ACCM Clinical Practice Parameters for Hemodynamic Support of Pediatric Patients In Septic Shock ÿ µ «Developmental Differences In the Hemodynam

19 211 ACCM Clinical Practice Parameters for Hemodynamic Support of Pediatric Patients In Septic Shock ÿ µ «Developmental Differences In the Hemodynamic Response to Sepsis What Clinical Signs and Hemodynamic Parameters to Direct Treatment of Shock Developmental Considerations In Monitoring and Treatment of Shock Recommendation For Stepwise Management of Hemodynamic Support In Infants and Children Stabilization: Beyond the First Hour

212 New Insight in Pediatric Critical Care 2003... æ Õß The American College of Critical Care Medicine â à«π π«ß «ªØ µ À «º ª µ Õß À «π À µ Ë Èπ π «septic shock µâõß Àâ ªìπ expert opinion evidencebased, age-specific, step-wise approach «π È ßµ æ æå π Critical Care Medicine Ë 6 ªï 2002 1 «µ ÿª ß å Àâ ªìπ à«π Ë æ Ë µ Practice Parameters for Hemodynamic Support of Sepsis In Adults Patients In Sepsis Ë º æ à ª πªï 1999 π Ëπ È µ µõπ æ ß à«π à π Èπ Developmental Differences In the Hemodynamic Response to Sepsis Àµÿ µ Ë Õß «septic shock πºÿâ À à vasomotor paralysis 2 æ «à ª µ «Õß À «π À µ Ë Õ tachycardia ventricular dilation π Ë π Á ªí À Ëæ àõ «à Õ ªí À severe hypovolemia Ëß à«π À àµõ πõß µàõ â Àâ πè (volume resuscitation) ºŸâªÉ«ÿà Ë «µ ªí À low cardiac output à à low SVR À Õπ ºŸ â À à πõ π È ßæ «à π Õß Á æ Ë oxygen delivery æ ËÕ π Àâ oxygen consumption æ Ë ÈπÕ à«àâ outcome Èπ â 3 What Clinical Signs and Hemodynamic Parameters to Direct Treatment of Shock ß π â Àπ π«ß π «π «pediatric septic shock «à Àâ ß πºÿâªé«á Ë Õ ß ß π 3 ª Õß «inflammation ( â à fever, tachycardia vasodilation) Ëß ª Ë π ª ß Õß «Ÿâ µ «Õ ß â«õ âõß «π, à, à ßªØ µâµõ ºŸâª Õß À Õ à Ÿâ µ ««π «septic shock π Á Ë ß «à µ ÈÕ â Õ» Õ ß ß π ßµàÕ ªπ È â à hypothermia À Õ hyperthermia à«õ ß Õß «decreased perfusion â à - Altered mental status - Prolonged capillary refill > 2 «π (cold shock) À Õ flash capillary refill (warm shock) - Diminished (cold shock) À Õ bounding (warm shock) peripheral pulses - Mottled cool extremities (cold shock) - Decreased urine output < 1 ml/kg/hr - Hypotension, not necessary but if present is confirmatory Fluid-refractory/dopamine-resistant shock À ß «ÁÕ Ë àµõ πõßµàõ â«àâ πè (fluid resuscitation) πª > 60 /. π «Ë«ß Õß à«àâ dopamine infusion π π 10 /./π Catecholamine resistant shock À ß «ÁÕ Ë àµõ πõßµàõ â«àâ π ÿà catecholamines Ëß «ß epinephrine norepinephrine Refractory shock «ÁÕ Ë àµõ πõßµàõ â«àâ π ÿà inotropic agents, vasopressors, vasodilators â «º ª µ ß µ Õ (glucose, calcium) ŒÕ å π (thyroid, hydrocortisone) ªÑ À Õß «septic shock Õ â æ ËÕ Àâ «Ÿâ µ «peripheral

ACCM Clinical Practice Parameters for Hemodynamic Support of Pediatric Patients In Septic Shock, ÿ µ «213... perfusion ªìπª µ Èßπ ȵâÕß π ß ß Õß perfusion pressure (MAP-CVP or MAP- IAP) Àâ æ ßæÕ àµë «à ÿ «ƒµ Ëß ÀâÕ««µà ßÊ à ß π âµ ª µ Developmental Considerations In Monitoring and Treatment of Shock Intravascular access π Á Guideline π ËÕßπ È Ëß Èπ AHA AAP æ â intraosseous route æ ËÕ â π Àâ πè Fluid therapy π Õß πè Ë Àâ Õ 20 /. Àâ æ Ë â æ heart rate, urine output, capillary refill «Ÿâ µ «ÕߺŸâªÉ«π â «ÁÕ Ë Èπ π «septic shock µâõß πè ª 40-60 /. π Ë à µõ πõßµàõ Àâ πè π«π Àâæ invasive hemodynamic monitoring Ëßæ «à maximal cardiac output Èπ ËÕ pulmonary capillary occlusion pressure Õ Ÿà À«à ß 12-15.ª Õ πè Ë Õ âõ ªìπ crystalloids (normal saline) À Õ colloids (albumin, dextran, gelatins) à π π Àâ â fresh frozen plasma push æ ËÕ â «Hypovolemia π ËÕß hypotensive effects Ë vasoactive kinins Intravascular catheters and monitoring πºÿâªé«ë àµõ πõßµàõ Àâ πè π π Àâ central venous pressure (CVP) arterial pressure monitoring π π Àâæ perfusion pressure ÕßÕ««π ß Õ ªìπµâÕß µ «echocardiography æ ËÕ rule out «à «pericardial effusion à«â«à Õ à πõ π È ΩÑ µ µ ª π oxygen saturation π SVC Àâ Ÿß «à 70% Õ à«àâ outcome Èπ â µ π â pulmonary artery catheter monitoring π π Àâ â æ «ÁÕ Ë àµõ πõßµàõ æ ËÕ â peripheral perfusion, SVC oxygen saturation organ perfusion pressure À â echocardiography, gastric tonometry æ ËÕª ß à âõ Ÿ æ ßæÕ Ë π π π π È Vasopressor therapy Dopamine ªìπ first line drug Ë â π fluid-refractory hypotensive shock Ë low SVR À ºŸ âªé«ë àµõ πõßµàõ dopamine (dopamineresistant shock) µõ πõß µàõ norepinephrine À Õ high dose epinephrine ß π«à ºŸâªÉ«Ë àµõ πõßµàõ norepinephrine Àâ â«angiotensin À Õ arginine vasopressin π ËÕß ÕÕ ƒ Ï Ë µ µà ß π À nitric oxide inhibitors methylene blue π π È ß Õ«à ªìπ investigational therapies ª π Õß π ÿà vasopressors Àâ â«àπ µ «Õß targeted blood pressure Èßπ È æ ËÕ Õß perfusion pressure (MAP- CVP) æ À µ Àâ optimum urine output creatinine clearance Õ Ÿà π ±åª µ Inotropic Support Dobutamine mid-dosage dopamine ªìπ first line of inotropic support àπ «ºŸâ À à À ºŸ âªé«ë àµõ πõßµàõ dopamine À Õ dobutamine (dopamine-, dobutamine-refractory shock) µõ πõß µàõ epinephrine infusion ºŸâ Ë «ß à π π π Àâ â low dose epinephrine ªìπ firstline choice À cold hypodynamic shock ºŸâªÉ«Ë ß ß ªí À low cardiac output π Ë blood pressure ª µ (normotensive low cardiac output) à«low SVR â«à â epinephrine nitrosovasodilators â«áµ π π Àâ

214 New Insight in Pediatric Critical Care 2003... æ â milrinone ( â ªí À Liver dysfunction) À Õ amrinone ( â ªí À renal dysfunction) π ËÕß ÿà π È (Type III phosphodiesterase inhibitors) overcome ªí À down-regulation Õß β 1 β 2 receptor π Ë Àâ bolus dose Õß milrinone À Õ amrinone Õ ªìπµâÕß Àâ fluid bolus π à«ß æ ËÕ â ªí À ËÕ µë ß π à«ß Vasodilator therapy π ÿà π È Ë â π ºŸâªÉ«Ë ß ßÕ Ÿà π hypodynamic shock high SVR â«à â fluid resuscitation inotropic support â«áµ Èßπ È π ÿà nitrosovasodilators â à nitroprusside nitroglycerin ªìπ first line drug À epinephrine-resistant low cardiac output Ë high SVR À ÿà Ë àµõ πõßµàõ À Õ æ π ÿà nitrosovasodilators Àâæ â milrinone À Õ amrinone π Glucose, calcium, thyroid and hydrocortisone replacement ªí À «º ª µ Õß µ Õ Ëßæ π ºŸâªÉ«septic shock â à - Hypoglycemia - Hypocalcemia - Hypothyroid - Adrenal insufficiency (total cortisol level < 18 mg/dl) ÿà Ë ß Ë â à ºŸâªÉ«Ë ªí À purpura fulminans, â corticosteroids À àõπ, À Õ «º ª µ ÕßµàÕ pituitary À ÕµàÕ À «µ Recommendation For Stepwise Management of Hemodynamic Support In Infants and Children ABCs: First Hour of Resuscitation Goals «µ ÿª ß å Õß â à 1) Maintain airway, oxygenation, and ventilation 2) Maintain circulation [defined as normal perfusion (µ ß Ë 1) and blood pressure] 3) Maintain threshold heart rates - µ ß Ë 1 Therapeutic end points µ «Ë Õ«à ªìπ ªÑ À Õß â à 1) Capillary refill < 2 «π 2) Normal pulses with no differential between peripheral and central pulses 3) Warm extremities 4) Urine output > 1mL/kg/hr 5) Normal mental status 6) Normal blood pressure for age Monitoring ΩÑ µ µ æ ËÕª π «µ ß Ë 1 ß Threshold heart rates and perfusion pressure (MAP-CVP or MAP-IAP) for age Age (yrs) Term newborn < 1 < 2 < 7 < 15 Heart Rate (beats/min) 120-180 120-180 120-160 100-140 90-140 Perfusion pressure = MAP-CVP (cmh2o) 55 60 65 65 65

ACCM Clinical Practice Parameters for Hemodynamic Support of Pediatric Patients In Septic Shock, ÿ µ «215... ª Õ â«- Pulse oximeter - Continuous electrocardiography - Blood pressure - Temperature - Urine output - Glucose and ionized calcium Airway and breathing ºŸâªÉ«septic shock ÿ «â Ÿ Èß ß πà À ªìπÕ à ß π ËÕß «º ª µ ÕßªÕ Àâ lung compliance ß ªìπ Àµÿ Àâ work of breathing æ Ë Èπ âõ à ß «Á«Õ ß Ë Õ Õ ß Õß «æ àõßõõ π π Õ (hypoxemia) «Õ ªìπ (metabolic acidosis) Õ Ë ß Ÿß Ë «respiratory acidosis µ π à àõà Õ Õ «æ µ π Õ ß ß π Ë È àß«à ªí À increased work of breathing, impaired mental status Ë àµâõß Õ π π àßµ «ßÀâÕßªØ µ (arterial blood gases) âõ ß µ Õ ºŸâªÉ«ß Õ ªìπµâÕß Àâ πè æ Ë µ π ËÕß ªí À hypovolemia Circulation ªî âπ Õ ªìπ Ëß ªìπ π â «ÁÕ Ë Èπ π Ë à ªî âπ Õ à«π ª âõ Àâæ ß Ÿ Ë «µâπ æ ËÕ â ªìπÀπ ß π À πè â Ÿà À «π À µ ß central vein â«catheter π À à ªìπ æ ËÕ â ªìπÀπ ß π Àâ π ÿà vasopressors Fluid resuscitation Àâ πè æ ËÕ â «ÁÕ ªìπµâÕß Àâ π IV bolus Õ à ß «Á«π π 20 /. Õ à ß Áµ ºŸâ Ÿ ªìπµâÕß ΩÑ µ µ ª π ºŸâªÉ«Õ à ß â «à ª ØÕ ß Õß «πè π ßµàÕ ªπ ÈÀ Õ à â à rales, gallop rhythm, hepatomegaly increased work of breathing Èßπ È ß π«à ºŸâªÉ«ß Õ ªìπµâÕß â Àâ πè πª Ÿß ß 200 /. π à«ß Ë«ß Õß Õ à ß Áµ à Ë Õߪ πè Ë ªìπµâÕß âõ Ÿ à À«à ß 40-60 /. ªÑ À Õß â««àâ πè Õ â Àâ perfusion blood pressure Õ Ÿà π ±åª µ Hemodynamic support ºŸâªÉ«Ëª ªí À severe shock ªìπ µâõß Àâ vasoactive support π À«à ß Ë Àâ πè π à«ß Èßπ È Ë vasoactive infusion Ë Àâ ËÕ ªî second catheter ( ªìπ central venous access) â â«dopamine ªìπ first line drug Ë π π Õ à ß Áµ À ºŸâªÉ«àµÕ πõß µàõ dopamine (dopamine-resistant shock) Àâæ Õ â epinephrine À cold shock norepinephrine À warm shock æ ËÕ â Àâ Perfusion blood pressure Õ Ÿ à π ±å ª µ Hydrocortisone therapy ºŸâªÉ«Á ˪ ªí À severe shock Ëß ª «µ «à ªÉ«â«À Õ «º ª µ ß Õß, π π ÿ à corticosteroids ªìπ «π π À Õµ «æ Õß purpura fulminans Ë Õ Ÿà πª catecholamine-resistant shock Àâ ß π ß«à Õ «adrenal insufficiency à«â«õ Õ ªìπµâÕßæ Àâ hydrocortisone π π 1-2./. ß 50./. æ ËÕ â «ÁÕ ÀâµàÕ π ËÕß ªìπ «24 Ë«ß

216 New Insight in Pediatric Critical Care 2003... Stabilization: Beyond the First Hour Goals «µ ÿª ß å Õß â à 1) Normal perfusion 2) Perfusion pressure (MAP-CVP or MAP- IAP) appropriate for age 3) SVC or mixed venous oxygen saturation > 70% 4) Cardiac Index > 3.3 L/min/m 2 < 6.0 L/min/m 2 Therapeutic end points µ «Ë Õ«à ªìπ ªÑ À Õß â à 1) Capillary refill < 2 «π 2) Normal pulses with no differential between peripheral and central pulses 3) Warm extremities 4) Urine output > 1mL/kg/hr 5) Normal mental status 6) CI > 3.3 L/min/m 2 < 6.0 L/min/m 2 with normal perfusion pressure (MAP-CVP or MAP- IAP) appropriate for age 7) SVC or mixed venous oxygen saturation > 70% Monitoring ΩÑ µ µ æ ËÕª 𠫪 Õ â«- Pulse oximeter - Continuous electrocardiography - Continuous intraarterial blood pressure - Temperature - Urine output - CVP and oxygen saturation - Pulmonary artery pressure and oxygen saturation - Cardiac output - Glucose and ionized calcium Fluid resuscitation ºŸ âªé«septic shock Ÿ πè à ß ªí À persistent hypovolemia Èπ â Ë Õ diffuse capillary leakage Ëß Èπ âπ π ªìπ«πÊ ßπ Èπ ß ªìπµâÕß ΩÑ «ß Àâ πè π πª Ë À Èßπ È Õ» ËÕß È«ß π (clinical end points) â à perfusion, pulmonary capillary occlusion pressure cardiac output Èßπ È crystalloid ªìπ fluid of choice π Ë hemoglobin concentration > 10 gm/dl À ºŸâªÉ«Ë Hgb πâõ «à 10 gm/dl «æ Àâ packed red blood cells transfusion Hemodynamic support æ ËÕª ª Õß Àπâ Ë Õß À «π À µ «ªìπÕ à ß Ëß π ÿà ºŸâªÉ«Ëª ªí À fluid-refractory shock Èßπ ȺŸâªÉ«hemodynamic profile ˵ «æ âà Ÿª â à - Low cardiac output with high SVR - High cardiac output with low SVR - Low cardiac output with low SVR - ºŸâªÉ«Ë ß ß ªí À poor perfusion (reduced urine output, acidosis, hypoperfusion) â«à «Àâ πè, π ÿà Inotropes vasopressors âõ ß ß π à«blood pressure analysis, echocardiographic analysis arterial / SVC oxygen saturation analysis ªìπ π«ß â«áµ Àâæ à pulmonary artery catheter æ ËÕÀ âõ Ÿ æ Ë µ Ë Ë «âõß hemodynamics â à cardiac output oxygen

ACCM Clinical Practice Parameters for Hemodynamic Support of Pediatric Patients In Septic Shock, ÿ µ «217... consumption ªìπµâπ Èßπ È ªÑ À Õß ª Õ Õß mixed venous oxygen saturation > 70%, CI > 3.3 L/min/m 2 normal perfusion pressure for age (MAP-CVP) Èßπ È æ ËÕ Àâ perfusion Õ Ÿà π ±åª µ Shock with low CI Epinephrine ªìπ first-line drug À dopamine-resistant shock Õ à ß Áµ À ºŸâªÉ«ªìπµâÕßæ Ëß epinephrine µ Õ Õß cortisol level < 18 mg/dl Àâæ Àâ hydrocortisone π π stress dose À Õ shock dose π Ë µ «æ «à ºŸâªÉ«T3, T4 µë exclude «sick euthyroid syndrome ÕÕ ª â Õ æ Àâ oral levothyroxine À Õ iv liothyronine æ ËÕ π Àâ Èπ Õ Ÿà π ±åª µ Shock with low CI, normal blood pressure, high SVR Nitroprusside À Õ nitroglycerin ªìπ first - line vasodilator π epinephrine-resistant shock Ë ß ß «π À µõ Ÿà π ±åª µ À æ ªí À æ Õß π ÿà ß à «π π Àâ Õ â milrinone À Õ Amrinone ( ÿà Type III phosphodiesterase inhibitor) Shock with high CI, low SVR Norepinephrine ªìπ drug of choice Õ à ß Áµ À ºŸâªÉ«ªìπµâÕßæ Ëß norepinephrine µ Õ Õß cortisol level < 18 mg/dl Àâæ Àâ hydrocortisone π π stress dose À Õ shock dose π ˵ «æ «à ºŸâªÉ«T3, T4 µë exclude «sick euthyroid syndrome ÕÕ ª âõ æ Àâ oral levothyroxine À Õ iv liothyronine æ ËÕ π Àâ Èπ Õ Ÿà π ±åª µ Refractory shock ºŸâªÉ«Ë Õ Ÿà πª catecholamine-refractory shock Àâ ß π ß «µàõ ªπ È«à Õ ªìπ Àµÿ Ëæ à«â«â à - Pericardial effusion - Pneumothorax - Hypoadrenalism - Hypothyroidism - Ongoing blood loss - Intraabdominal catastrophe - Necrotic tissue Ë àõπ âπ ΩßÕ Ÿà À exclude Àµÿ ÈßÀ â â«π Ë» æ Ë â««extracorporeal membrane oxygenation (ECMO) âõ ªìπµâÕßæ ß Õ π È â«õ à ß Áµ Õ Õ «µ â««ß à «π È à π âõ 50 Õ Õâ ßÕ ß 1. Carcillo JA, Fields AI, Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002;30:1365-78 2. Parker MM, Shelhamer JH, Natanson C, et al. Serial cardiovascular variables in survivors and nonsurvivors of human septic shock: Heart rate as anaearly predictor of prognosis. Crit Care Med 1987;15:923-29 3. Ceneviva G, Paschall JA, Maffei F, et al. Hemodynamic support in fluid refractory pediatric septic shock. Pediatrics 1998;102:e19

218 New Insight in Pediatric Critical Care 2003... π Ë 0 π Ë 5 «π «Decreased mental status perfusion Ÿ ß πà ૪î âπµ PALS guidelines Àâ πè π π 20 /./ Èß Àâ â ß 60 /. â «hypoglycemia hypocalcemia π Ë 15 Fluid refractory shock Fluid responsive π Ë 60 ß µõ π PICU ªî âπ Õ À à, Ë Àâ dopamine infusion, ΩÑ µ µ arterial BP monitoring Fluid refractory - dopamine resistant shock ª π Õß epinephrine π cold shock norepinephrine π warm shock Catecholamine-resistant shock At risk of adrenal insufficiency? Àâ Hydrocortisone Not at risk? àµâõß Àâ Hydrocortisone Normal BP-Cold shock Low BP-Cold shock Normal BP-Warm shock SVC O 2 sat < 70% Add vasodilator or Type II PDE inhibitor With volume loading SVC O 2 sat < 70% Titrate volume and epinephrine Titrate volume and norepinephrine low dose vasopressin or Angiotensin Persistent catecholamine-resistant shock à PA catheter ª πè, inotrope, vasopressors, vasodilator hormonal therapy ªÑ À Õ Normal perfusion pressure CI > 3.3, < 6.0 L/min/m 2 Refractory shock Consider ECMO ºπ Ÿ Ë 1 ß π π π Ÿ Stepwise management of hemodynamic support The American College of Critical Care Medicine (ACCM) 1