A 10-year-old male with cerebral palsy and chronic lung disease presented with fever and abdominal distension. He was hypotensive, febrile, and tachycardic. After fluid resuscitation and placement of a gastric tube to aspirate fluid from his stomach, he was admitted to the pediatric ICU requiring inotropic support. His condition was monitored closely using non-invasive cardiac output monitoring (USCOM) to guide fluid resuscitation and weaning of vasoactive drugs to achieve hemodynamic stability.
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
Tracheitis is a bacterial infection of the windpipe (trachea).
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
No improvement in BP, HR or CVP.Fluid refractory shock!
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.
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.