【体外膜肺ECMO精品课件】 SEVERE SEPSISSEPTIC SHOCK IN PEDIATRICS.pptVIP

Fluid resuscitation of pediatric patients is weight based and aggressive, with initial resuscitation of 20ml/kg and often up to 40–60ml/kg required during the initial resuscitation. Blood pressure itself is not a reliable endpoint for resuscitation. Physical exam, urine output, and pulse response are the primary response monitors. Physical exam findings indicating successful resuscitation include a capillary refill 2sec, warm extremities, and normal mental status. Other objective targets include urine output 1ml/kg/hr and normalization of lactate, and as in the adult, central venous O2 sat ?70%. The hemodynamic profile of pediatric sepsis is quite variable. Dopamine with its combined inotrope and vasopressor characteristics is recommended for pediatric hypotension because of the tendency for a lower cardiac output in this patient population. Epinephrine or norepinephrine are then added for dopamine refractory shock. When cardiac output is measured, dobutamine is recommended for low cardiac output states. Inhaled nitric oxide may be useful in neonates who are septic with post-partum pulmonary hypertension. As in adults, steroids are recommended for children with catecholamine resistance and suspected or proven adrenal insufficiency. Activated protein C has not been studied in pediatric severe sepsis. Unlike adults GM-CSF has been shown to be of benefit in neonates in circumstances of neutropenia and sepsis. ECMO, not recommended in adults, may be useful in children with refractory shock or respiratory failure. Most patients mechanically ventilated with severe sepsis require some degree of sedation and analgesia. However, overuse of these drugs leads to prolonged need for mechanical ventilation. It is therefore important to titrate sedation and analgesia to the minimal effective dose. This is likely best done using bolus administration so that the drug is only given when bedside evaluation indicates a lack of sedation or analgesia. When cont