseline cortisole
Evaluate Scvo2 >70%
Normal BP ,poor perfusion
SVC < 70%
Transfuse PRBC Hb>10
Add Dopamine/NPS
Milrinone
Low BP,poor perfusion
Cold Shock
SVC < 70%
Transfuse PRBC,Hb>10
Adrenaline
Dobutamine+Norad.
ECMO
Low BP
Scvo2 >70
Warm Shock
Additional volume
& Noradrenaline
±
Vasopressin

26. Therapeutic endpoints
Clinical
 Heart Rate normalized for age
 Capillary refill < 2sec
 Normal pulse quality
 No difference in central and peripheral pulses
 Warm extremities
 Blood pressure normal for age
 Urine output >1 mL/kg/h
 Normal mental status
 CVP >8 mmHg

27. During the first 6 hrs, if the venous O2 saturation target not
achieved with fluid resuscitation:
 Packed RBC transfusion to achieve a hematocrit of ≥ 30%
Active source control

28. SOURCE CONTROL
 Specific anatomic site of infection should be established as rapidly as
possible and within the first 6 hours of presentation
 Formally evaluate patient for a focus of infection amenable to source
control measures (eg: abscess drainage, tissue debridement)
 Implement source control measures as soon as possible following
successful initial resuscitation
(Exception: infected pancreatic necrosis, where surgical intervention best
delayed.)
 Choose source control measure with maximum efficacy and
minimal physiologic upset.
 Remove intravascular access devices /cathetor if potentially infected.

29. Investigations
Sepsis Work up
 Lactate , ABG , CBC
 PCT , CRP
 Metabolic Panel /Electrolyte
 Coagulation Profile
 Urine, blood, sputum ,stool, throat swab cultures
 Viral cultures
 Never do CSF in shocked patient.
Imaging:
 CXR, CT, MRI, PET scan, ECHO, Ultrasound

30. Other treatment
Maintain Glucose control
Nutrition
Maintain Hb > 10g/dL
No stress ulcer protection /no DVT protection before
puberty age
Early CVVH

31. Drug
Dose
Comments
Dopamine
2-20mcg/kg/min
Historically 1st choice in kids
Alpha, beta and dopamine receptor
activation
Can be given peripherally
Dobutamine
5-10mcg/kg/min
Chronotropic as well as inotropic
Afterload reduction
Adrenaline
0.05- 1mcg/kg/min
Initially increases contractility/heart rate
High doses increase PVR
Noradrenaline
0.05 – 1 mcg/kg/min
Vasopressor
Increases PVR
Milrinone
0.25-0.75mcg/kg/min
Phosphodiesterase inhibitor
Afterload reduction

32. Take home points….
Early Recognition
Early goal directed therapy
Remember golden hour
Early and Emperic antimicrobials
Early source control and aggressive therapy

33. qUESTIONS????????????????