Post Resuscitation. Fluids or Inotropes? David Rowney Anaesthesia & Intensive Care Royal Hospital...

Post Resuscitation. Fluids or Inotropes?Post Resuscitation. Fluids or Inotropes?

David RowneyDavid Rowney

Anaesthesia & Intensive CareAnaesthesia & Intensive Care

Royal Hospital for Sick ChildrenRoyal Hospital for Sick Children

EdinburghEdinburgh

Scottish Paediatric Anaesthesia NetworkScottish Paediatric Anaesthesia NetworkBiennial Educational Meeting, November 2013Biennial Educational Meeting, November 2013

Teachers Building, GlasgowTeachers Building, Glasgow

Resuscitation- Aetiology?Resuscitation- Aetiology?

Sepsis / SIRSSepsis / SIRS World-wide World-wide PneumoniaPneumonia

MalariaMalaria

MeaslesMeasles

Bacterial sepsisBacterial sepsis

DiarrhoeaDiarrhoea

TraumaTrauma ‘‘Western’ worldWestern’ world TBITBIBlunt traumaBlunt traumaPenetrating traumaPenetrating trauma

Bacterial sepsisBacterial sepsis

What is ‘Post Resuscitation’ ?What is ‘Post Resuscitation’ ?

Sepsis / SIRS responseSepsis / SIRS response

Can remain for 48 hours or more.Can remain for 48 hours or more.

Ongoing requirement for fluid resuscitation and Ongoing requirement for fluid resuscitation and titration of appropriate vasoactive drug infusions.titration of appropriate vasoactive drug infusions.


Highlight what evidence is available to guide Highlight what evidence is available to guide ‘post-resuscitation’ management. ‘post-resuscitation’ management.

Extrapolate available evidence / expert opinion / Extrapolate available evidence / expert opinion / guidelines from the ‘resuscitation’ phase to help guidelines from the ‘resuscitation’ phase to help guide the use of fluids and inotropes in ‘post-guide the use of fluids and inotropes in ‘post-resuscitation’ care.resuscitation’ care.

Physiology revisionPhysiology revision

MAP = CO x SVRMAP = CO x SVR CO = HR x SVCO = HR x SV

SV depends on:SV depends on: Preload (Venous Return)Preload (Venous Return) Contractility (inotropy)Contractility (inotropy) Afterload (SVR)Afterload (SVR)

DaoDao22 = CO x Cao = CO x Cao22

CaoCao22 Hb x Sao Hb x Sao22

Preload depends on:Preload depends on: CVP (end-diastolic volume)CVP (end-diastolic volume) HRHR Diastolic function (compliance)Diastolic function (compliance)

…….see abstract.see abstract

Paediatric Septic Shock - PathophysiologyPaediatric Septic Shock - Pathophysiology

In children with septic shockIn children with septic shock

‘‘cold’ shockcold’ shock (low CO and high SVR) (low CO and high SVR)

is more common thanis more common than

‘‘warm’ shockwarm’ shock (high CO and low SVR) (high CO and low SVR)

Presentation 6 hours 48 hours 28 day survival

Group 1 29 patients

Cold Shock inotropes 21 8 80%

Low CO inotropes & vasodilator 8 19

High SVR inotropes & vasopressor 1

vasopressor 1

Group 2 10 patients

Warm Shock vasopressor 10 5 72%

High CO inotropes & vasopressor 2

Low SVR inotropes 2

inotropes & vasodilator 1

Group 3 11 patients

Warm Shock inotropes & vasopressor 11 6 90%

Low CO inotropes 5

low SVR

Warm shockWarm shock

Cold shockCold shock

Take home message - 1Take home message - 1

In children with In children with community acquiredcommunity acquired septic shock septic shock

‘‘cold’ shockcold’ shock (low CO and high SVR) (low CO and high SVR)

Is more common thanIs more common than

‘‘warm’ shockwarm’ shock (high CO and low SVR) (high CO and low SVR)

MortalityMortality is associated with severe hypovolaemia and is associated with severe hypovolaemia and low cardiac output.low cardiac output.

First hour:First hour:

•Normal heart rate & blood pressureNormal heart rate & blood pressure

•Capillary refill of Capillary refill of 2s2s

•Normal pulses with no differentialNormal pulses with no differentialbetween peripheral and central pulsesbetween peripheral and central pulses

•Warm extremitiesWarm extremities

•Urine outputUrine output> > 1 ml/kg/h 1 ml/kg/h

•Normal mental status. Normal mental status.

Post-resuscitation optimisation:Post-resuscitation optimisation:

•Superior vena cava oxygen saturationSuperior vena cava oxygen saturation(ScvO(ScvO22) ≥ 70%) ≥ 70%

•Cardiac indexCardiac index> > 3.3 and 3.3 and < < 6.0 l/min/m6.0 l/min/m22

The American College of Critical Care The American College of Critical Care Medicine – Paediatric Advanced Life Medicine – Paediatric Advanced Life Support (ACCM-PALS) guidelines Support (ACCM-PALS) guidelines

2002 (rev. 2007)2002 (rev. 2007)

‘‘Goals’ / ‘Targets’ of resuscitationGoals’ / ‘Targets’ of resuscitation

First hour: First hour:

•Normal heart rate & blood pressureNormal heart rate & blood pressure

•Capillary refill of Capillary refill of 2s2s

•Normal pulses with no differentialNormal pulses with no differentialbetween peripheral and central pulsesbetween peripheral and central pulses

•Warm extremitiesWarm extremities

•Urine outputUrine output> > 1 ml/kg/h 1 ml/kg/h

•Normal mental status. Normal mental status.

Post-resuscitation optimisation:Post-resuscitation optimisation:

•Superior vena cava oxygen saturationSuperior vena cava oxygen saturation(ScvO(ScvO22) ≥ 70%) ≥ 70%

•Cardiac indexCardiac index> > 3.3 and 3.3 and < < 6.0 l/min/m6.0 l/min/m22

The Surviving Sepsis Campaign The Surviving Sepsis Campaign guidelines for management of severe guidelines for management of severe sepsis and septic shocksepsis and septic shock

2004 (rev. 2008 & 2012)2004 (rev. 2008 & 2012)

• Decreased lactate Decreased lactate

• Improved base deficitImproved base deficit

‘‘Goals’ / ‘Targets’ of resuscitationGoals’ / ‘Targets’ of resuscitation

A caution about Capillary Refill Time..A caution about Capillary Refill Time..

Best predictive value for a reduced SVIBest predictive value for a reduced SVI

Superior vena cava oxygen saturation Superior vena cava oxygen saturation (ScvO(ScvO22)) ACCM-PALS 2007 Guideline goal: ACCM-PALS 2007 Guideline goal: ScvOScvO22 ≥ 70% ≥ 70%

Because children with shock, Because children with shock, die of low cardiac output and oxygen delivery,die of low cardiac output and oxygen delivery,

the ScvOthe ScvO22 has become the has become the ““fifth vital sign”fifth vital sign”

of paediatric intensive care.of paediatric intensive care.

Joseph CarcilloJoseph CarcilloCrit Care Med 2006 Vol. 34, No. 9 (suppl.)Crit Care Med 2006 Vol. 34, No. 9 (suppl.)

Addition of a treatment target of ScvOAddition of a treatment target of ScvO22 ≥ 70% ≥ 70%

to the 2002 ACCM-PALS guidelines.to the 2002 ACCM-PALS guidelines.

NNT- 3.6NNT- 3.6


Continuum of ‘high-quality’ /Continuum of ‘high-quality’ / ‘aggressive’ care ‘aggressive’ care

from the first hour of resuscitationfrom the first hour of resuscitation

through Interhospital transportthrough Interhospital transport

and the early period of intensive care admission and the early period of intensive care admission

saves lives.saves lives.

Fluid TherapyFluid Therapy

Aggressive early fluid resuscitation is the cornerstone of Aggressive early fluid resuscitation is the cornerstone of shock management. shock management.

20 ml/kg bolus of isotonic intravenous fluid over 20 ml/kg bolus of isotonic intravenous fluid over 5-10 minutes repeated up to 3 times in the first hour until: 5-10 minutes repeated up to 3 times in the first hour until:

haemodynamic targets are reached haemodynamic targets are reached or or

signs of fluid overload: signs of fluid overload: new onset crepitationsnew onset crepitations

increased work of breathingincreased work of breathinghepatomegalyhepatomegalyworsening hypoxaemiaworsening hypoxaemia

How fast is too fast?How fast is too fast?

Comparing two EGDT regimens Comparing two EGDT regimens both using fluid and dopamine to achieve haemodynamic targetsboth using fluid and dopamine to achieve haemodynamic targets fluid administration over 15 minutes vs. 60 minutes fluid administration over 15 minutes vs. 60 minutes

No difference in:No difference in: mortalitymortality

rapidity of shock resolutionrapidity of shock resolution

requirement for intubationrequirement for intubation

incidence of complicationsincidence of complications







Crystalloid or Colloid?Crystalloid or Colloid?

Exclusive use of 4.5% AlbuminExclusive use of 4.5% Albumin

AlbuminAlbumin

SalineSaline

A caution about ‘Normal’ saline…A caution about ‘Normal’ saline…

A caution about ‘Normal’ (0.9%) salineA caution about ‘Normal’ (0.9%) saline

81 children with meningococcal septic shock81 children with meningococcal septic shock

BE appeared to change by approximately -0.4 for every mmol/kg of chloride administered







Crystalloid or Colloid?Crystalloid or Colloid?

There is broad agreement that There is broad agreement that crystalloids crystalloids are are preferable in the treatment of paediatric burns, preferable in the treatment of paediatric burns, trauma, surgical pathologies and gastroenteritis.trauma, surgical pathologies and gastroenteritis.







Blood?Blood?

Addition of a treatment target of ScvOAddition of a treatment target of ScvO22 ≥ 70% to the ≥ 70% to the

2002 ACCM-PALS guidelines2002 ACCM-PALS guidelines

Transfusion to a target Hb >10 g/dL to achieve ScvOTransfusion to a target Hb >10 g/dL to achieve ScvO22 ≥ 70% ≥ 70%


Patients with Patients with fluid refractory shockfluid refractory shock (after 40-60 ml/kg) (after 40-60 ml/kg)

Should be considered for CVP and Scv0Should be considered for CVP and Scv022 monitoring. monitoring.

CVP / MAP-CVP response to a fluid bolus will help determine CVP / MAP-CVP response to a fluid bolus will help determine the need for further fluid.the need for further fluid.

Profound capillary leak as part of the sepsis/SIRS Profound capillary leak as part of the sepsis/SIRS response can remain for 48 hours or more requiring response can remain for 48 hours or more requiring ongoing fluid resuscitation ongoing fluid resuscitation (up to 200 ml/kg)(up to 200 ml/kg) over this over this period. period.

““Give Fluid Often. Remove Fluid Often”Give Fluid Often. Remove Fluid Often”

Joseph CarcilloJoseph CarcilloCrit Care Med 2006 Vol. 34, No. 9 (suppl.)Crit Care Med 2006 Vol. 34, No. 9 (suppl.)

Institution of a Dengue fever shock protocol that included diuretics and peritoneal dialysis, if not diuresing, was associated with improved survival.

Early administration of CVVH (before 10% fluid overload) to control fluid overload was associated with improved survival in septic shock


AggressiveAggressive early fluid resuscitationearly fluid resuscitation

withwith 20 ml/kg bolus of isotonic intravenous fluid 20 ml/kg bolus of isotonic intravenous fluid

over over 5-10 minutes 5-10 minutes

repeated up to 3 times in the first hour untilrepeated up to 3 times in the first hour until

haemodynamic targets are reached / signs of fluid overloadhaemodynamic targets are reached / signs of fluid overload

FOLLOWED BYFOLLOWED BY

Further Fluid boluses (Further Fluid boluses (up to up to 200 ml/kg in first 48 hours)200 ml/kg in first 48 hours)

to maintain haemodynamic stability.to maintain haemodynamic stability.

The American College of Critical Care The American College of Critical Care Medicine – Paediatric Advanced Life Medicine – Paediatric Advanced Life Support (ACCM-PALS) guidelinesSupport (ACCM-PALS) guidelines 20072007

First hour:First hour:

Fundamental requirement for early inotrope Fundamental requirement for early inotrope administration in fluid refractory shock. administration in fluid refractory shock. (after (after 40-60 ml/kg of fluid) 40-60 ml/kg of fluid)

New recommendation:New recommendation:

Administer peripheral / intraosseous inotropes Administer peripheral / intraosseous inotropes pending placement of a central venous line.pending placement of a central venous line.

Vasoactive drugs– what, when, how much?Vasoactive drugs– what, when, how much?


Case-control study of deaths from meningococcal sepsis Case-control study of deaths from meningococcal sepsis

Failure to administer inotropes was independently Failure to administer inotropes was independently associated with increased risk of death associated with increased risk of death

OR 23.7 (95% CI 2.6 to 213, p=0.005).OR 23.7 (95% CI 2.6 to 213, p=0.005).

Vasoactive drugs– what, when, how much?Vasoactive drugs– what, when, how much? ‘‘Cold’ shockCold’ shock

Community acquired septic shock.Community acquired septic shock.

Low CO and high SVR. Low CO and high SVR.

Immediate inotrope treatment if fluid refractory Immediate inotrope treatment if fluid refractory (40-60 ml/kg)(40-60 ml/kg) Dopamine (up to 10 mcq/kg/min) Dopamine (up to 10 mcq/kg/min) Adrenaline (up to 0.3 mcq/kg/min)Adrenaline (up to 0.3 mcq/kg/min)

There is no evidence to support a recommendation for a There is no evidence to support a recommendation for a particular ‘first choice agent’ and practice varies widely.particular ‘first choice agent’ and practice varies widely.

Vasoactive drugs– what, when, how much?Vasoactive drugs– what, when, how much? ‘‘Cold’ shock- Cold’ shock- refractory to fluid and first–line inotropesrefractory to fluid and first–line inotropes

If low MAP –If low MAP –

High-dose High-dose dopaminedopamine (> 10 mcq/kg/min) (> 10 mcq/kg/min) High-dose High-dose adrenalineadrenaline (>0.3 mcq/kg/min) (>0.3 mcq/kg/min) (NB: more fluid, acid-base, ionised calcium, blood sugar, steroids etc)(NB: more fluid, acid-base, ionised calcium, blood sugar, steroids etc)

If normal MAP –If normal MAP – Add a vasodilator to reduce afterload resultingAdd a vasodilator to reduce afterload resultingin improved CO and global oxygen delivery. in improved CO and global oxygen delivery.

DobutamineDobutamine MilrinoneMilrinone

Vasoactive drugs– what, when, how much?Vasoactive drugs– what, when, how much? ‘‘Warm’ shockWarm’ shock

Hospital acquired septic shock (CVL infection). Hospital acquired septic shock (CVL infection).

High / normal / low CO and low SVR. High / normal / low CO and low SVR.

Immediate inotrope treatment if fluid refractory Immediate inotrope treatment if fluid refractory (40-60 ml/kg)(40-60 ml/kg) Dopamine (up to 10 mcq/kg/min) Dopamine (up to 10 mcq/kg/min) Adrenaline (up to 0.3 mcq/kg/min)Adrenaline (up to 0.3 mcq/kg/min)

There is no evidence to support a recommendation for a There is no evidence to support a recommendation for a particular ‘first choice agent’ and practice varies widely.particular ‘first choice agent’ and practice varies widely.

Vasoactive drugs– what, when, how much?Vasoactive drugs– what, when, how much? ‘‘Warm’ shock- Warm’ shock- refractory to fluid and first–line inotropesrefractory to fluid and first–line inotropes

Add vasoconstrictorAdd vasoconstrictor NoradrenalineNoradrenaline

High-dose High-dose dopaminedopamine (> 10 mcq/kg/min) (> 10 mcq/kg/min)

High-dose High-dose adrenalineadrenaline (>0.3 mcq/kg/min) (>0.3 mcq/kg/min)

VasopressinVasopressin (up to 0.008 U/kg/min) (up to 0.008 U/kg/min)

Intubation & ventilation – the ideal time?Intubation & ventilation – the ideal time?

ShockShockRRxx

Vasoactive drugsVasoactive drugs Intubation & ventilationIntubation & ventilation

FluidFluid


All cases refractory to 40 ml/kg of fluid

Signs of fluid overload / pulmonary oedema

Facilitate central vascular access

ACCM-PALS sedation to facilitate central vascular access intubate & ventilate for fluid overload

ShockShockRRxx


FluidFluid


Take home message - 4

1. Administer 40-60 ml/kg of fluid rapidly

2. Start an inotrope: dopamine / adrenaline via a peripheral or intraosseous line

Prior to administering drugs for intubation.

ShockShockRRxx


FluidFluid

Put it all together and what have we got?Put it all together and what have we got?

Put it all together and what have we got?Put it all together and what have we got?

There is no clear evidence of benefit for There is no clear evidence of benefit for any particular regimen or any any particular regimen or any

recommendations for fluid therapy and recommendations for fluid therapy and cardiovascular support beyond the initial cardiovascular support beyond the initial

resuscitation phase.resuscitation phase.

There is widespread agreement that there There is widespread agreement that there should be a should be a continuum of ‘high-quality’ / continuum of ‘high-quality’ / ‘aggressive’ care‘aggressive’ care from the first hour of from the first hour of

resuscitation through Interhospital transport resuscitation through Interhospital transport and the early period of intensive care and the early period of intensive care admission, until the child improves.admission, until the child improves.

There is unequivocal evidence that specific There is unequivocal evidence that specific treatment interventions for paediatric treatment interventions for paediatric

septic shock septic shock ‘bundled’‘bundled’ together in an together in an ‘Early ‘Early Goal Directed Therapy’Goal Directed Therapy’ regimen saves regimen saves

lives.lives.

Caveat….Caveat….

EGDT CriticsEGDT Critics

Rivers study is yet to be confirmed in other centres.Rivers study is yet to be confirmed in other centres.

ProMISeProMISe (Protocolised Management in Sepsis, UK)(Protocolised Management in Sepsis, UK) ARISEARISE (Australian Resuscitation in Sepsis Evaluation)(Australian Resuscitation in Sepsis Evaluation) ProCESS ProCESS (Protocolised Care for Early Septic Shock, USA)(Protocolised Care for Early Septic Shock, USA)

PERSPECTIVEPERSPECTIVE (Pediatric Reversal of Shock with Fluids) (Pediatric Reversal of Shock with Fluids)

ACCM-PALS guidelines followed In only 38%

If shock present at PICU admission-

OR death 3.8 (95% CI 1.4 to10.2, p=0.008)

Summary Summary ““Post Resuscitation. Fluids or Inotropes?”Post Resuscitation. Fluids or Inotropes?”

Heterogeneous nature of the ‘collapsed’ child aetiology / age-range. Heterogeneous nature of the ‘collapsed’ child aetiology / age-range.

Not discussedNot discussed• Severe trauma / traumatic brain injury.Severe trauma / traumatic brain injury.• Congenital heart disease or inborn errors of metabolism. Congenital heart disease or inborn errors of metabolism. • Diabetic Ketoacidosis. Diabetic Ketoacidosis.

Focused on the child with Focused on the child with septic shockseptic shock Clinical teams can extrapolate good published evidence and validated Clinical teams can extrapolate good published evidence and validated

treatment guidelines from the resuscitation to post resuscitation treatment guidelines from the resuscitation to post resuscitation stages of management. stages of management.


Thank you.Thank you.

Scottish Paediatric Anaesthesia NetworkScottish Paediatric Anaesthesia NetworkBiennial Educational Meeting, November 2013Biennial Educational Meeting, November 2013

Teachers Building, GlasgowTeachers Building, Glasgow

Post Resuscitation. Fluids or Inotropes? David Rowney Anaesthesia & Intensive Care Royal Hospital...

Documents

Transcript of Post Resuscitation. Fluids or Inotropes? David Rowney Anaesthesia & Intensive Care Royal Hospital...