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Clinical management guidelines of pediatric septic shock  [cached]
Khilnani Praveen
Indian Journal of Critical Care Medicine , 2005,
Abstract: Septic shock in children is the prototype combination of hypovolemia,cardiogenic and distributive shock. Recently published American college of critical care medinie(ACCM )recommendations for hemodynamic support of neonatal and pediatric patients with sepsis,Surviving sepsis campaign and its pediatric considerations and subsequent revision of definitions for pediatric sepsis has led to compilation of this review article. Practical application of this information in Indian set up in a child with septic shock will be discussed based on available evidence.Though guidelines mainly apply to pediatric age group,however a reference has been made to neonatal age group wherever applicable.
The use of recombinant factor VIIa in a pediatric septic shock patient with disseminated intravascular coagulation
Ronaldo Arkader,Eduardo Juan Troster,Albert Bousso
Einstein (S?o Paulo) , 2008,
Abstract: This is a report on a pediatric patient with septic shock and disseminated intravascular coagulation, who developed life-threatening bleeding which was successfully treated with recombinant factor VIIa.
Influence of vasopressor agent in pediatric septic shock mortality
CMF Mangia, LPS Jose, FL Monteiro, AT Fernandes, P Biasi, F Menezes, EL Lima, C Oliveira, F Bueno, P Paiva, MC Andrade
Critical Care , 2011, DOI: 10.1186/cc10164
Abstract: A retrospective study based on the institutional database analyzing 1,050 patients admitted from October 1999 to January 2005. We studied children with SS after the neonatal period admitted to the pediatric intensive care (PICU) and we assessed the vasopressor support in the first 24 hours, PICU and hospital (HSP) length of stay (LOS), number of vasoactive drugs used, association between drugs and HSP mortality.There were 101 consecutive patients with SS, mean age 41 months (95% CI = 30 to 52 months); mean of PICU LOS 16.73 days (95% CI = 11.18 to 22.28) and hospital LOS 55.46 days (95% CI = 43.16 to 67.75). PICU mortality was 32% and HSP mortality after PICU discharge was 10.8%. Of these, 33% patients received dobutamine and 26% patients dopamine as the only vasoactive drug. Dopamine plus dobutamine was used in 17.8%; dobutamine plus norepinephrine in 18% and dopamine plus norephinephrine in 3.9%. The HSP mortality associated with dobutamine was 29.4%; dopamine 53.8%; dopamine plus dobutamine 50%; dopamine plus norepinephrine 25%. The dopamine and dopamine plus dobutamine groups had higher hospital mortality (66% vs. 34%). Dopamine was associated with hypertensive state (odds ratio, 0.433; 95% CI = 0.192 to 0.976; P = 0.047), hypoxemia (odds ratio, 0.190; 95% CI = 0.040 to 0.909) and mechanical ventilation utilization (odds ratio, 2.625; 95% CI = 1.085 to 6.327; P = 0.035).Adrenergic support for pediatric patients with SS remains controversial. A prospective randomized controlled trial will be important to determine which subgroups of SS patients will benefit most with each drug.
Survey of cases with sepsis & septic shock in the pediatric intensive care unit of Children's Hospital Medical Centre
Salmanzadeh S,Kadivar M
Tehran University Medical Journal , 1999,
Abstract: Sepsis is the systemic response to severe infection in critically ill patients. Sepsis, septic syndrome & septic shock represent the increasingly severe stages of the same disease. Despite the remarkable improvements in outcome, sepsis & septic shock remain an important cause of morbidity & mortality in children. This is a retrospective study among the patients who were admitted in the pediatric intensive care unit (PICU) of Children's Hospital Medical Center from Farvardin 1371 till Esfand 1375. During this period 4018 children were admitted in the PICU, 138 of these patients (3.4%) had the initial diagnosis of sepsis or septic shock. The age of these patients were from 3 months to 14 years (mean of 23.5 months). The male to female ratio was 2.1:1. Out of these 138 patients only 16 cases (11.6%) had sepsis and the others (88.4%) had criterias of severe sepsis or septic shock. Multiple Organ Dysfunction (MOD) were found in 96 cases (69.3%). Diarrhea was the most common primary disease that resulted in sepsis or septic shock. Only 20.3% of the cultures were positive, among which E-Coli was the most in 8.7%, Staphylococcus aureus in 5.7%, Klebsiella in 2.9% and pseudomonas in 1.4%. 66.7% of these patients expired, the mortality rates of the patients with severe sepsis or septic shock that concommitantely had MOD were higher than the other (P<0.0005). So it may be better if children with clinical diagnosis of sepsis be hospitalized in an intensive care unit or at minimum in a facility that can closely monitor these patients during the initial stabilization period.
Identification of pediatric septic shock subclasses based on genome-wide expression profiling
Hector R Wong, Natalie Cvijanovich, Richard Lin, Geoffrey L Allen, Neal J Thomas, Douglas F Willson, Robert J Freishtat, Nick Anas, Keith Meyer, Paul A Checchia, Marie Monaco, Kelli Odom, Thomas P Shanley
BMC Medicine , 2009, DOI: 10.1186/1741-7015-7-34
Abstract: Genome-wide expression profiling was conducted using whole blood-derived RNA from 98 children with septic shock, followed by a series of bioinformatic approaches targeted at subclass discovery and characterization.Three putative subclasses (subclasses A, B, and C) were initially identified based on an empiric, discovery-oriented expression filter and unsupervised hierarchical clustering. Statistical comparison of the three putative subclasses (analysis of variance, Bonferonni correction, P < 0.05) identified 6,934 differentially regulated genes. K-means clustering of these 6,934 genes generated 10 coordinately regulated gene clusters corresponding to multiple signaling and metabolic pathways, all of which were differentially regulated across the three subclasses. Leave one out cross-validation procedures indentified 100 genes having the strongest predictive values for subclass identification. Forty-four of these 100 genes corresponded to signaling pathways relevant to the adaptive immune system and glucocorticoid receptor signaling, the majority of which were repressed in subclass A patients. Subclass A patients were also characterized by repression of genes corresponding to zinc-related biology. Phenotypic analyses revealed that subclass A patients were younger, had a higher illness severity, and a higher mortality rate than patients in subclasses B and C.Genome-wide expression profiling can identify pediatric septic shock subclasses having clinically relevant phenotypes.While septic shock is fundamentally an infection-based disease entity, it is not a singular, homogenous disease in the traditional sense. Rather, septic shock is more akin to a syndrome or a broad, heterogeneous disease classification within which likely exist several disease subclasses. The concept of septic shock subclasses is clinically relevant in that potentially it could have major implications for the design of more specifically targeted therapies [1].Physiology-based subclassifications of s
Adverse events associated with long-term ketamine use in pediatric septic shock
CMF Mangia, AFCF Martins, AP Loretti, RM Sousa, MC Andrade
Critical Care , 2011, DOI: 10.1186/cc10157
Abstract: We describe long-term use of ketamine in the pediatric intensive care unit (PICU) inducing pyramidal liberation in a septic shock patient.A 15-month-old boy with congenital cardiopathy and developmental delay without previous chronic encephalopathy history. He was admitted with septic shock and during the PICU stay received association of multiple analgesic-sedative agents and high doses of ketamine intravenous infusion (Figure 1). The patient presented after 10 days of PICU stay symptoms associated with pyramidal liberation: deep hyperreflexia with sinreflexia, Babinski sign on both sides, opisthotonus, trismus. The clinical signs were not associated with new metabolic or structural intracranial lesion. The patient was discharged from hospital after 36 days receiving pericyazine that was interrupted 1 week after hospital discharge.The ketamine side effects after short-term use include [1,2]: hypertension, apnoea, laryngospasm, emergence phenomena, vomiting, nystagmus, ataxia, myoclonus, random limb movements, opisthotonus, transient facial rash or flushing, intracranial hypertension. The long-term-use side effects are unknown. This is the first report of pyramidal liberation-associated intravenous ketamine for a prolonged period.
Early recognition and management of septic shock in children  [cached]
Paolo Biban,Marcella Gaffuri,Stefania Spaggiari,Federico Zaglia
Pediatric Reports , 2012, DOI: 10.4081/pr.2012.e13
Abstract: Septic shock remains a major cause of morbidity and mortality among children, mainly due to acute haemodynamic compromise and multiple organ failures. In the last decade, international guidelines for the management of septic shock, as well as clinical practice parameters for hemodynamic support of pediatric patients, have been published. Early recognition and aggressive therapy of septic shock, by means of abundant fluid resuscitation, use of catecholamines and other adjuvant drugs, are widely considered of pivotal importance to improve the short and long-term outcome of these patients. The aim of this paper is to summarize the modern approach to septic shock in children, particularly in its very initial phase, when pediatric healthcare providers may be required to intervene in the pre-intensive care unit setting or just on admission in the pediatric intensive care unit.
Equipment review: The success of early goal-directed therapy for septic shock prompts evaluation of current approaches for monitoring the adequacy of resuscitation
Scott R Gunn, Mitchell P Fink, Benjamin Wallace
Critical Care , 2005, DOI: 10.1186/cc3725
Abstract: In 2001, Rivers and coworkers [1] reported findings from a landmark investigation of early goal-directed therapy (EGDT) for septic shock. They hypothesized that current resuscitation strategies rely on inadequate indices of the adequacy of perfusion, and that resuscitation titrated to central venous oxygen saturation (SCVO2) would improve survival. In their trial, protocol-driven resuscitation of patients with systemic inflammatory response syndrome (SIRS) and a systolic blood pressure below 90 mmHg (after a 30 ml/kg fluid challenge) or a blood lactate concentration of 4 mmol/l or greater resulted in a hospital mortality rate of 30.5%, which was significantly less than the mortality rate (46.5%) in the cohort randomly assigned to usual care. As a result of this single-center randomized trial, the use of SCVO2 was given a grade B recommendation in the recent Surviving Sepsis Campaign recommendations [2].The study's findings are compelling, but the universal adoption of the 'Rivers protocol' would require a departure from current practice in many institutions. The results from the study by Rivers and colleagues have stimulated debate in the fields of critical care and emergency medicine. One of the central questions in this debate is whether it is necessity to use measurements of SCVO2 to guide resuscitation. Is SCVO2 essential to the EGDT approach, or might other, alternative indices of the adequacy of resuscitation serve as well or better? In view of this debate, our aims here are to review briefly previous sepsis resuscitation studies and discuss factors that may have made EGDT successful as compared with previous attempts, and to examine other currently available markers of resuscitation.Benjamin WallaceEdwards Presep Central Venous Oximetry catheters measure oxygen concentration in venous blood via reflection spectrophotometry. Because deoxygenated hemoglobin and oxyhemoglobin absorb light differently at selected wavelengths, the reflected light can be analyzed t
Human protein C concentrate in pediatric septic patients
Signa Vitae , 2010,
Abstract: Severe sepsis and septic shock are leading causes of morbidity and mortality in the pediatric population. Unlike what is suggested for the adult population, recombinant human activated protein C (rhAPC) is contraindicated in children. Long before rhAPC was considered for use in pediatric patients, case reports appeared on the safe administration of protein C zymogen. Therefore, we conducted a systemic review of currently available data on protein C zymogen (PC) use among children affected by severe sepsis or septic shock.A total number of 13 case series or case reports and a dose-finding study were found on the use of PC in the pediatric intensive care unit, reporting on 118 treated children, with an overall survival of 84%. There was no bleeding complication, the only reported complication being a single mild allergic reaction. These studies show that PC is safe, not associated with bleeding and possibly useful for improving coagulation abnormalities of sepsis.
Choice of vasopressor in septic shock: does it matter?
Gourang P Patel, Robert A Balk
Critical Care , 2007, DOI: 10.1186/cc6159
Abstract: The significant economic and mortality impact of severe sepsis and septic shock has often resulted in some controversy concerning optimum management strategies, particularly in regard to choice of vasopressor support [1,2]. Annane and colleagues have recently reported on the evaluation of two vasopressor strategies in a multicenter trial of adult French septic shock patients [1]. The results of such controlled clinical trials are valuable to clinicians since septic shock has a reported mortality rate of 40–70% and currently there are no convincing data supporting the use of one vasopressor strategy over another [2]. Current consensus recommendations from 11 different societies in the Surviving Sepsis Campaign guidelines recommend either dopamine or norepinephrine as the initial vasopressor for patients with septic shock [3]. The 2004 practice parameter for hemodynamic support of sepsis in adult patients from the Society of Critical Care Medicine (SCCM) also recommends the use of dopamine or norepinephrine as the initial vasopressor(s) to use in adults with septic shock [4]. Dopamine was the traditional vasopressor choice for shock management, until recent reports of dopamine resistance and/or its potential for tachyarrhythmias resulted in norepinephrine's emergence as the preferred initial vasopressor in North America and Europe [4-6].In an attempt to determine the optimum vasopressor to use in the management of patients with septic shock, Annane and coworkers conducted a multicenter, prospective, randomized, double-blind, controlled clinical trial evaluating epinephrine versus norepinephrine (with dobutamine, if indicated) in the management of a well-defined adult population with septic shock [1]. The trial involved patients from 19 intensive care units throughout France and was funded by the French Ministry of Health. The study enrolled adults with well-defined septic shock and evidence of organ dysfunction and/or hypoperfusion. The primary outcome parameter was 2
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