The Pediatric Hypotension Treatment Summary below from Sutter Health is based on the 2002 SCCM Pediatric Hypotension Guidelines.
The SCCM issued updated 2007 Pediatric Hypotension Guidelines. These guidelines are the same as the 2002 Guidelines except for the following: “The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. Conclusion: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specificallyrecommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates*, normal blood pressure, and capillary refill <2 secs, and 2) subsequent intensive care unit hemodynamic support directed to goals of central venous oxygen saturation>70% and cardiac index 3.3–6.0 L/min/m2. (Crit Care Med 2009; 37:666–688)
*“Threshold HR associated with increased mortality in critically ill (not necessarily septic) infants are a HR < 90 beats per minute (bpm) or >160 bpm, and in children a HR < 70 bpm or >150 bpm (67). Emergency department therapies should be directed toward restoring normal mental status, threshold HR, peripheral perfusion (capillary refill < 3 secs), palpable distal pulses, and normal blood pressure for age. (Table 3).”. . . “One member of the [writing] committee wishes to emphasize that these signs are important only if the patients are considered ill [that is, only if the patient looks sick—if you have the chase the patient down hall, he or she is not sick (not in immediate danger)]”. p. 669, above.
See References at the end of this blog post.
The following is from the Pediatric Page of Sutter Health and is an outstanding brief summary of this important medical problem based on the 2002 Society of Critical Care Medicine (SCCM) guidelines on pediatric hypotension.
The Pediatric Page
Pediatric Septic Shock (July/August 2005)
The Golden Hour
Mortality from pediatric and neonatal sepsis has declined significantly with the development of neonatal and pediatric intensive care units. A recent article in Pediatrics by Han et al described the improved outcome associated with the early reversal of pediatric and neonatal septic shock by community physicians (1). The American College of Critical Care Medicine (ACCM) recently published guidelines forClinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Patients in Septic Shock (2), which has been incorporated into the American Heart Association’s Pediatric Advanced Life Support (PALS) Provider Manual (3). These guidelines advocate rapid, stepwise execution of therapeutic interventions with the goal of restoring normal blood pressure and perfusion within one hour of patient presentation. Han et al performed a retrospective chart review of 91 patients who were transported to a children’s hospital with septic shock. They found that community physicians successfully reversed shock in 26% of patients at a median time of 75 minutes (when the transport team arrived), which was associated with 96% survival and a >9-fold increased odds of survival. Each additional hour of persistent shock was associated with >2-fold increased odds of mortality. Resuscitation practice was consistent with ACCM-PALS Guidelines in only 30% of patients, but when practice was in agreement with the recommendations, a lower mortality was observed (8% vs. 38%). This study suggests that early recognition and aggressive management of pediatric and neonatal septic shock impacts patient outcome.
ACCM-PALS Recommendations for Pediatric Septic Shock (2)
Diagnosis
The clinical diagnosis of septic shock is made in children with suspected infection with hypothermia or hyperthermia, and clinical signs of decreased perfusion including decreased mental status, prolonged capillary refill time of >2 seconds (cold shock) or flash capillary refill (warm shock), diminished (cold shock) or bounding (warm shock) peripheral pulses, mottled cool extremities (cold shock), or decreased urine output of <1ml/kg/hr. Hypotension is not necessary for the clinical diagnosis of septic shock.
Definitions
- Fluid-refractory/dopamine-resistant shock: Shock persists despite ≥60ml/kg fluid resuscitation in first hour and dopamine infusion to 10mcg/kg/min.
- Catecholamine resistant shock: Shock persists despite use of catecholamines epinephrine or norepinephrine.
- Refractory shock: Shock persists despite goal-directed use of inotropic agents, vasopressors, vasodilators, and maintenance of metabolic (glucose and calcium) and hormonal (thyroid and hydrocortisone) homeostasis.
ABCs — First Hour of Resuscitation
Therapeutic Endpoints: Capillary refill time <2 seconds, normal pulses with no differential between peripheral and central pulses, warm extremities, urine output >1 ml/kg/hr, normal mental status, normal BP for age.
Airway and Breathing: Airway and breathing should be carefully monitored and maintained. The decision to intubate and ventilate is made on the clinical diagnosis of increased work of breathing, impaired mental status and presence of a moribund state. Waiting for confirmatory lab tests is discouraged. Induction agents that maintain cardiovascular integrity should be used.
Circulation: Vascular access should be rapidly obtained. Intraosseus access should be established if reliable venous access cannot be rapidly attained. Central access will usually be required for vasoactive infusions.
Fluid resuscitation: Rapid fluid boluses of 20ml/kg (isotonic saline or colloid) should be administered. In the absence of rales, gallop rhythm, hepatomegaly or increased work of breathing, fluid can be administered to as much as 200ml/kg in the first hour. The average requirement is 40-60ml/kg in the first hour.
It has been demonstrated that early aggressive fluid resuscitation in children with septic shock results in improved survival, and children who receive larger volumes in the initial hour have lower mortality. Large volumes of fluid for acute stabilization in children have not been shown to increase the rate of acute respiratory distress syndrome (ARDS) or non-cardiogenic pulmonary edema. (4) Debate on the efficacy of exclusive use of colloids is ongoing. Oxygen delivery depends significantly on hemoglobin concentration (oxygen delivery = CI x (1.36 x %hemoglobin x %O2 saturation + PaO2 x 0.003). However, there are no published studies or recommendations on targeted hemoglobin concentration in children. The recommended minimum hemoglobin for adults with sepsis is 10g/dl. It seems reasonable to maintain hemoglobin within the normal range for age.
Hemodynamic support: Dopamine can be used as the first line agent, but dopamine-resistant shock should be quickly recognized. Epinephrine is used for cold shock while norepinephrine is used for warm shock to restore normal blood pressure and perfusion.
There is an age specific insensitivity to dopamine. Dopamine causes vasoconstriction by releasing norepinephrine from sympathetic vesicles. Immature animals and young humans (<6months) may not have developed their full complement of sympathetic vesicles. Dopamine-resistant shock commonly responds to norepinephrine or high-dose epinephrine.
Hydrocortisone Therapy: Suspect adrenal insufficiency in catecholamine-resistant hypotensive shock in children with a history of CNS abnormality, chronic steroid use or purpura fulminans. Recommended doses vary from a bolus of 1-2 mg/kg hydrocortisone for stress coverage to 50mg/kg for shock, followed by the same dose as a 24 hr infusion.
References
- Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003; 112:793-799
- Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30:1365-1378
- Zaritsky AL, Nadkarni VM, Hickey RW, Schexnayder SM, Berg RA, eds. Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2002
- Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA 1991; 266:1242-1245
This information provided by Anne Tseng, M.D. and the Pediatric Intensive Care Unit Tel: (415) 600-3420.
