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shock
Safaa A. EL Meneza
Professor of Pediatrics
Faculty of Medicine for
Girls
AL Azhar University
Objectives
Definitions
Epidemiology
Pathophysiology
Management of septic
shock
Prevention
Direct Causes of Neonatal
Deaths
☛ Infections 32%
☛ Asphyxia 29%
☛ Complications of prematurity
24%
☛ Congenital anomalies 10%
World Health Organization.State of the World’s Newborns 2005
☛ Other 5%
Septic shock
Diagnosis and treatment
of neonatal septic shock
are quite difficult as :
Septic shock
The hyperdynamic phase
of septic shock in
newborns can be short.
VLBW may have acute
hypotension ,bradycardia
without preceding
tachycardia
Septic shock
2. Sepsis is a clinical
diagnosis and does not
rely on early isolation of
the causative infectious
organism .
Bacterial isolates in
neonatal sepsis in NICUs
in Egypt
Bakr AF. J Trop Pediatrics 2003
45 cases of neonatal sepsis
Klebsiella 78%, E. coli 11%, Candida
6.6%, Pseudomonas 4.4%
Moore KL, Kainer MA, Badrawi N,et
al.
Pediatr Inf Dis J. 2005
33 infants with clinical sepsis
21 (64%) blood cultures + < 24 hours after
birth
Klebsiella 80%, Enterobacter 10%, E.coli
6%,
Acinetobacter 3%.
Bacterial isolates in neonatal
sepsis in NICUs in Egypt
In NICU of AL Zhraa University
hospital
we found that gram negative in
55% of cases ; K. pneumoniae , E
coli, enterobactr spp, citrobacter
spp and serratia m.
K. pneumoniae phenotyping and
genotyping showed
macrorestriction profiles of
chromosomal DNA of 15 distinct
patterns.
Abd ELHalim N. MD thesis 2009 ,supervised by Aly G.,
ELMeneza S. and EL salakawy A. , FMG , AL Azhar University
What is septic shock
administration of isotonic
intravenous fluid bolus ≥40
Goldistein et al Ped.cri.car.Med.6,1,2oo5
mL/kg in 1 hr OR
● Cardiovascular
dysfunction
Need for vasoactive drug to
waste products is
Septic Shock
Septic shock is a
subclass
of distributive shock
commonly associated
with bacterial and viral
infections in neonates.
Septic Shock
The hallmark of septic
shock is marked
progressive hypotension
frequently refractory to
therapy .
SEPSIS-SEPTIC SHOCK
CONSIDERATIONS
There are a number of well known host-
related risk factors for sepsis. They
include:
Extremes of age
A compromised immune system
Malnourishment
Asplenia
Chronic antibiotic or steroid use
Additionally, any insult (shock, trauma,
burn) that makes the gastrointestinal
tract permeable to gram negative
bacteria puts individuals at risk for gram
SEPSIS-SEPTIC SHOCK
CONSIDERATIONS
Genetic polymorphisms
Inflammatory cell function
Endothelial activation and injury
Coagulation and fibrin deposition
Vasodilatory shock
Vasopresin
Hipothalamic-pituitary-adrenal axis
Cardiac dysfunction
Tissue oxygenation and perfusion
SEPSIS-SEPTIC SHOCK
CONSIDERATIONS
Genetic polymorphisms
Vasodilatory shock
Septic Shock
Septic shock
characterized by
arteriolar and venous
vasodilatation
that results in low
systemic vascular
resistance despite initial
SEPSIS-SEPTIC SHOCK
CONSIDERATIONS
Hypothalamic-pituitary-adrenal
axis
•Relative adrenal insufficiency
•Corticotrophin resistance +
•Reduced adrenal glucocorticoids
synthesis
Longer length of stay and more
organ dysfunction
Cardiac dysfunction
▪Direct depressive effect
on CVS by organisms or their
endotoxins as TSST-1
▪ Release of vasoactive
agents.
Cardiac dysfunction
Cardiac dysfunction
There is significant
decrease in the
myocardial contractility
among the newborn infant
suffered from septic shock
EL Meneza S,et al . Perinatology,Vol 21,No 7
505-06(Abs)2001
-Cardiac dysfunction
through uncoupling of
β adrenergeic receptors
&
by direct inhibition of
intracellular calcium
homeostasis
Cardiac dysfunction
vasoregulation due to
“immaturity of autonomic
nervous system”
Cardiac dysfunction
The proinflammatory
cytokines
may delay apoptosis in
activated
macrophages and neutrophils
but
other tissues such as gut
epithelium, may undergo
5-
Immunosuppression
The interaction between
proinflammatory
and
anti-inflammatory mediators
may lead to an imbalance
It is currently believed that if
pro-inflammatory predominate
an inflammatory cascade
ensues ,and immediate
pathophysiologic
processes are initiated
Septic shock
Signs of early septic shock
may be subtle and there is a
danger of overlooking them in
a busy emergency department.
The patient may not always
1- Haemodynamic
resuscitation and organ
support
Adequate blood flow
Preserve organ perfusion and
2- Eradicate infection
Early recognition
Early and adequate antibiotic
therapy
Source control
Thus -state –of- the art
management
3- Sustained support
Minimizing iatrogenic injury
Ventilation,Haemoglobin,
Glucose
4- Modulation of
inflammatory response
Coagulation, adrenal response
RESUSCITATION OF
PEDIATRIC SEPTIC SHOCK
First Hour of
Resuscitation
(Level III)
- 0 min
Recognize
decrease perfusion,
cyanosis, RDS
- 5 min
Maintain airway and access
according to NRP guidelines
-Push 10 cc/kg isotonic
crystalloid
or colloid boluses to 60cc/kg
-Correct hypoglycemia &
hypocalcaemia
-Begin prostaglandin infusion
until echocardiogram
shows no dependent
lesion
It is important to distinguish
newborn septic shock from
cardiogenic shock caused by
closure of the PDA in
newborns with ductal
dependent complex
congenital heart disease
15 min
Fluid responsive
Observe in NICU
15 min
Fluid refractory shock
-Titrate epinephrine
-Systemic-alkalinization if
PPHN and acidosis is
present
Phenomenon of non
responding to
vasopressor during shock
is due to decrease sensitivity
to dopamine due to
1-Down regulation of β
adrenergic receptors
2-Decrease in expression
of adrenergenic receptors
in critically ill neonates
3-Immaturity as depleted
myocardial nor epinephrine stores
Zhang 1999
60 min
Catecholamine - resistant
shock
Cold shock
Normal blood pressure
Poor LV function
Central venous O2 sat < 70%
Titrate vasodilator or
type III PDE inhibitor with
volume loading
60 min
Catecholamine - resistant shock
Warm shock
Low blood pressure
ECMO
What drug should we use?
In general when blood pressure is low in a sick
neonate, dopamine is more effective than
dobutamine* in raising blood pressure and increasing
systemic vascular resistance probably best to use if
low BP but normal cardiac function
If myocardial performance is impaired, the addition
of dobutamine may be beneficial as it has more
effect on left ventricular output; Dobutamine, used
without an alpha- adrenergic medication, may well
cause worsened hypotension…but still can improve
organ perfusion
Epinephrine increases both cardiac output and blood
pressure: best to use when blood pressure and
Therapeutic End Points
(Level III)
When
Should be used
??????
SCHEMATIC SUMMARY OF GLUCOCORTICOID
PROPERTIES
Carcillo,task force.Shock,
20(3):197-207,2003
Is There a Role for
Glucocorticoids in Neonatal
Shock ?
1-Immunoglobulin
2-Granulocytes infusions
3-Double volume exchange
transfusions
4-rhu-GM-CSF
Granulocyte Macrophage
Colony Stimulating Factor
Break the chain of
inflammation /tissue
injury
Emphasized that no
single therapy would be
beneficial for all patient
with sepsis
Gene therapy
production
Blockade IL-1 activity
Inhibition of nitric oxide
synthase
Exogenous surfactant
High Mobility Group
Box Protein 1
•Nuclear protein bind DNA
stabilize nucleosomes
•Extracellular mediator in
systemic inflammation
•Could be therapeutic target in
management of sepsis
Triggering receptor expressed on
myeloid cells
hygiene
Simple interventions
that work