OBJECTIVE. Early aggressive resuscitation is accepted best practice for severe pediatric sepsis. Targeting of therapy to individual hemodynamic patterns is recommended, but assessment of patterns is difficult early in the disease process. New technologies enabling earlier hemodynamic assessment in shock may inform choices for vasoactive drugs in fluid-resistant cases.
METHODS. This was a prospective observational study of 30 children with suspected fluid-resistant septic shock (minimum: 40 mL/kg) admitted to the PICU of a tertiary care children's hospital between July 2004 and July 2005. Children were classified according to admission diagnosis (community-acquired sepsis or central venous catheter-associated infection) and assessed within 4 hours after the onset of shock with a noninvasive cardiac output device. Cardiac index and systemic vascular resistance index were measured for all patients. Central venous oxygen saturation was measured for patients with accessible central venous lines at the time of hemodynamic measurements (typically at the superior vena cava-right atrium junction).
RESULTS. Fluid-resistant septic shock secondary to central venous catheter-associated infection was typically “warm shock” (15 of 16 patients; 94%), with high cardiac index and low systemic vascular resistance index. In contrast, this pattern was rarely seen in community-acquired sepsis (2 of 14 patients; 14%), where a normal or low cardiac index was predominant.
CONCLUSIONS. The hemodynamic patterns of fluid-resistant septic shock by the time children present to the PICU are distinct, depending on cause, with little overlap. If these findings can be reproduced, then targeting the choice of first-line vasoactive infusions in fluid-resistant shock (vasopressors for central venous catheter-associated infections and inotropes for community-acquired sepsis) should be considered.
Comments
�CA vs CVC? Involvements.
¿CA vs CVC? Involvements.
Dr. Guillermo Luis Montalván González Paediatric Intensive Care Unit. Hospital Pediátrico Docente “Eliseo Noel Caamaño” Matanzas Cuba. Email: [email protected]
The article of Joe Brierley and Mark J. Peters (1) is interesting, because add new evidences to the hemodynamic patterns that shows the pediatric patient in septic shock, besides doing it with a noninvasive cardiac output device ( Doppler ultrasonography). Each day increases in quantity and quality the publications they improve the understanding of the initial handling of the pediatric patient with severe sepsis and septic shock (2,3,4 ) . Recent guidelines and initiatives show that the progression from sepsis to severe sepsis and septic shock can be effectively halted and reversed with timely therapeutic interventions by recognizing the importance of the reconnaissance early of the sepsis with hypoperfusion. However, the article is confused in the way that shows the profiles hemodynamic of the patients according to presenting fluid-resistant septic shock secondary to central venous catheter-associated infection and community-acquired sepsis .
I think that the proposed hypothesis not trusts make evident solid and yes maybe to the personal experience of the investigators and this takes away you quality to the investigation. I think that it is very simplistic the analysis of the because of these finds, in a so complex phenomenon as the sepsis, where many factors as the genetics, premorbid illness , age, sex, characteristics of infecting pathogens, source control, patient response to infection, the functional reserve of the patient, and the degree of dysfunction of organs plays important roles (5). For the professional it is important knowledge that the child with septic shock resistant to fluids can show varied hemodynamic patterns and the therapeutic employee will depend of these finds, but the hemodynamic presentation depends of many factors implied, and this article does not give clarity in the topic. It is important to consider that the sepsis, severe sepsis and the septic shock does not function as a simple system of causes-effect, existing much more complex mechanisms implied in the pathogeny.
Still in the child the signs they correspond to high suspicion of sepsis + organs dysfunction ( severe sepsis, septic shock), will be the important elements to value for the professional the capillary refill, quality of the peripheral pulses, shock index, mental status, central and peripheral temperatures, urine output and also when results possible the measurement of the SvO2, lactate levels, anion gap acidosis and cardiac output(6). With these tools we show an impressive reduction of the mortality for sepsis (97% in the late 1960 to as low as 2% in 2003 in previously healthy children) (7) . In the middle of the important international effort to foment the reconnaissance and manage early of the severe sepsis and septic shock, do you see it code show encouraging results. I think that the article is a step more in the arduous and important task to improve the knowledge of the problem.
If see it of this way the article takes importance.
References: 1. Brierley J. , Peters M J. Distinct Hemodynamic Patterns of Septic Shock at Presentation to Pediatric Intensive Care. Pediatrics 2008 122: 752-759. 2. Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Hemodynamic support in fluid-refractory pediatric septic shock. Pediatrics. 1998;102(2). 3. De Oliveira CF, de Oliveira DS, Gottschld AF et al.: ACCM/PALS maemodynamic support guidelines for paediatric septic shock: an outcomes comparoson with and without monitorinng central venous oxigen saturation. Intensive Care Med.(2008). 4. Han Y, Carcillo J, Dragotta M, et al. Early reversal of pediatricneonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003;112(4):793–799 5. R. Scott Watson, Carcillo JA. The Epidemiology of Severe Sepsis in Children in the United States. Am J Respir Crit Care Med Vol 167.pp 695–701,2003. 6. Carcillo JA et al.Goal-Directed Management of Pediatric Shock in the Emergency Department. Clin Ped Emerg Med 8:165-175 2007 7. Carcillo JA, Han YY, Kissoon N. Sepsis guidelines and the global pediatrics sepsis initiative: implications for treatment. Future Medicine.Therapy (2008) 5(4), 301- 394.
Conflict of Interest:
None declared