MANAGEMENT OF

SEPTIC SHOCK

By AKASH CHOUDHURY
MODERATED BY : DR VIRENDER KUMAR
MAJOR GOALS

◆ Early recognition
◆ Resuscitate the patient, using fluid.
◆ Supportive measures to correct hypoxia, hypotension and hypoperfusion, metabolic
abnormalities etc.
◆ Early initiation of antimicrobial and Source control (source of infection)
◆ Pharmacological and supportive management of cardiovascular dysfunction guided by
non invasive and invasive monitoring
◆ Maintain adequate organ system function, and interrupt the progression of MODS(multi
organ dysfunction syndrome)
Challenges for pediatric shock

★ Early Recognition ★ Fluid Management

○ Children compensate well; shock signs appear ○ Fear of fluid overload (e.g., in dengue,
late. myocarditis) may delay resuscitation.5
○ Tachycardia and cool extremities may be ★ Drug Dosing
overlooked.1 ○ Dosing is weight-based;
★ Non-specific Signs ○ Emergency situations may lack accurate
○ Symptoms like irritability, poor feeding, lethargy weight estimation tools.4
can mimic non-shock illnesses.2 ★ Monitoring Limitations
★ Communication ○ Inadequate access to lactate,
○ Infants can’t describe symptoms. History depends ○ BP monitoring, or
on parental reporting, which may be vague.3 ○ Bedside echocardiography in many
★ Vital Sign Interpretation centers.2
○ Normal HR, RR vary by age; abnormal values may ★ Training & Protocols
be misread.4 ○ Many centers lack pediatric-specific
★ Vascular Access emergency protocols or trained
○ IV access is often difficult in shock due to personnel.2
collapsed veins. IO access requires training.1,4

1
Source: American College of Critical Care Medicine (ACCM) Guidelines, 2013 2Source: WHO Pocket Book of Hospital Care for
Children 3Source: Nelson Textbook of Pediatrics, 21st Edition 4Source: Pediatric Advanced Life Support (PALS) Guidelines,
5
Surviving Sepsis Campaign 2020
WHO CRITERIA

Signs able to identify most of paediatric shock cases

★ Cold hand
★ Capillary refill time (CRT>= 3sec)
★ Fast and weak pulse

History and examination help in identifying and assessing a child with shock.

Drawback:

★ It may miss early distributed shock like warm septic shock who don't do not have cold
extremities and prolonged CRT.
★ again hypothermic child present with cold peripheries and CRT> 3sec.

WHO, IMNCI
Algorithm for management of Septic Shock
 Algorithm for management of Septic Shock

0 min Recognise decreased mental status and perfusion.

Begin high flow nasal cannula O2 and established IO/IV access according to PALS

5 min If no hepatomegaly or rales/ Crackles than push 20 ml/kg isotonic saline boluses and reassess after each bolus up to 60
ml/kg until improved perfusion. Stop for rales, Crackles or hepatomegaly. Correct hypoglycemia and
hypocalcemia. Begin antibiotics.

15 min Fluid refractory shock?

Begin IV/ IO Inotrope infusion preferably epinephrine 0.05-0.3 mcg/kg/min

Use atropine/ketamine IV/IO/IM if needed for Central vein or Airway access

If central excess available titrate Central epinephrine 0.03-0.3 mcg/kg/min to reverse cold shock
( titrate Central dopamine 5-10 mcg/kg/min if epinephrine not available)
titrate Central norepinephrine 0.05 mcg/kg/min and upward to reverse warm shock
( titrate Central dopamine >10 mcg/kg/min if norepinephrine is not available)

60 min Catecholamine resistant shock?

If at risk for absolute adrenal insufficiency begin hydrocortisone infusion

Use Doppler US, PICCO, FATD, or PAC to direct fluid, Inotrope, vasopressor, vasodilators
Goal is normal MAP CVP, ScvO2>70% and CI 3.32-6.0 l/min/metre square
 Normal blood pressure Low blood pressure Low blood pressure
cold shock cold shock Warm shock
ScvO2<70%/Hgb>10 g/dl on epinephrine ? ScvO2<70%/Hgb>10 g/dl on epinephrine ? ScvO2>70% on norepinephrine ?

Begin milrinone infusion Add norepinephrine to epinephrine to attain If euvolemic add vasopressin, terlipressin,
Add nitroso-vasodilator if CI index <3.3 normal diastolic blood pressure. If CI <3.3 or angiotensin but if CI decreases below 3.3
l/min/m sq. with high SVRI and/ or poor skin l/min/m sq. Add dobutamine,enoximone, add epinephrine, dobutamine, enoximone,
perfusion. Consider levosimendan if Levosimendan, or milrinone. levosimendan
unsuccessful

Persistent catecholamine resistant shock? Refractory shock?

Evacuate pericardial effusion or Pneumothorax, maintain IAP < 12 mmHg ECMO

CRRT 35ml/ kg/hr when stable

American College of Critical care Medicine Algorithm 2013

IMPORTANCE OF GOLDEN HOUR IN
MANAGEMENT OF SHOCK

◆ If diagnosed and treated in first hour following presentation with sepsis, the patient had
>80% survival rate.

◆ For each hour of delay during the subsequent 6 hours, the chances of survival decreased by
7.6%

◆ After 6th hour survival rate is only 30%.

3 Major Delays: delay in recognition, delay in transport, delay in initiating treatment

Rivers E. et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N
Engl J Med 2001;345:1368-1377

Shankar J et al. Management of Septic Shock: where do we stand? Indian. J Pediatr. 2008;75:1167-9
 Algorithm for management of Septic Shock

0 min Recognise decreased mental status and perfusion.

Begin high flow nasal cannula O2 and established IO/IV access according to PALS

5 min If no hepatomegaly or rales/ Crackles than push 20 ml/kg isotonic saline boluses and reassess after each bolus up to 60
ml/kg until improved perfusion. Stop for rales, Crackles or hepatomegaly. Correct hypoglycemia and hypocalcemia. Begin
antibiotics.

15 min Fluid refractory shock?

Begin PIV/ IO Inotrope infusion preferably epinephrine 0.05-0.3 mcg/kg/min

Use atropine/ketamine IV/IO/IM if needed for Central vein or Airway access

If central excess available titrate Central epinephrine 0.03-0.3 mcg/kg/min to reverse cold shock
( titrate Central dopamine 5-10 mcg/kg/min if epinephrine not available)
titrate Central norepinephrine 0.05 mcg/kg/min and upward to reverse warm shock
( titrate Central dopamine >10 mcg/kg/min if norepinephrine is not available)

60 min Catecholamine resistant shock?

If at risk for absolute adrenal insufficiency begin hydrocortisone infusion

Use Doppler US, PICCO, FATD, or PAC to direct fluid, Inotrope, vasopressor, vasodilators
Goal is normal MAP CVP, ScvO2>70% and CI 3.32-6.0 l/min/metre square
EARLY GOAL DIRECTED
THERAPY
OXYGEN THERAPY

★ No spontaneous efforts:
○ Maintain a patent Airway and support breathing.
○ Give 100% oxygen and positive pressure ventilation using Bag & mask.
★ Spontaneous efforts:
○ Early administration of oxygen in order to optimize and reduce oxygen consumption(VO2), by
increased work of breathing is recommended.
○ O2 should be given to all children with suspected sepsis.
○ O2 may be given by high flow nasal cannula, face mask, venti mask, non rebreathing mask
(NRM) , or nasopharyengeal ​CPAP.
★ Oxygen therapy should be titrated to normoxemia (PaO2 = 9.5kPa- 13.5kPa) and SPO2 of 94-97% is
titrated.
○ Hypoxia (PaO2 < 9.5kPa) and hyperoxia both were reported to have adverse outcomes.
○ Hyperoxia(PaO2> 13.5kPa) leads to increase production of free radicals, which can augment
inflammation and tissue damage.
○ Indian Academy of Pediatrics basic life support , IMNCI
SECURING IV/IO ACCESS

★ Adequate venous access must be ensured in all patients of septic shock. At

least two large bore IV lines should be placed.
★ If peripheral line is not quickly available intraosseous access should be
obtained and fluid resuscitation should not be delayed.
★ Withdraw samples while Cannulating.
★ Central venous line allows administration of medication centrally and
provides multiple ports for rapid fluid administration, antibiotics and
vasopressors if needed.
○ It also allows measurement of central venous pressure(CVP) a surrogate for volume status.
○ and ScvO2 continuous monitoring.
○ SSG 2021 recommends starting inotropes by peripheral lines before securing central access.
SAMPLES to be withdrawn & LABORATORY studies

★ Complete Blood Count

★ Random Blood Sugar at admission and 4-6 hourly
★ CRP
★ LFT, KFT
★ Blood Gas Analysis
★ Coagulation profile
★ Blood lactate:
○ elevated lactate(>2 mmol/L) shows poor outcome in all types of shock shock.
○ elevation in arterial and Venus lactate has greater chance of organ dysfunction if
measured in ED and higher chance of death if measured in PICU
★ Blood Culture:( 2 BCS before initiating Antibiotics)
○ Culture sensitivity is required for escalating and de-escalating antibiotics

Nelson 22nd edition, IMNCI

 Algorithm for management of Septic Shock

0 min Recognise decreased mental status and perfusion.

Begin high flow nasal cannula O2 and established IO/IV access according to PALS

5 min If no hepatomegaly or rales/ Crackles than push 20 ml/kg isotonic saline boluses and reassess after each bolus up to 60
ml/kg until improved perfusion. Stop for rales, Crackles or hepatomegaly. Correct hypoglycemia and hypocalcemia. Begin
antibiotics.

15 min Fluid refractory shock?

Begin PIV/ IO Inotrope infusion preferably epinephrine 0.05-0.3 mcg/kg/min

Use atropine/ketamine IV/IO/IM if needed for Central vein or Airway access

If central excess available titrate Central epinephrine 0.03-0.3 mcg/kg/min to reverse cold shock
( titrate Central dopamine 5-10 mcg/kg/min if epinephrine not available)
titrate Central norepinephrine 0.05 mcg/kg/min and upward to reverse warm shock
( titrate Central dopamine >10 mcg/kg/min if norepinephrine is not available)

60 min Catecholamine resistant shock?

If at risk for absolute adrenal insufficiency begin hydrocortisone infusion

Use Doppler US, PICCO, FATD, or PAC to direct fluid, Inotrope, vasopressor, vasodilators
Goal is normal MAP CVP, ScvO2>70% and CI 3.32-6.0 l/min/metre square
INITIAL FLUID BOLUS

Septic shock commonly manifest as intra-vascular hypovolemia due to reduced fluid intake, vascular dysfunction
and micro-vascular leak.

★ Fluid: Normal saline or Balanced / bufferred crystaloids.

★ Amount: 40-60 ml/kg in the first hour of Management, given as 10-20ml/kg bolus
★ If the centre doesn't have an ICU 40 ml/kg is the maximum limit
★ Avoid colloids like albumin.
★ Avoid using bolus if there is no hypotension
★ Maintenance fluid may be started in sick septic non hypotensive children.
★ Close monitoring of vitals (RR, HR) every 5 to 10 minutes is critical during fluid resuscitation.
★ Reassessment of perfusion should be performed for improvement or signs of fluid overload.

Surviving Sepsis consensus 2020

 CHOICE OF FLUID
CRYSTALLOIDS COLLOIDS

CHARACTERI Particles less than 1 nm in size. These can be Homogenous, large particles of one substance
STICS isotonic, hypotonic or hypertonic. dispersed through a second substance.

ADVANTAGE These are cheap, non allergic and no risk of expansion of plasma volume is superior ans
S transmission of infection and coagulopathy. sustained

EXAMPLE NS ★ Semisythetic coloids: Gelatins, Dextrans 70 &

Balanced/ Buffered: RL, Plasmalyte 40 Hydroxyethyl
★ (K+/Ca2+/lactate are commonly added to
Starch
make composition similar to plasma)
★ Human Plasma Derivatives:Albumin Solutions
★ NS can cause hyperchloremic metabolic
(5%), FFP Plasma Protein Fractions (OCTAPLAS)
acidosis, AKI, Coagulopathy.
★ Surviving Sepsis guideline 2021
★ Surviving Sepsis guideline 2021
○ recommend against gelatin and starch.
○ Balanced crystalloid > NS
○ Albumin can be used when received
★ Nelson says Balanced fluids better but
large volume crystalloids
pediatric studies are conflicting.
★ Methods
○ 8 studies (4 RCTs), 12,231
patients
○ Databases: PubMed,
EMBASE, Cochrane
★ Outcomes: AKI, mortality, stay,
RRT, hyperchloremia, ventilation
★ Results
○ No difference: AKI,
mortality, ventilation, PICU
stay
○ BS ↓ hyperchloremia and
RRT need
○ NS ↓ hospital stay
Literatu ★ Objective: To compare outcome between

re lactated ringer and normal cell line in

paediatric sepsis
★ Design: Matched retrospective study using
data from 12529 patients under 18 years
with severe sepsis or septic shock across
382 US hospitals (2000- 2013)
★ Results:
○ no significant difference in mortality,
AKI
○ Longer hospital stay in LR group.
★ Drawback: LR group was older, received
larger fluid volume.
FEAST TRIAL

★ Design: The only randomised control trial comparing bolus fluid resuscitation with no
bolus. Published in 2011
★ Participants: conducted in 6 African hospitals without ICU in Kenya Tanzania Uganda.
Enrolled 3141 children with fever and shock( one or more features of impaired
perfusion with impaired consciousness or respiratory distress or both)
★ Intervention: 3 Groups- albumin bolus, saline bonus, no bonus (control group )
★ Results: The trial was stopped early by data monitoring committee repeat
resuscitation resulted in a 45% relative increase in 48 Hour mortality compared with
control( 10.6% versus 7.3% compared to the control group)
★ Interpretation:
○ Broad criteria used to define shock affected the applicability of result in various
International guidelines only 65 (2%) fullfilled WHO criteria for shock
○ Concerns expressed about the consequences of not giving bolus fluid to children
with moderate hypotension and severe dehydration
FEAST trial: impact on WHO guidelines

★ 2013 edition WHO pocket hand book

○ Continued to recommend aggressive 20ML/kg bolus of isotonic crystalloids for any
child fulfiling WHO definition of shock (upto a total of 60 ml/kg)
○ This is much more aggressive treatment than in the FEAST trial (single 20ml/kg
over 1 hour)
○ For children with suspected Malaria or anemia with shock the new WHO guidelines
state that fluid be administered cautiously and/or blood transfusion should be
given for severe anaemia
○ Leaving clinicians unclear about the rate and speed in volume of fluid to be given
in this to conditions
○ WHO doesn't give advice on how to manage children who do not meet it's
definition of shock
○ Bolus therapy for septic shock in children especially in setting without Intensive
Care
★ 10 Sub Saharan Africa countries sent a letter to WHO in March 2013, of WHO's lack of
MONITORING

Assess the effectiveness of fluid resuscitation and inotropic therapy by frequent monitoring, every 5 to 10
minutes during first hour and then every 30 minutes.

★ Heart rate
★ Respiratory rate
★ Level of consciousness
★ Spo2
★ Blood pressure
★ Hepatomegaly and crepitations

also monitor

★ Temperature at 1-2 hourly interval

★ Urine output at 1-2 hourly interval and
★ IVC diameter wherever available before deciding next fluid bolus

IMNCI
SHOCK IN SAM

❖ Differences from septic

shock management:
➢ Difficult to identify.
➢ Low cardiac capacity.
➢ High chance of fluid
overload.
➢ should be monitord for
features of CHF
➢ Dextrose containing
fluid given as bolus.
CORRECT METABOLIC ABNORMALITIES

★ HYPOGLYCEMIA: hypoglycemia is common as result of inadequate glycogen store

increased glucose consumption and metabolic failure.
○ Those of dextrose is 0.5-1 gram per kg it can be given as follows
■ 5-10 ml/kg of d10w
■ 2-4 ml/kg of d25w
■ 1-2ml/kg of d50w

★ Hypocalcemia: Calcium if ionic Ca+ <0.9 mmol/L. causes myocardial depression.

Sustained decrease in ionized calcium is seen in shock as
○ Decreased in ionized Ca as PH return to normal
○ Renal calcium losses
○ Parathyroid ischemia
■ 10– 20 mg/kg(1-2 ml/kg) of 10% Ca gluconate diluted under cardiac
monitoring

Surviving Sepsis guideline 2020

CORRECT METABOLIC ABNORMALITIES

★ HYPERGLYCEMIA: Hormonal imbalance with increased insulin resistance produce stress

hyperglycemia.
○ Insulin if blood sugar >180 mg/dl ( 0.1 U /kg/hr infusion)
○ Hyperglycemia diminishes the ability of neutrophils and macrophages to combat
infections. Also insulin possesses antiapoptotic effects.
★ Metabolic Acidosis: NAHCO3 only if metabolic acidosis with PH < 7.2 and acute kidney
injury with AKIN ⅔.(allows better cellular and myocardial function, decrease systemic
and pulmonary resistance)
★ Anaemia: Hb >10 for better O2 delivery ( PCV >35-40.)
○ Transfusion avoided if Hb>7.
★ Hypomagnesimia: frequently seen and should be corrected with i.v MgSO4

Surviving Sepsis guideline 2020

EARLY INITIATION OF ANTIBIOTICS & SOURCE CONTROL

★ The administration of Empirical antimicrobials within 1st hour of recognition of septic

shock
○ Each hour delay is associated with a measurable increase in mortality.
★ The choice of empirical antimicrobial therapy is
○ third generations cephalosporins and aminoglycosides.
○ Cloxacillin or Vancomycin if staphylococcus is suspected.
○ Clindamycin if TSS.
★ The antimicrobial regimen should be reassessed daily for potential de-escalation and
shorter duration.
★ No prophylaxis for fungal and viral infection.
★ Source control -It includes drainage of abcess, debridement of infected necrotic tissue,
removal of potentially infected device and definitive control of a source of ongoing
microbial contamination.
○ CV line, urinary catheter, TPN be checked everyday under BUNDLE care.
○ Fungal infection dictates immediate removal. coagulase negative streptococcus
and gram negative bacilli infection, CV line can be retained.
Fluid-refractory shock

Signs of improvement

★ Good volume and

★ slowing Pulse rate
★ faster capillary refill

Signs of deterioration

★ Increase in respiratory rate > 5/min and

★ heart rate > 15/min

Fluid refractory shock:

If no improvement with two fluid bolus in Sick looking children.

IMNCI
 Algorithm for management of Septic Shock

0 min Recognise decreased mental status and perfusion.

Begin high flow nasal cannula O2 and established IO/IV access according to PALS

5 min If no hepatomegaly or rales/ Crackles than push 20 ml/kg isotonic saline boluses and reassess after each bolus up to 60
ml/kg until improved perfusion. Stop for rales, Crackles or hepatomegaly. Correct hypoglycemia and hypocalcemia. Begin
antibiotics.

15 min Fluid refractory shock?

Begin IV/ IO Inotrope infusion preferably epinephrine 0.05-0.3 mcg/kg/min

Use atropine/ketamine IV/IO/IM if needed for Central vein or Airway access

If central excess available titrate Central epinephrine 0.03-0.3 mcg/kg/min to reverse cold shock
( titrate Central dopamine 5-10 mcg/kg/min if epinephrine not available)
titrate Central norepinephrine 0.05 mcg/kg/min and upward to reverse warm shock
( titrate Central dopamine >10 mcg/kg/min if norepinephrine is not available)

60 min Catecholamine resistant shock?

If at risk for absolute adrenal insufficiency begin hydrocortisone infusion

Use Doppler US, PICCO, FATD, or PAC to direct fluid, Inotrope, vasopressor, vasodilators
Goal is normal MAP CVP, ScvO2>70% and CI 3.32-6.0 l/min/metre square
FLUID REFRACTORY SHOCK
Fluid refractory shock

★ Epinephrine/nor epinephrine is preferred over dopamine

★ Cohort studies show that delay in use of inotropes associated with major increase in
mortality risk.
★ Surviving sepsis guideline 2021 discourages classification of septic shock as warm and
cold shock.
○ Cold shock- Dopamine and epinephrine
○ Warm shock- Nor epinephrine
★ Epinephrine is preferred if septic shock plus myocardial dysfunction present. In low SVR
/ vasogenic shock nor epinephrine is preferred
★ Whether to use epinephrine or NE is left to the treating physician
○ Dose of both is same 0.1-1 mcg/kg/min IV / IO as infusion
★ Dopamine may be used if E/NE is not available
○ Dose up to 10 mcg/kg/min as an infusion
★ In initial resuscitation phase inotropes/ vasopressor therapy may be required to sustain
perfusion pressure, even when hypovolemia has not been resolved (before CVP
insertion and even with 2nd bolus)
CLOVER TRIAL

★ The CLOVER (Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis)Published

in 2023
★ Objective: Compare early vasopressor use versus liberal IV fluid in patients with septic
shock.
★ Design: Multicenter, randomized, unblinded trial.
★ Participants: Patients with septic Shock requiring treatment in an ICU or emergency
setting
★ Intervention:
○ One group received liberal IV fluids before vasopressors.
○ The other group received early vasopressors with restricted IV fluids.
★ Outcome Measures:
○ Primary outcome: 90-day mortality.
○ Secondary outcomes: Organ failure, length of hospital stay, adverse events.
★ Key Findings (Published in 2023)
○ No significant difference in 90-day mortality.
○ The early vasopressor group received significantly less fluid and had a lower risk
of fluid overload.
Drug α1 α 2 b2 vasodil β1 β1 Side Remarks
vasocons ionotrope chrono effects
trope
Dopamine Dopaminergic receptors First line drug in shock and
ug/kg/min hypotension with low or nor
0.5-5 CO

5-10 __ ++ viscera +++ +++ Give in Central vein

Ionotropic Recent studies in adults and
dose 2 in children show more
+++ Arrhyth arrythmias and poorer
10-15 +++ ++ +++
mias + outcome and recommend
Vasopressor
dose Skeletal epinephrine as first ionotrope.
muscle

Dobutamine +/- ++ +++ + Low CO with Nor BP

2-20 (↑SVR) e.g. cardiogenic
ug/kg/min shock with nor BP
Drug α1 α 2 β 2 vasodil β1 β1 Side Remarks
vasocons ionotrope chrono effects
trope

Adrenaline ++ ++ Now considered 1st drug

<0.03µg/kg/min of choice
inotrope dose
Dilute 10 times for
Adr + ++ ++++ +++ peripheral or
0.03-0.2 Skeletal intraosseous access
µg/kg/min muscle Dose
inotrope dose SVR ↑ >0.3microgm/kg/min
0.2-3 ++++ + ++++ +++ Arrhythmias ++
Risk for renal ischemia,
µg/kg/min SVR h myocardial ischemia
inoconstrictor potent and hypertension
dose vasopressor
Nor ++++++ + ++++ +++ Useful in
adrenaline Intense Warm shock
0.3-2µg/kg/ vasoconstriction Anaphylaxis
min Spinal shock

Dilute 10 times for

peripheral or
intraosseous access
CATECHOLAMINE RESISTANT SHOCK

Catecholamine-resistant shock is defined as

Persistent hypotension and signs of inadequate tissue perfusion despite the

administration of at least 60 mL/kg of isotonic fluid resuscitation and the use of
at least one high-dose catecholamine infusion.

1. American College of Critical Care Medicine (ACCM) Clinical Practice

Parameters for Hemodynamic Support of Pediatric and Neonatal Septic
Shock (2017)
2. Surviving Sepsis Campaign: International Guidelines for the Management of
Septic Shock and Sepsis-Associated Organ Dysfunction in Children (2020)
 60 min Catecholamine resistant shock?

If at risk for absolute adrenal insufficiency begin hydrocortisone infusion

Use Doppler US, PICCO, FATD, or PAC to direct fluid, Inotrope, vasopressor, vasodilators
Goal is normal MAP CVP, ScvO2>70% and CI 3.32-6.0 l/min/metre square

Normal blood pressure Low blood pressure Low blood pressure

cold shock cold shock Warm shock
ScvO2<70%/Hgb>10 g/dl on epinephrine ? ScvO2<70%/Hgb>10 g/dl on epinephrine ? ScvO2>70% on norepinephrine ?

Begin milrinone infusion Add norepinephrine to epinephrine to attain If euvolemic add vasopressin, terlipressin,
Add nitroso-vasodilator if CI index <3.3 normal diastolic blood pressure. If CI <3.3 or angiotensin but if CI decreases below 3.3
l/min/m sq. with high SVRI and/ or poor skin l/min/m sq. Add dobutamine,enoximone, add epinephrine, dobutamine, enoximone,
perfusion. Consider levosimendan if Levosimendan, or milrinone. levosimendan
unsuccessful

Persistent catecholamine resistant shock? Refractory shock?

Evalute pericardial effusion or Pneumothorax, maintain IAP < 12 mmHg ECMO

CRRT 35 ml/ kg/hr when stable

American College of Critical care Medicine Algorithm 2013

Role Of Corticosteroids

★ Consider in Fluid refractory and catecholamine resistant shock if cortisol deficiency is proven.
★ Not to be used routine Only if
○ Purpura fulminans
○ Chronic steroid use
○ Evidence of adrenal insufficiency
★ 25% of children with septic shock have absolute adrenal insufficiency.
★ Death from absolute adrenal insufficiency and septic shock occur within 8 hr of presentation
★ obtaining serum cortisol level at the time of empirical hydrocortisone administration may be helpful.
★ Initial treatment is hydrocortisone infusion given at stress dose (100mg/m2/24hr).

(sepsis: a review of advances in management 2017 by Jordi Rello et al.)

Vasoactive agents & inodilators

★ Vasopressin may be added to E/NE in case of poor response or high dose needed .
○ Dose of Vasopressin 0.0007 U/kg/min up to 0.002 U/kg/min
○ Terlipressin 0.02 mg/kg 4 hourly ( synthetic long acting analogue ) can be used as a bolus.
■ SSG 2020 recommends against terlipressin use.

★ Inodilators are needed only if there is cardiac dysfunction and hypoperfusion despite
the inotropes
○ Milrinone 0.75 mcg/kg/min or dobutamine 10 mcg/kg/min
○ Levosimendan is avoided in case of hypotension

Surviving Sepsis Guidelines 2020

Drug α β2 β1 chronotrope Side effects Remarks
ionotrope

Phosphodiasterase inhibitor increase cyclic adenosine monophosphate

Inamrinone __ ++++ + • Long T ½ Preferred in

hepatic
1-20 ++ ↑CO Minimal effect Hypotension dysfunction
on HR
µg/kg/min
+ Thrombocytopenia

Preferred in
Milrinone
++ Long T ½
Renal
dysfunction
0.5-0.75
++ Hypotension

µg/kg/min

Ca /actin/tropomyosin binding lower phosphodiestrase inhibitory activity

LEVOSIMENDAN
Current trend single
dose via continuous
perfusion over 24 hour +++
++
at 0.2 microgm/kg/min

(max 12.5mg)
★ Design: Systematic review and meta-analysis of ★ Outcomes Assessed:
randomized controlled trials (RCTs) ○ Length of ICU stay
○ Days on mechanical ventilation
★ Method: Patients with sepsis or septic shock ○ Time to vasopressor discontinuation
RCTs comparing methylene blue vs placebo ○ Incidence of methemoglobinemia

★ Studies Included: ★ Key Findings:

○ 3 RCTs ○ ↓ ICU stay (MD −1.58 days; p = 0.03
○ Total patients: 141 ○ ↓ Ventilation days (MD −0.72; p = 0.01)
○ Methylene blue group: 70 ○ ↓ Time to stop vasopressors (MD −31.49
○ Control group: 71 hrs; p < 0.0001)
○ No increase in methemoglobinemia
★ Mechanism
○ Acts via non-adrenergic
mechanism
○ Catecholamine-sparing
strategies.
○ Increases vascular tone and
MAP.
★ Advantage:
○ Reduce norepinephrine
requirement.
○ Maintains cardiac contractility.
○ Low-cost and widely available.
○ Shortening ICU stay
○ Short time to vasopressor
discontinuation
★ Cons:
○ No proven mortality benefit.
○ Risk of mesenteric
vasoconstriction,
methemoglobinemia, and
serotonin syndrome.
○ Contraindicated in pregnancy
and G6PD deficiency.
THERAPEUTIC END POINT

1.Capillary refill time <2 sec

2.Normal blood pressure for age,

3.Normal pulse with no difference between peripheral and central pulses,

4.Warm extremities,

5.UO >1ml/kg/hr

6.Normal mental status

7. Normalisation of heart rate

8. Normal range Respiratory Rate

9..Normal blood lactate and ScvO2>=70%

American College of Critical care Medicine Algorithm 2013

ADVANCED MONITORING
TOOLS
INVASIVE BLOOD PRESSURE MONITORING
★ Mean arterial pressure (MAP) is the driving perfusion pressure of the
tissues.
★ MBP=(SBP+2 x DBP)/ 3
★ Advantage:
○ Invasive arterial monitoring is a highly useful tool in shock as non
invasive BP is unreliable.
○ Specially useful in management of patients receiving adrenaline
and catecholamine resistant shock.
★ Technique: Insertion of a catheter into a suitable artery and measured
pressure wave displayed on monitor.
★ Location:
○ radial artery as it is superficial, easily accessible, and collateral blood supply from the ulnar artery.
○ It is advisable to perform Allen’s test.
○ Brachial artery should be avoided if at all possible (no collateral supply);
○ Femoral artery, the ulnar artery, arteries of the foot and ankle, and even the axillary artery should
be used in preference if necessary.
★ SSC 2020 recommends MAP of 65 mm Hg or higher to be maintained in patients with septic shock.
★ Surviving Sepsis Guidelines 2021, American College of Critical Care Medicine 2014, European Society of Critical
Care Medicine
CVP

★ CVP reflect right atrial Pressure is a major determinant of right ventricular preload.
○ Used as a marker for predicting Fluid responsiveness
○ CVP is measured from central catheters and is determined by interaction of cardiac function and
venous return.
○ It is affected by venous tone, intrathoracic pressures, RV LV compliance.

Goals of management of septic shock

○ CVP 8-12 mm of Hg
○ MAP >65 mmof Hg
○ Urine output >0.5 ml/kg/hr
○ Superior vena cava oxygenation saturation(ScvO2) or mixed venous saturation (SvO2) 70 or
65% respectively.
Central venous oxygen saturation (ScvO2) monitoring

★ Provides a surrogate measure of oxygen flux,

○ O2 flux = oxygen delivery (DO2) – oxygen consumption (VO2)
★ Advocated by the Surviving Sepsis Guidelines as part of early goal directed therapy for septic shock
★ The SVO2 is best measured at the level of the pulmonary artery and referred to as the mixed
venous saturation.
○ target SvO2 >70%
★ The central (ScVO2) obtained from the superior vena cava or right atrium
○ will approximate the mixed venous saturation.
○ ScvO2 is less than SvO2 by about 2–3%
○ Target ScvO2 >65%
★ Placement of a pulmonary artery catheter with a risk/benefit relationship is a matter of controversy.

Surviving Sepsis Guidelines 2020, American College of Critical Care Medicine 2013, European Society of Critical Care Medicine
OXYGEN THERAPY

Delivery of oxygen (DO2) to tissues is defined by

the following equation

DO2= CO x (Hb x1.39xSaO2) + (PaO2x0.003) O2

content

CO is cardiac output (SV x HR)

Factors effecting/decreasing the any one of

parameter leads to decrease in oxygen delivery
to tissues.

When the above measures fails to maintain

saturation then early intubation is recommended.

Russell, Amy & Rivers, Emanuel & Giri, Paresh & Jaehne,
Anja & Nguyen, H.. (2020). A Physiologic Approach to
Hemodynamic Monitoring and Optimizing Oxygen Delivery
in Shock Resuscitation. Journal of Clinical Medicine. 9. 2052.
10.3390/jcm9072052.
Central venous oxygen saturation
(ScvO2) monitoring

★ ScvO2 can be measured

○ intermittently: central venous gas
○ continuously: via a spectrophotometer
★ Continuous systems typically have either:
○ A standard CVC with specialised fiberoptics on the tip (e.g. PreSep CVC, attaches to a Vigileo
monitor),
○ A fiberoptic line fed down a lumen of a pre-existing CVC (e.g. CeVox, attaches to a PiCCO
monitor
★ Normal oxygen extraction is 25–30% corresponding to a ScvO2 >65%
○ < 65% = Impaired tissue oxygenation
○ >80% = High PaO2; suspect:
■ Cytotoxic dysoxia (e.g. cyanide poisoning, mitochrondial disease, severe sepsis)
■ Microcirculatory shunting (e.g. severe sepsis, liver failure, hyperthyroidism)
FLUID RESPONSIVENESS
Fluid overload is an independent risk facror for
mortality.
★ Juglar venous distention
★ Increased Liver span
★ Pulmonary congestion on CXR
★ Crepitations

FRANK STARLING CURVE

Fluid Responsiveness: cardiac output improves only

when both ventricles operating in the ascending
Limb of frank starling curve i.e. CO solely
dependent on preload.

Horizontal level adding fluid is burden on heart

Fluid Responsiveness is assessed by the increase in 10-15 % cardiac output

In ICU setting ScvO2 and lactate monitoring helps to assess fluid Responsiveness
Surviving Sepsis Guidelines 2020, American College of Critical Care Medicine 2013, European Society of Critical
Care Medicine
 CARDIAC OUTPUT MONITORING METHOD
★ Passive leg raising Test:
★ Simulation of a fluid challenge by passive legising from
horizontal position.
○ Manual increase pre load resulting in change of cardiac
output.
○ The change in preload is completely reversible and
feasible in emergency or ICU setting.
★ Cardiac output can be measured by
○ aortic blood flow velocity (Doppler)
○ velocity time integral (echocardiography)
★ change is transient lasting 30-90sec.
○ Non invasive device like PICCO, NICOM for continuous monitoring of cardiac output.
★ Invasive Method: Fick’s method and Femoral Artery thermodilution(FATD) method

Surviving Sepsis Guidelines 2020, American College of Critical Care Medicine 2013, European Society of Critical Care
Medicine
CARDIAC OUTPUT MONITORING METHOD

★ Femoral artery thermodilution (FATD)

is a method of measuring cardiac
output in shock, where a cold saline
bolus is injected into a central vein
and the subsequent temperature
change in the femoral artery is
monitored to calculate CO.
★ FATD measures CO by using the
Stewart-Hamilton principle,
analyzing the thermodilution curve
created after the saline injection.
IVC VARIABILITY
Spontaneously Mechanically
Breathing Ventilated

IVC collapse during IVC collapse during

Inspiration, expand expiration, expand
during expiration. during inspiration.

Collapsibility index: Distensibility index:

(Max-Min)/Max (Max-Min)/Min
>50% >18%
IVC diameter Delta
<1.5 cm IVC:(Max-Min)/Mean
>12%

Prerequisite is child is not breathing

spontaneously and @ TV of 8ml/kg
Surviving Sepsis Guidelines 2020, American
College of Critical Care Medicine 2013,
European Society of Critical Care Medicine
Advanced methods of EVOLUTION OF TISSUE
PERFUSION

★ Near-infrared spectroscopy:
○ ❑ Allows measurement of the balance between oxygen consumption (VO2) and oxygen delivery (DO2) by
the fractional oxygen extraction (FOE): VO2/DO2
○ ❑ NIR light (700-1000 nm) penetrates superficial layers (skin, subcutaneous fat, skull, etc.) and is either
absorbed by chromophores (oxy- and deoxyhemoglobin and myoglobin) or scattered within the tissue
★ Temperature Gradient: Core peripheral temperature gradient of >3°C indicate decreased reasonal blood flow.
★ Tissue capnometry (gastric and ileal)
★ Peripheral perfusion index
★ Spectral transplatinous Oxygen and CO2 measurement

Surviving Sepsis Guidelines 2020, American College of Critical Care Medicine 2013, European Society of Critical Care
Medicine
MULTI ORGAN DYSFUNCTION SYNDROME
MULTI ORGAN DYSFUNCTION SYNDROME
SUPPORTIVE THERAPY

★ Ventilatory support- routine intubation is avoided.

○ Indications for intubation in shock are:
■ 1) Respiratory failure (severe respiratory distress or hypoxemia or gasping)
■ 2) GCS <8 at any time (to protect airways)
■ 3) Desaturation during bolus therapy due to fluid overload
■ 4) Persistent hypotension despite pharmacological therapy
★ Avoid using Etomidate during intubation , ketamine can be used.
★ In Sepsis induced ARDS
○ low tidal volume ventilation (6ml per kg)
○ with upper limit of Plateau pressure of 30 cm H2O, With higher PEEP
○ traditional recruitment maneuvers, prone ventilation
○ NMBA continuous infusion over bolus
★ if conventional mechanical ventilation fail ECMO

Surviving Sepsis Guidelines 2020 , PARDS Guidelines

SUPPORTIVE THERAPY

★ Nutrition Start early- enteral fed within 72 hours.

○ Nutritional support improves wound healing and decreases susceptibility to infection.
○ Nutritional support results in higher lymphocyte counts and higher serum albumin (surrogate markers of
immune competency
★ Hematological support:
○ Infusion of blood products on Hb <7g/dl,
○ Platelet transfusion if
■ <5000(with or without bleed),
■ 5000-30000(if risk of bleed,
■ >50000(planned for surgery or invasive procedures
★ VTE Prophylaxis:
○ Most DVT in young children are associated with central venous catheters.
○ SSG strongly recommends VTE prophylaxis and use of LMWH over unfractioned heparin.
○ Both mechanical and pharmacological prophylaxis.
SUPPORTIVE THERAPY

★ GIT bleed- Stress ulcer prophylaxis

★ Diuretics and renal replacement therapy
○ Use of diuretics to reverse fluid overload when shock has resolved.
○ if diuretics are not responsive, then continuous veno-venous hemofiltration or intermittent dialysis
★ Long Term outcome and Goal of Care:
○ Palliative Care:
○ Peer support referral:
○ Structured Handoff tool:
○ Sepsis education written and verbal
○ Shared Decision making
○ Proper discharge plan: information about ICU stay, diagnosis, treatment, common impairment, post ICU /
post sepsis syndrome
Surviving Sepsis Guidelines 2020, Nelson 22nd edition
Recent updates in surviving sepsis campaign 2021

A total of 93 recommendations and changes from previous General 3

2016 recommendation were made.
Initial resuscitation 5
Recommendations are broadly classified under headings as
described in table below. Mean arterial pressure 1

Recommendations are made according to strength as Admission to Intensive Care 1

★ Strong
★ Infection 21
Weak
★ Best practice statement
Hemodynamic management 14
According to quality of evidence as
Ventilation 12
★ High
★ Moderate Additional therapies 16
★ Low
★ Very low Long term outcome and goals of 20
care
Recent updates in surviving sepsis campaign 2020

★ Using CRT, falling lactate to guide fluid resuscitation, however dynamic measures are
better than static measures.
★ Shift from earlier aggressiveness of initiating antimicrobials within 1 hour for both
sepstic shock and sepsis without shock to course of rapid investigation within 3
hours for sepsis without shock.
★ Recommendation on MRSA and MDR organism management according to high and low
risk, and to daily Assessment for de-escalating according to culture, deciding
optimal duration of therapy.
★ Suggests using balanced crystalloids over normal saline (week low quality
evidence). Also recommendation against using gelatin and starch, however albumin
can be given after large volume crystalloids.
★ Suggestions of adding new ionotropes rather than increasing the dose of the
same. Vasopressors can be started peripheraly.
★ Use of high flow nasal oxygen over non invasive ventilation and use of ecmo in
experienced centres.
★ In case of ongoing requirement of vasopressor therapy suggest using IV