Pediatric Shock

Definitions
-SIRS = tachycardia or bradycardia for age, tachypnea for age (acidosis), fever or hypothermia, elevated wbc or 10% bands
-sepsis = SIRS + source of infection
-severe sepsis = sepsis + end organ dysfunction
-septic shock = sepsis + hypotension (rare in peds) or poor perfusion

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Pediatric septic shock
-unlike adults, present as cold shock*:
—cool, mottled, cyanotic extremities
—narrow pulse pressure (high SVR)
—thready pulses
—delayed cap refill (check central skin in neonates)
—oliguria (place Foley, note I&Os)
—CNS dysfunction: irritable, lethargic, jittery, poor feeding

*exception: septic peds chemo pts tend to present in warm/vasodilatory shock (warm extremities, low SVR, bounding pulses, widened pulse pressure)
—bc tend to get Gram negative sepsis (endotoxin)
**note that the problem in peds septic shock (cold) is O2 delivery, whereas in adult septic shock (warm) is O2 extraction. It’s difficult to determine in neonates as their circulatory physiology is complex.

Screen Shot 2017-07-31 at 9.35.54 PM(lactate less useful in peds pts)

Management: early, aggressive intervention
60 mL/kg bolus, given rapid push
broad spectrum abx
early intubation: 30-40% of pediatric CO goes to WOB!

Fluid-refractory septic shock
-if malperfusion is NOT responsive to 60 mL/kg bolus, begin peripheral pressors immediately (within the golden hour, ideally within 15m of arrival)
-young kids cannot increase their cardiac contractility; their cardiac output is entirely dependent on increases in HR
—the younger the pt, the higher the baseline HR, the less likely pt is able to maintain adequate perfusion by increasing HR    =>    the younger the pt, the faster they crash

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*just go with Norepi as first-line and Epi as second pressor

-http://pedemmorsels.com/capillary-refill-shock/
-Hector’s peds sepsis PPT

 

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