Dr Ralph Diedericks

Emergency Paediatrics

Red Cross Hospital

FLUID THERAPY IN THE

EMERGENCY UNIT

Management of Septic Shock in the

Emergency Unit

Recognition

Initial management

Pathophysiology

Clinical

Goal Orientated Approach

Recent controversy

Resolution

Presentation to Emergency Unit

Severe dehydration with/- hypovolaemic shock

Septic shock

Seizures

Acute Encephalopahty

Acute Severe Respiratory Infection

Metabolic Disease

Initial assessment

TRIAGE

A – AIRWAY

B – BREATHING SATs

C – CIRCULATION

VENOUS ACCESS - RAPID!!

LABS – ABGs, Blood cultures, Elecs , LACTATE etc

Intra osseous Lines

Rapid

Access

Initial assessment

Fluid Balance

Shock/ no shock

Which Fluid?

Circulatory Shock is defined as a failure of the

cardiovascular system to maintain effective tissue

perfusion causing cellular dysfunction and acute

organ system failure if not promptly restored [ Crit

Care Med 2011 Vol 39 ]

Clinical manifestations of Shock Early recognition is essential

Signs of poor tissue perfusion

Prolonged CRT > 2 sec

Low pulse volume, tachycardia

Cool peripheries. Increased toe-core gap

Mottled extremities

Tachypnoea

Measure UO 1-2ml/kg/hr

Impaired LOC – altered mental state

Normal BP ( compensated), hypotension ( uncompensated)

Types of Shock

Hypovolaemic – GIT, burns, trauma

Distributive – sepsis, anaphylaxis

Cardiogenic – pump failure

Obstructive – obstruction to blood flow

Dissociative – inadequate O2 releasing capacity

Clinical features of shock common to all groups

Evaluating haemodynamics

FLOW = perfusion pressure / Resistance

Cardiac Output ≈ SV X Heart rate

CO ≈ MAP – Central venous press/ systemic vasc

resistance

Renal BF = Mean renal art pressure – mean renal

venous press

Effect on Micro circulation

Micro circulation is where oxygen release to tissues

takes place.

Arterioles,venules and capillaries < 100µm diam.

Flow

Blood Flow – determined by cap. Patency, driving

pressure, arteriolar tone

OOO

Oxygen

extraction

Micro circulatory Failure Regulation of micro vasculature – neuro endocrine,

paracrine, mechano sensory pathways.

Can be compromised by:

RBC morpholgy, viscosity

Products of inflammatory response

Coagulation cascade

Neutrophil response

Ince 2011

Effect of Micro circulatory Failure

Carcillo , Clin Ped Emerg Med:

“Shock is a state of acute energy

failure in which there is not enough

ATP production to support systemic

cellular function”

ATP

Failure of Oxygen Delivery

Mitochondrial dysfunction

Acid base status and Lactate

levels

Metabolic acidosis reflects poor tissue perfusion

Lactate levels ( anaerobic metabolism)

- Levels above 2,5 mmol/L associated with

increased mortality

- level of 4,0 mmol/L associated with 27% mortality

rate in septic shock ( cf 2.5%)

Goal Directed management of Shock

Early recognition and treatment saves lives

Fluid resuscitation

Step wise management in first hour

Han ,Pediatrics 2003,112

Carcillo, Clin Ped Emerg Med 2007

ACCM, Crit Care Med 2009

ETAT

Initial resuscitation

Push boluses of 20ml/kg of isotonic fluid

Up to and exceeding 60ml/kg until perfusion

improves

Watch the liver edge

[ correct hypoglycaemia, commence antibiotics ]

Evidence supports safety and improvements in

outcomes for shock : Septic, hypovolaemic,

Dengue

Which fluid?

Isotonic Crystalloid fluids:

Ringers lactate

Normal saline

Colloid:

SAFE study 2004 – adults

Cochrane 1998

Composition of IV Fluids Fluid Na

Mmo

l/l

Cl K Ca mOsmo

l/l

Glu lactate

N. Saline 154 154 308

Ringers Lactate 131 112 5 1.8 279

Half Dextrose-

Darrows

61 52 17 434 55 27

PMS 35 47 12 372 55

Rehydration Fluid 77 77 432 55

Neonatal Maint 33 33 5 627 110

Chasing the Base deficit? Monitor response to fluid boluses clinically

- CRT

- Pulse vol and rate

- Peripheries ? Warm/cool

- SATs ( continuous measurement)

- BP stable

- Urine output

- LOC , more alert

Avoid treating Blood gas result

Fluid refractory Shock

Begin INOTROPE:

Start Dopamine ( 5-9µg/kg/min) Low dose not effective

Dobutamine ( BP maintained )

Nor Adrenaline ( .05-1 µg/kg/min)

Must have adequate ventricular filling

Dedicated IV line

Continuous monitoring in place, experienced staff

Monitor effects

Intra vascular Volume and Cardiac

Output

0 5 10 15

Ventricle end-diastolic volume

A

B

C

D

Stroke

volume

CO= SV X HR Increase SV:

Inotropes

Vasoactive

drugs

Decrease SV:

Hypoxia, acidosis,

Endotoxin, metabolic

Rescuing the Microcirculation Microcirculatory and Mitochondrial distress

syndrome(MMS)

Monitoring the Microcirculation

- NIRS

- OPS ( Orthogonal polarization Spectral) imaging

Volume

iNOS inhibitors and Steroids

Vaso active and Inotropic support

APC

But what about FEAST?

NEJM 364,26 June 30 2011 FEAST Trial

Designed to investigate the practice of early resuscitation with saline or albumin bolus vs no bolus and

With albumin bolus vs saline bolus

Multi centre – Kenya, Uganda, Tanzania

Enrolled children with febrile illness with red. LOC, respiratory distress with impaired tissue perfusion

FEAST TRIAL

HYPOTENSION – Albumin/saline bolus 40ml/kg.

add 20ml/kg if impaired perfusion at 1 hr

NO HYPOTENSION – Albumin/saline bolus

20ml/kg /no bolus

Add 20ml/kg at 1 hr if still poor perfusion

If hypotension then given 40ml/kg

3170 enrolled, 29 hypotensive , 3141 randomised

FEAST TRIAL

OUTCOME

Mortality at 48 hrs

- 10,6% in albumin bolus

- 10,5 % in saline bolus

- 7,3% in control

NO EVIDENCE SUPPORTING BOLUS FLUID

INFUSION IN ANY SUBGROUP

PROBLEMS WITH FEAST

All children admitted and treated in general paed

ward

No High Care

No PICU

No ventilation

39 % lactate > 5

57% malaria

Excluded gastro enteritis, trauma, burns. All septic

shock

? Micro circulatory failure

Where do we go from here?

FEAST has challenged conventional established

treatment.

Raises issues about safety/ethics

Unexpected outcome, reasons not clear

Need for ongoing research

Concluding comments

Shock needs to be diagnosed and treated early and aggressively

ABC Oxygen is good stuff!

Rapid IV access

Isotonic Crystalloid volume expansion

Use inotropes and vaso active drugs

Think about the Microcirculation

DEFG Rx HYPOGLYCAEMIA!

Antibiotics in first hour

Caution

Watch out for malnutrition

Spare a thought for the Brain CPP= BP – ICP ?

Brain oxygenation better monitoring tool.

Nice to have ?

Essenti

al

Thank You