Upload
caitir
View
48
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Non-Dialytic Therapy for Sepsis in the Paediatric Patient. Desmond Bohn The Department of Critical Care Medicine The hospital for Sick Children, Toronto. Sepsis. Vascular failure. Cardiac failure. Hypovolaemia. Shock. Inadequate tissue oxygen delivery. Multi-organ failure. Death. - PowerPoint PPT Presentation
Citation preview
Non-Dialytic Therapy for Sepsis in the Paediatric Patient
Desmond BohnThe Department of Critical Care MedicineThe hospital for Sick Children, Toronto
Shock
Inadequate tissue oxygen delivery
Multi-organ failure
Death
Vascular failure Cardiac failure
Hypovolaemia
Sepsis
Albumin leak and vascular permeabilityFleck A Lancet 1985; 1:781
Albumin transcapillary escape rate
16 patients post CPB
H2O
Vascular space Interstitial space
Reduced Inravascular volume
hydrostatic
oncotic H2O
shock
H2O
H2O
Vascular space Interstitial space
crystalloid
hydrostatic
oncotic
H2O
H2O
Vascular space Interstitial space
hydrostatic
oncotic
5% albumin
early
H2O
H2O
Vascular space Interstitial space
hydrostatic
oncotic
albumin
late
Fluid Resuscitation in Septic ShockCarcillo JA JAMA 1991; 266:1242
•Effects of early fluid resuscitation in paediatric septic shock
•Patients septic shock & PA catheter at 6 hrs
•Mortality and morbidity endpoints
•ARDS defined by bilateral infiltrates, hypoxaemia & PCWP <15 mmHg
Fluid Resuscitation in Septic Shock
All patients 33±26 95±42n=34
Survivors 42±26‡ 97±49n=18
Non survivors 23±18 94±37n=16
Colloid 9 ml/kg 37 ml/kg
Carcillo JA JAMA 1991; 266:1242
1 h 6 h mean ± SD mean ± SD
‡ P<0.05, mean vol in 1st hr survivors vs nonsurvivors
Fluid administered (mls/kg)
Fluid Resuscitation in Septic Shock
Group 1 (n=14) 11±8 71±29<20 ml/kg
Group 2 (n=11) 32±5 108±5420-40 ml/kg
Group 3 (n=9) 69±19 117±29>40 ml/kg
Carcillo JA JAMA 1991; 266:1242
1 h 6 h mean ± SD mean ± SD
Mean PCWP at 6 h was 11.5 mmHg24% patients were hypovolaemic at 6 h
0
2
4
6
8
10
12
14
16
group 1 group 2 group 3 groups 1 & 2
no. o
f pat
ient
s
survivors
deaths
Fluid Resuscitation in Septic ShockCarcillo JA JAMA 1991; 266:1242
Group 1 <20 ml/kg
Group 2 20-40 m/kg
Group 3 >40 ml/kg
*
*Significant difference in survival between group 3 and groups 1 & 2 individually and combined
0
2
4
6
810
12
14
16
18
ARDS No ARDS
No.
of
pati
ents
survivors
deaths
Fluid Resuscitation in Septic ShockCarcillo JA JAMA 1991; 266:1242
Group 1 <20 ml/kg
Group 2 20-40 m/kg
Group 3 >40 ml/kg
Myocardial Function in SepsisMercier J-C Crit Care Med 1988; 16:27
Haemodynamic patterns of meningococcal shock in children
Septic ShockMyocardial Function in Sepsis
Myocardial Function and SepsisQuezado ZMN Am J Kid Dis
Myocardial Function in SepsisParillo JE J Clin Invest 1985; 76:1539
Circulating myocardial depressant substance in septic shock
Myocardial Function in Sepsis
Hours from baselinrHours from baselinr
Suffredini AF N Engl J Med 1989; 321:280
Endotoxin administration in normal humans
Myocardial Function in SepsisOgnibene FP Chest 1988; 93: 903
Response to volume infusion in sepsis
Myocardial Function and SepsisPagani FD J Clin Invest 1992; 90:389
Effect of TNF-on LV function
Myocardial Function and SepsisFinkel MS Science 1992; 257:387
Negative inotropic effect of cytokines mediated by NO
Haemodynamic support in sepsis
Pressor or inotrope?
Pressor or inotrope?
Norepinephrine and Septic ShockMartin C Crit Care Med 2000; 28:2758
Vasopressin in vasodilatory septic shockTsuneyoshi I Crit Care Med 2001; 29:487
Vasopressin in Septic ShockPatel B. Am J Respir Crit Care Med 1998;A608
• A randomised blinded study
• Patients with SIRS requiring pressor support
• Fluid resuscitated
• Randomised to nor-epinephrine or vasopressin
Vasopressin in Septic Shock
MAP (mmHg) 66±2 68±3 71±5 66±3
CI (L/min) 4.1±1 3.4±0.6 4.2±1.1 4±1.1
PVR 196±4 183±4 87±11 62±12
urine (ml/hr) 36±22 38±22 27±16 104±56
gast PCO2 grad 3.2±2.4 7.2±1.4 11.3±5.5 17.9±6
nor-epinephrine n=4 vasopressin n=4baseline post inf (4hr) baseline post inf (4hr)
Patel B. Am J Respir Crit Care Med 1998;A608
Rivers E N Engl J Med 2001; 345:1368
Early goal-directed therapy in the treatment of severe sepsis and septic shock
Rivers E N Engl J Med 2001; 345:1368
Early goal-directed therapy in the treatment of severe sepsis and septic shock
Steroid Response in SepsisAnnane D JAMA 2000; 283:1038
n=189
cortisol <34 ug/dl and delta > 9 ug/dl mort 26%
cortisol 34 ug/dl and delta <9 ug/dl mort 67% cortisol >34 ug/dl and delta >9 ug/dl
cortisol < 34 ug/dl and delta <9 ug/dl mort 82%
Stress dose steroids in hyperdynamic septic shock
Briegel J Crit Care Med 1999; 27:723
RCT40 patients randomised100 mg loading dose followed by 0.18 mg/kg/hr
Activated protein C in SepsisBernard GR New Engl J Med 2001; 344:699
Activated protein C in SepsisBernard GR New Engl J Med 2001; 344:699
Extracorporeal Life Support for Meningococcaemia
•12 patients with meningococcaemia7 with refractory shock5 with severe ARDS
•Age 4 mths to 18 yrs (median 26 mths)
•Median duration of support was 76 (20-263) hrs
•9 survivors
Goldman AP Lancet 1997; 349:466
Summary
Sepsis characterised by hypovolaemia, vasculopathy and decreased myocardial function
Therapy should be focused on strategies that maximise tissue oxygen delivery
Anti-cytokine therapies have so far proven ineffective
Steroids and APC may improve the outcome in severe sepsis
Stress dose steroids in hyperdynamic septic shock
Briegel J Crit Care Med 1999; 27:723
Myocardial Function in SepsisParillo JE J Clin Invest 1985; 761539
Circulating myocardial depressant substance in sepsis