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Pancreatitis – Septic Shock

   History
   10 year old male with cerebral palsy, chronic lung disease.
   Previously undergone a tracheostomy and gastric tube placement.
   Prior admissions for aspiration pneumonia and tracheitis.

   Presentation
   Fever and abdominal distension.
   Hypotensive, febrile, and tachycardic.




www.uscom.com.au                                The Measure of Life
Pancreatitis – Septic Shock

           Treatment
           60 cc/kg of fluid administered quickly and ventilated via his
           tracheostomy.
           After a nasal gastric tube is placed, 2300cc of fluid is aspirated
           from his stomach.

           Admitted to the pediatric ICU.
           BP       99/53 (68)
           HR       106
           CVP      14
           Started on inotropic support with dopamine (20) and
           epinephrine (0.1).
           Mechanical ventilation is continued.

           Fluid resuscitation is ongoing.
www.uscom.com.au                                   The Measure of Life
Pancreatitis – Septic Shock
           Presentation in PICU




www.uscom.com.au                   The Measure of Life
Pancreatitis – Septic Shock

           Volume resuscitation between measurements
           Between the 11:17 and 14:30 the patient receives:
               1200 ml Crystalloid
               350 ml Albumin
               250 ml Fresh Frozen Plasma
               72 ml Cryoprecipitate

               10.40             14.05         14.18           14.36
           BP 99/53 (68)         114/60 (75)   108/54 (70)     102/54 (68)
           HR     106            135           127             131
           CVP    14             16            15              16

           Fluid refractory shock!



www.uscom.com.au                                The Measure of Life
Pancreatitis – Septic Shock
           Treatment
           Inotropic support - Dopa 20 Epi 0.1




       14.32




                                  586




www.uscom.com.au                                 The Measure of Life
Pancreatitis – Septic Shock
           Treatment
           Dopa 20 Epi 0.08
           CI followed closely by USCOM as inotropic support is reduced




       14.49




                                 693




www.uscom.com.au                                The Measure of Life
Pancreatitis – Septic Shock
           Summary
           Fluid resuscitation and hemodynamic stability achieved.

           Conclusion
           Monitoring CI with USCOM provided confidence in weaning and
           optimzation of fluids, inotropes and vasoconstrictors.




www.uscom.com.au                                The Measure of Life

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Case Study - Pediatric - Pancreatitis - Septic Shock

  • 1. Pancreatitis – Septic Shock History 10 year old male with cerebral palsy, chronic lung disease. Previously undergone a tracheostomy and gastric tube placement. Prior admissions for aspiration pneumonia and tracheitis. Presentation Fever and abdominal distension. Hypotensive, febrile, and tachycardic. www.uscom.com.au The Measure of Life
  • 2. Pancreatitis – Septic Shock Treatment 60 cc/kg of fluid administered quickly and ventilated via his tracheostomy. After a nasal gastric tube is placed, 2300cc of fluid is aspirated from his stomach. Admitted to the pediatric ICU. BP 99/53 (68) HR 106 CVP 14 Started on inotropic support with dopamine (20) and epinephrine (0.1). Mechanical ventilation is continued. Fluid resuscitation is ongoing. www.uscom.com.au The Measure of Life
  • 3. Pancreatitis – Septic Shock Presentation in PICU www.uscom.com.au The Measure of Life
  • 4. Pancreatitis – Septic Shock Volume resuscitation between measurements Between the 11:17 and 14:30 the patient receives: 1200 ml Crystalloid 350 ml Albumin 250 ml Fresh Frozen Plasma 72 ml Cryoprecipitate 10.40 14.05 14.18 14.36 BP 99/53 (68) 114/60 (75) 108/54 (70) 102/54 (68) HR 106 135 127 131 CVP 14 16 15 16 Fluid refractory shock! www.uscom.com.au The Measure of Life
  • 5. Pancreatitis – Septic Shock Treatment Inotropic support - Dopa 20 Epi 0.1 14.32 586 www.uscom.com.au The Measure of Life
  • 6. Pancreatitis – Septic Shock Treatment Dopa 20 Epi 0.08 CI followed closely by USCOM as inotropic support is reduced 14.49 693 www.uscom.com.au The Measure of Life
  • 7. Pancreatitis – Septic Shock Summary Fluid resuscitation and hemodynamic stability achieved. Conclusion Monitoring CI with USCOM provided confidence in weaning and optimzation of fluids, inotropes and vasoconstrictors. www.uscom.com.au The Measure of Life

Notas del editor

  1. Tracheitis is a bacterial infection of the windpipe (trachea).
  2. Due to Low BP, patient treated for Cold Shock.Dopamine.Intermediate dosages from 5 to 10 μg/kg/min, known as the "cardiac dose", additionally have a positive inotropic and chronotropic effect through increased β1 receptor activation. Dopamine is used in patients with shock or heart failure to increase cardiac output and blood pressure.[64] Dopamine begins to affect the heart at lower doses, from about 3 μg/kg/min IV.[65]High doses from 10 to 20 μg/kg/min are the "pressor dose".[66] This dose causes vasoconstriction, increases systemic vascular resistance, and increases blood pressure through α1 receptor activation,[64] but can cause the vessels in the kidneys to constrict to the point that urine output is reduced.[66]http://en.wikipedia.org/wiki/DopamineEpinephrine (also known as adrenaline) is used as a drug to treat cardiac arrest and other cardiac dysrhythmias resulting in diminished or absent cardiac output. Its actions are to increase peripheral resistance via α1receptor-dependent vasoconstriction and to increase cardiac output via its binding to β1 receptors.http://en.wikipedia.org/wiki/Epinephrine
  3. Hypodynamic circulationLow MD - 15 (Typical 16-28)Low SVI – 23 (Typical 40-60)High HR – 111 (Typical 65-105)Low Vpk – 0.99 (Typical 1.1-1.6)Low CO – 3.0 (Typical 2.8-7.5)Low CI - 2.5 (Typical 3.2-5.0)
  4. No improvement in BP, HR or CVP.Fluid refractory shock!
  5. Hyperdynamic circulationHigh MD - 35 (Typical 16-28)HR – 139 (Typical 65-105)Low SVI – 44 (Typical 40-60)Low SVR – 586 (Typical 900-1800)Low SVRI – 682 (Typical 1000-2300)High Vpk – 1.8 (Typical 1.1-1.6)High CO – 7.1 (Typical 2.8-7.5)High CI – 6.1 (Typical 3.2-5.0)Dopamine.Intermediate dosages from 5 to 10 μg/kg/min, known as the "cardiac dose", additionally have a positive inotropic and chronotropic effect through increased β1 receptor activation. Dopamine is used in patients with shock or heart failure to increase cardiac output and blood pressure.[64] Dopamine begins to affect the heart at lower doses, from about 3 μg/kg/min IV.[65]High doses from 10 to 20 μg/kg/min are the "pressor dose".[66] This dose causes vasoconstriction, increases systemic vascular resistance, and increases blood pressure through α1 receptor activation,[64] but can cause the vessels in the kidneys to constrict to the point that urine output is reduced.[66]http://en.wikipedia.org/wiki/DopamineEpinephrine (also known as adrenaline) is used as a drug to treat cardiac arrest and other cardiac dysrhythmias resulting in diminished or absent cardiac output. Its actions are to increase peripheral resistance via α1receptor-dependent vasoconstriction and to increase cardiac output via its binding to β1 receptors.
  6. Dopamine.Intermediate dosages from 5 to 10 μg/kg/min, known as the "cardiac dose", additionally have a positive inotropic and chronotropic effect through increased β1 receptor activation. Dopamine is used in patients with shock or heart failure to increase cardiac output and blood pressure.[64] Dopamine begins to affect the heart at lower doses, from about 3 μg/kg/min IV.[65]High doses from 10 to 20 μg/kg/min are the "pressor dose".[66] This dose causes vasoconstriction, increases systemic vascular resistance, and increases blood pressure through α1 receptor activation,[64] but can cause the vessels in the kidneys to constrict to the point that urine output is reduced.[66]http://en.wikipedia.org/wiki/DopamineEpinephrine (also known as adrenaline) is used as a drug to treat cardiac arrest and other cardiac dysrhythmias resulting in diminished or absent cardiac output. Its actions are to increase peripheral resistance via α1receptor-dependent vasoconstriction and to increase cardiac output via its binding to β1 receptors.