ERIA

Emergensi dan
Rawat Intensif Anak
RESUSITASI CAIRAN
DAN LEBIH CAIRAN
(Globa Increased Permeability Syndrome)
GIPS
(PADA SYOK SEPSIS ANAK)

Dadang Hudaya Somasetia

Padang 4 Juli 2017 1
 DISCLOSURE

This presentation of Dr Dadang Hudaya Somasetia

DISCLOSURE STATEMENT
Nothing else to disclose

I certify that there is no conflict of interest

in relation to this presentation

Padang 4 Juli 2017 2

 The Third International Consensus
Definitions for Sepsis and Septic Shock
(Sepsis-3)
Sepsis adalah disfungsi organ yang mengancam
kehidupan (life-threatening organ dysfunction) yang
disebabkan oleh disregulasi imun pejamu terhadap infeksi’
• Syok sepsis bagian dari sepsis (subset) yang menyebabkan
gangguan sirkulasi, selular dan metabolik yang sangat hebat
sehingga meningkatkan risiko mortalitas.
• SIRS dan Sepsis berat ”dihilangkan”
• Clinical criteria:
Despite adequate fluid resuscitation
vasopressors needed to maintain MAP ≥65 mmHg
AND lactate >2 mmol/L

Singer M, Deutschman CS,Padang

Seymour CW, Hari MS, Annane D, Bauer M, dkk. 2016 4
4 Juli 2017
 Patofisiologi Syok Sepsis - GIPS
Volume <<
DO ≠ VO
Hipoksia jaringan
Glikopenia
Disoksia sel
Mitokondria ATP
Endoteliopati
Vasoplegi
Cardioplegi
Gastroparesis
MODS
MOF
Mati
GIPS Padang 4 Juli 2017 5
 CX-Ray on Septic Shock
Pre-Fluid Bolus

CX-Ray after bolus of 3 x 20 mL/kg

Padang 4 Juli 2017 6
Same kid
 Children blood volume = 80 mL/kg BW

25/100 x 80 mL/kg BW = 20 mL/kg BW

Figure 1 Systemic vasoconstriction can maintain MAP and perfusion pressure despite
hypovolemia and reduced CO, so shock must be recognized as tachycardia and
prolonged capillary refill before hypotension occurs.
JA Carcillo et al. Management of pediatic shock in the ED. Clin Ped Emerg Med 8:165-175 C 2007
Padang 4 Juli 2017 7
ALUR PENEGAKAN DIAGNOSIS SEPSIS

Padang 4 Juli 2017 PNPK SEPSIS ANAK 2016 9

 Kecurigaan Disfungsi Organ

Kecurigaan disfungsi organ (warning signs)

bila ditemukan salah satu dari 3 tanda klinis:
1) penurunan kesadaran (metode AVPU),
2) gangguan kardiovaskular (penurunan
kualitas nadi, perfusi perifer, atau tekanan
arterial rerata), atau
3) gangguan respirasi (peningkatan atau
penurunan work of breathing, sianosis)

Padang 4 Juli 2017 PNPK SEPSIS ANAK 2016 10

Kriteria Disfungsi Organ – PELOD-2

Disfungsi (5) Organ

1. Kardiovaskular,
2. Respiratori,
3. Sistem saraf pusat,
4. Hematologis, dan
5. Hepatik.
Disfungsi organ ditegakkan berdasarkan skor
PELOD-2. Diagnosis sepsis ditegakkan bila
skor ≥11 (atau ≥7).

Padang 4 Juli 2017 PNPK SEPSIS ANAK 2016 11

 qSOFA, SOFA vs Pediatric Sepsis Six vs PELOD2
From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
Pediatric Pediatric sepsis six
Identification Recognize (SIRS):
Pathway • Temperature
Temperature • Tachycardia
Respiration • Altered Mentation
Heart rate • Peripheral
perfusion

PELOD 2 Score
• Glasgow coma score
• Pupillary reaction
• Lactate
• MAP
• Creatinine
• PaO2 (mm Hg) / FiO2
• PaCO2 (mm Hg)
• Mech Ventilation
• Leukocoyte
• Platelet count

Figure Legend:
Operationalization of Clinical Criteria Identifying Patients With Sepsis and Septic Shock The baseline Sequential [Sepsis-related]
Organ Failure Assessment (SOFA) score should be assumed to be zero unless the patient is known to have preexisting (acute or
chronic) organ dysfunction before the onset of infection. qSOFA indicates quick SOFA; MAP, mean arterial pressure.
Copyright © 2016 American Medical
Date of download: 8/1/2016 Padang 4 Juli 2017 12
Association. All rights reserved.
qSOFA (Quick SOFA) Criteria
PNPK SEPSIS IDAI –
Compared to Pediatric
Disfungsi Organ
Scores 1. Penurunan kesadaran
qSOFA (adult)
(metode AVPU)
• Respiratory rate ≥ 22/min
• Altered mentation
2. Kardiovaskular (penurunan
• Systolic blood pressure kualitas nadi, perfusi perifer,
≤100 mm Hg atau tekanan arterial rerata),
atau
3. Recognition of a child at risk
Gangguan respirasi
Pediatric Identification (2 of 4 criteriaatau
(peningkatan [SIRS):
penurunan
Pathway •work
Temperature
of breathing, sianosis)
• Temperature • Tachycardia
• Respiration • Altered Mentation
• Heart rate • Peripheral perfusion
Pediatrics 2016 Then apply PELOD2:
Pediatric sepsis six
Padang 4 Juli 2017 13
 Paediatric Sepsis Six – Red Flag
Aplikasi EGDT SSC 2012 di Inggris (2015)
Red Flag Sepsis identifikasi awal anak dengan respons sistemis
terhadap infeksi seperti berikut ini: 16
1. Hipotensi: TD sistole <2 SB untuk usia, rata-rata TD < 2 SB untuk
usia (70 + 2 x usia dalam tahun)
2. HR >30 denyut diatas batas normal untuk usia
3. Laktat, gas darah > dua kali diatas batas normal
4. Capillary refill time > 5 detik
5. Pucat/mottled/biru atau ruam non-blanching atau purpura
6. Oksigen untuk memertahankan saturasi oksigen >92%
7. RR >60 x/menit atau > 5 di bawah normal, atau grunting
8. Penurunan kesadaran, nilai AVPU = V, P atau U
9. Orang tua melaporkan popok sangat kering, kurang respons
terhadap isyarat sosial, aktifitas menurun bermakna atau lemah,
menangis nada tinggi atauPadang
terus
4 Julimenerus
2017 14
EGDT dari pedoman Surviving Sepsis Campaign 2016
diadaptasi dari ACCM update 2007

Padang 4 Juli 2017 15

Applying EGDT: Pediatric Sepsis Six from UK

Padang 4 Juli 2017 16

Applying EGDT: Pediatric Sepsis Six from UK

Padang 4 Juli 2017 17

Applying EGDT: Pediatric Sepsis Six from UK

Padang 4 Juli 2017 18

Applying EGDT: Pediatric Sepsis Six from UK

Padang 4 Juli 2017 19

Applying EGDT: Pediatric Sepsis Six from UK

Padang 4 Juli 2017 20

Applying EGDT: Pediatric Sepsis Six from UK

Padang 4 Juli 2017 21

Key Components of Pediatric SSC 2016 - GDT
• ABC of resuscitation
• Established vascular access: i.v., I.O., CVC
• Fluid resuscitation: crystalloids and/or colloids
• Appropriate cultures prior to antibiotic administration
• Early targeted antibiotics and source control – 1 hour
• Early intubation – low tidal volume mech. ventilation
• Correct hypoglicemia & hypocalcemia
• Blood transfusion – optimized DO to meet VO
• Vasopressors/inotropes: when fluid refractory shock
• Steroid: Hydrocortisone when dopamine resistant fluid
refractory shock
Padang 4 Juli 2017 22
 RESUSITASI CAIRAN DAN RISIKO LEBIH CAIRAN

• Cairan kristaloid isotonis, 20 cc/kgBB (5 menit)

NaCl 0,9%, Ringer laktat, Ringer asetat
• Cairan berimbang (balanced solution)
komposisinya mirip plasma (RingerFundin)
• Koloid natural - albumin 5% - setelah kristaloid
• Koloid semisintetis – HES, Gelatines, dekstran
• Cairan kristaloid hipertonis
NaCl 3%, Na Laktat Hipertonis
resusitasi volume kecil, 5 cc/kgBB (15 menit)

Padang 4 Juli 2017 23

 Resusitasi Cairan pada Syok
Wet, Dry, or Even?
Kristaloid isotonis Kristaloid hipertonis
• Tekanan hidrostatis • Tekanan Osmosis Koloid
• ‘Isotonis’ 280 mOsm/L • Hipertonis 1200 mOsm/L
Cairan resusitasi standar’ • Resusitasi volume kecil,
• Bolus 20 mL/kgBB - 5-10’ • Bolus 5mL/kgBB - 15 mnt
• NaCl 0,9%, RL, RA • NaCl 3%, Na laktat hipertonis
• Lebih cairan • Hemat cairan,
• Proinflamasi • Antiinflamasi,
• Jejas reperfusi • Menghindari edema, jejas
• Edema jaringan interstitial reperfusi dan lebih cairan

Koloid natural atau Koloid semisintesis

Padang 4 Juli 2017 24
 Resusitasi Cairan pada Syok
Wet, Dry, or Even?
Koloid natural Koloid semisintesis

• Albumin 5% • HES, Gelatin, Dekstran

• Tekanan Osmosis Koloid
• Antiinflamasi
• Hindari jejas reperfusi
• Antioksidan
• Bertahan di ruang
intravaskular 7 hari
(Kristaloid: 1 jam)
• Tekanan Osmosis Koloid
• Antiinflamasi
• Hindari jejas reperfusi
• Risiko AKI, alergi,
gangguan hematologis
• Bertahan di ruang
intravaskukar 3-8 jam

Padang 4 Juli 2017 25

 EGDT: EARLY FLUID RESUSCITATION IS ESSENTIAL
Wet, Dry, or Even?
WHICH FLUID TO AVOID AND WHAT IS THE NEW?

Colloids Crystalloids Others

Albumin NaCl 0.9% Glucose 5%

Natural
0,45%
3% Mannitol 20%
Dextran
Semisynthetic RL Electrolyte
Gelatin concentrates
HES RA
Hypertonic
(Hydroxyethyl starch)
Saline Lactate
Balanced Totilac ®
consist of : Fluid
electrolytes Ringerfundin®
consist of :
& high
macro consist of : concentration
molecule electrolytes
Padang 4 Juli 2017 of electrolytes 26
 Avoid Volume Overload
[Fluid Overload (FO)/Lebih Cairan]
• Tolerated as long as volume responsive
– Deficit-Maintenance-Concomittant/Ongoing loss
– Fluid Resuscitation 20 mL/kg w/i 5-15 min.
– Fluid challenges - required for the initial 24-48 hours
• Finfer S. N Engl J Med 2004; 350:2247–2256
• Decrease the rate when no longer volume responsive
• FO = Fluid In – Fluid Out x100% = 90-110% Maintenane
BW on admission
• Zero balance targetted (90-110% of Maintenance)
• FO of >10% contribute to morbidity and mortality

Grade 1D Padang 4 Juli 2017 27

 Target Resusitasi Cairan pada Syok Sepsis
Wet, Dry, or Even?

• Pulih perfusi, pasokan O2 dan nutrien sel

• Normotensi
• Luaran urin meningkat >0,5 cc/kgBB/jam
• CRT, nadi perifer dan derajat kesadaran normal,
• Tanpa hepatomegali, asites atau ronki
• Bila hepatomegali, asites atau ronki, diberi inotrop
• Anemia hemolitik berat (malaria berat, sickle cell
crisises), nonhipotensif: transfusi darah lebih
bermanfaat daripada bolus kristaloid atau albumin
• Hindari HES karena risiko jejas ginjal akut.

Padang 4 Juli 2017 28

 EGDT - Tata laksana syok sepsis pada anak
Wet, Dry, or Even? SSC 2012 vs 2016
Bundle resusitasi
sepsis berat 3 jam
1. Kadar laktat plasma
diperiksa awal
2. Kultur darah dilakukan
sebelum antibiotik
3. Antibiotik spektrum luas
(diberikan dalam 1 jam
setelah deteksi sepsis)
4. Resusitasi Cairan
Kristaloid 20 mL/kgBB bila
hipotensi atau kadar
laktat ≥ 4 mmol/L
* USG/Echo, Uscom, PiCCO
Bundle resusitasi syok sepsis 6 jam
5. Vasopresor (bila hipotensi tidak
respons terhadap resusitasi cairan
awal untuk memertahan mean
arterial pressure [MAP])
6. Hipotensi arteri persisten sesudah
resusitasi cairan (syok sepsis) atau
kadar awal laktat ≥ 4 mmol/L: *
a. Ukur tek vena sentral (CVP)
b. Ukur saturasi O2 vena sentral
(central venous O2 saturation/ ScvO2)
7. Periksa ulang kadar laktat bila
kadar laktat awal ≥ 4 mmol/L
Padang 4 Juli 2017 30
 Fase Resusitasi ABC:
Tata laksana 1 jam pertama di emergensi
• memertahankan dan memperbaiki jalan
napas, oksigenasi, dan ventilasi;
Tujuan • sirkulasi: perfusi dan tekanan darah
normal; denyut jantung normal

• CRT ≤2 detik, nadi normal tanpa beda kualitas nadi

Target sentral dan perifer, ekstremitas hangat, luaran urin
>1 mL/kgBB/jam, status mental normal, tekanan
terapi darah normal sesuai umur, konsentrasi glukosa darah
normal, dan konsentrasi ion kalsium normal

• pulse oximetry, elektokardiografi kontinu,

tekanan darah dan tekanan nadi,
Pemantau temperatur, produksi urin, glukosa dan
kalsium ion
Padang 4 Juli 2017 31
0–5
menit
Identifikasi Dini Status Mental dan Perfusi

Trias:
demam, takikardia, vasodilatasi

Penurunan kesadaran

Disfungsi kardiovaskuler

Padang 4 Juli 2017 32

5 - 15
menit

Resusitasi cairan

Koreksi hipoglikemia

Koreksi hipokalsemia

Antibiotik awal

Bila ada akses vaskular perifer Pantau AKU

lain, mulai beri inotrop Hati hati lebih cairan
Padang 4 Juli 2017 35
 5 - 15
menit
Resusitasi cairan: Volume
• Bolus awal 20 mL/kgBB dalam 5-10 menit (sampai 40-60 ml/kgBB)
• Titrasi dg pemantauan
• Denyut jantung
• Luaran urin
• Waktu pengisian kapiler: CRT
• Derajat kesadaran AVPU
Pantau tanda Lebih Cairan
(fluid overload)
• Hepatomegali
• Peningkatan respiratory effort
• Rales pada pemeriksaan paru
Padang 4 Juli 2017 36
• Hipoksemia
5 - 15
menit

Resusitasi cairan:
• Kristaloid isotonis
• Koloid natural vs semisintetis
• Kristaloid hipertonis
Wheeler dkk UpToDate 2017
• Tidak ada perbedaan luaran antara cairan kristaloid dan koloid
Schierhout dan Roberts; Wheeler dkk UpToDate 2017
• Koloid: efek gangguan hemostasis, alergi, AKI dan kematian
Kristaloid hipertonis – Resusitasi Volume Kecil 5 mL/kgBB

Padang 4 Juli 2017 37

15 - 60
menit

Syok refrakter cairan:

Belum ada perbaikan hemodinamis
setelah resusitasi cairan ≥60 mL/kgBB
Simultan melakukan:
- Terapi inotrop IV/IO - Dopa-Epi-Dobu-NorEpi
-Pasang akses vena sentral + jalan napas (bila perlu, intubasi)
- Atropin/ketamin IV/IO/IM untuk untubasi
Padang 4 Juli 2017 41
 Resusitasi Cairan pada Syok (Sepsis) Anak
• Sesudah Resusitasi Cairan, selanjutnya
terapi cairan sesuai kebutuhan pasien:
• Defisit – Maintenance – Concomitant loss
• Holliday – Segar: Sedikit lebih cairan
• Resusitasi – Stabilisasi – De-resusitasi –
Hindari Hipovolemia kembali
• Hindari Hipervolemia fase Resusitasi – GIPS
• Global Increased Permeability Syndrome
Septic shock: Rapid recognition and initial resuscitation in children
Scott L Weiss, MD et al. UpToDate May 2017
Strategies for Intravenous Fluid Resuscitation in Trauma Patients
Robert Wise, Michael Faurie, Manu L. N. G. Malbrain, Eric Hodgson
World J Surg (2017) 41:1170–1183 DOI 10.1007/s00268-016-3865-7
Padang 4 Juli 2017 42
 Dry, Wet, Even or Something Else?
The Ebb phase was characterised by Cuthbertson in 1932 as:
“Ashen faces, a thready pulse and cold
clammy extremities…”,
while during the Flow phase “the patient warms up, cardiac
output increases and the surgical team relaxes…”

Global Increased Permeability Syndrome (GIPS).

GIPS is characterised by high capillary leak index (CLI,
expressed as the ratio of CRP over albumin), excess
interstitial fluid and persistent high extravascular lung water
index (EVLWI), no late conservative fluid management
(LCFM) achievement, and progression to organ failure.
GIPS represents a ‘multi-organ dysfunction syndrome-MODS
(second hit). third hit’ following the acute injury (first hit) with
progression to
Padang 4 Juli 2017 43
 Three hit Model
Resusitasi-De-resusitasi Cairan
• First hit = jejas akut
(pneumonia menyebabkan syok sepsis)
• Second hit = multi-organ dysfunction syndrome (MODS)
• Third hit = Global Increased Permeability Syndrome
(GIPS)
• Fourth hit: De-Resuscitate
Malbrain et al 2014
Strategies for Intravenous Fluid Resuscitation in Trauma Patients
Robert Wise, Michael Faurie, Manu L. N. G. Malbrain, Eric Hodgson
World J Surg (2017) 41:1170–1183 DOI 10.1007/s00268-016-3865-7
Padang 4 Juli 2017 44
 Frirst Hit

EGDT

Ebb Phase

Second Hit

Third Hit
LGFR
GIPS
Flow Phase

Padang 4 Juli 2017 45

Malbrain et al 2014
THREE HIT MODEL + GIPS:
First hit refers to INJURY,
Second hit to REPERFUSION, and
Third hit to UNREPAIRED
CAPILLARY LEAK.
Rhadbo – rhabdomyolysls;
ECS – extremity compartment syndrome;
ICFH – intracranial hypertension;
ALI – acute lung injury;
ARDS – acute respiratory distress syndrome;
IAFH – intra-abdominal hypertension;
ABI – acute bowel injury;
ACS – abdominal compartment syndrome;
AIDS – acute intestinal distress syndrome;
AIPS – acute intestinal permeability syndrome;
AKI – acute kidney injury;
ATN – acute tubular necrosis;
GIPS – global increased permeability syndrome
Padang 4 Juli 2017 46
Duchesne, Malbrain et al 2015
Konsep Three Hit Model dan Pemantau
Mampu Respons Cairan (Fluid Responsiveness) Mallbrain el al 2014

Fist Hit Second Hit Third Hit

Etiologi Efek merugikan Reperfusi iskemia GIPS
inflamasi
Fase Ebb (Surut) Flow (Alir) No Flow
Resusitasi cairan Resusitasi Biomarker peny. kritis Toksis

Pemantauan Hemodinamis Fungsi organ Perfusi

Mampu fungsional (EVLWI, IAP) (ICG, PDG)
Respons Cairan (SSV, PPV)
Terapi Konsep EGDT Late conservative fluid Late goal directed
management (LCFM) fluid removal (LGFR)
Keseimbangan Lebih cairan Netral Negatif
cairan
SSV: stroke volume variation, PPV: pulse pressure variation,
EVLWI: extravascular lung water index, IAP: intra abdominal pressure
ICG-PDG: indocyanine green plasma dissapearrance rate
Padang 4 Juli 2017 47
 ROSE CONCEPT Malbrain 2014

KONSEP R.O.S.E. PADA FASE SAKIT KRITIS/SYOK

DAN MONITOR/TATA LAKSANA HEMODINAMIS
• Model Three-hit syok diperluas menjadi model Four-hit
dgn lima fase dinamis/stadium pemberian cairan:
• Resusitasi,
• Optimisasi,
• Stabilisasi, dan
• Evakuasi (R.O.S.E.), diikuti oleh risiko terjadinya

• Hipoperfusi

Hindari lebih cairan atau kurang cairan/dehidrasi

Padang 4 Juli 2017 48
Rasionalisasi dan Cara Kerja PEEP, Albumin dan Lasix (PAL)
Malbrain et al 2014

Protokol PAL treatment:

PEEP ~ IAP 12 mmHg
Cairan bergeser dari alveoli
ke dalam interstitium (IS)
Albumin 20% 200 mL (dewasa),
(anak 1-3 gr/kg)
Target kadar albumin darah 3 gr/dL
Cairan bergeser dari IS
ke dalam kapiler
Lasix 60 mg/jam (4 jam),
selanjutnya 10-20 mg/jam
anak: i.v. 0,5-1 mg/kg sampai
5mg/kg bila resisten
infus 0.1-1 mg/kg/jam
Padang 4 Juli 2017Target luaran urin 2 mL/kg/jam 49
 Fluid Management
Dry, Wet, Even or Something Else?
If I Give Too Much Fluid . . .

Avoid Fluid Overload of >10%

• Check for Hepatomegaly
• Check for Rales
• Evaluate Perfusion pressure (MAP – CVP)
• Give (albumin), diuretics
• Use Dialysis CRRT if unsuccessful

Padang 4 Juli 2017 50

 Fluid overload is associated with impaired oxygenation and
morbidity in critically ill children*
Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Pediatr Crit
Care Med 2012; 13:253–258

AVOID FLUID OVERLOAD (FO)

FO% = (mL fluid in – mL fluid out from admission) (100%)
admission weight in kg
Warning when FO 10-20%
(FO15%  increased of morbidity and mortality)
Conclusion:
While timely administration of fluids is lifesaving,
positive fluid balance after hemodynamic stabilization may
impact organ function and negatively influence important
outcomes in critically ill patients.
Padang 4 Juli 2017 51
Target Resusitasi pada Syok Sepsis Anak
No Parameter Target
1 Klinis  Frekuensi denyut jantung atau nadi menurun
 Kualitas nadi sentral dan perifer sama
 Akral hangat, CRT <2 detik
 Diuresis >1 mL/kg/jam
 Kesadaran membaik
 Tekanan sistole >P5 sesuai usia
2 Hemodinamis
 Inotropy index >1,44 W/m2
 Stroke volume index (SVI): 40-60 ml/m2
 Cardiac index (CI): 3,3 – 6,0 L/m2/mnt
 SVRI: 800 - 1600 d.s/cm5/m²
 ScvO2  70%

3 Laboratorium  Laktat darah 1,6

Padang 4 Juli 2017 PNPK SEPSIS ANAK 2016 52

 Parameter Refrakter Cairan
No Parameter Kriteria Refrakter Cairan

1 Passive leg raising (PLR) Kenaikan cardiac index <10%

2 Diameter vena cava inferior Collapsibility index (napas spontan) <50%

(Ultrasonografi)
Distensibility index (ventilator) <18%

3 Stroke volume variation USCOM: <30%

(SVV)
Pulse contour analysis: <13%

4 Systolic pressure variation <13%

(SPV) atau
Pulse pressure variation
(PPV)

Padang 4 Juli 2017 PNPK SEPSIS ANAK 2016 53

•Modified fluid challenge
- Passive leg raise (PLR) pada dewasa memobilisasi cairan 300 cc
- Bolus cairan mini (100−200 mL,
anak sesuaikan dengan berat badan 5 mL/kgBB)

Posisi setengah telentang 450,

kemudian pasien telentang,
kaki diangkat 450 dan
variabel hemodinamis (EVLWI) atau curah
jantung dievaluasi setelah 30-60 detik.
Passive leg raise
Fluid Challenge, Auto-bolus dari Ekstremitas Bawah
Dikutip dari: Mackenzie DC, Noble VE19
Padang 4 Juli 2017 54
 RESPON TERHADAP CAIRAN
(FLUID RESPONSIVENESS)

1. Fluid challenge
2. Passive leg raising – PLR (kenaikan cardiac index ≥10%)
3. Ultrasonografi
-- Pengukuran diameter vena cava inferior (VCI)
-- Ultrasound Cardiac Output Monitoring (USCOM):
stroke volume variation (SVV) ≥30%
4. Arterial waveform: Systolic Pressure Variation (SVV) atau
Pulse Pressure Variation (PPV) ≥13%
5. Pulse contour analysis: Stroke Volume Variation (SVV) ≥13%
Malbrain et al 2014
Padang 4 Juli 2017 55
 Close Monitoring of Septic Shock

• Continued reassessments – vital signs

• Foley cath – maintain UOP at least 1 mL/kg/hr
• Gastric tube – monitoring of gut paralysis
• Pulse Oxymetri, End-tidal CO2 monitor ?
• Non invasive monitoring:
- Conventional vs Ultrasound/echo/USCOM ?
• Invasive monitoring:
- CVC for central venous pressure monitoring ?
- Swanz-Ganz cath, intra-arterial monitoring ?
Padang 4 Juli 2017 56
 Echocardiography

IVC - SVC
Collapsible Index
Hypodynamic Padang 4 Juli 2017 57
Fluid Responsiveness
• A patient who is fluid
responsive will have
a significant (>15%)
increase in CO in
response to a fluid
challenge.
• This indicates that
the heart is on the
steep portion of the
Frank-Starling
Curve

Padang 4 Juli 2017 58

On a PiCCO Monitor

Padang 4 Juli 2017 59

Padang 4 Juli 2017 60
 PiCCO
 SVV – determined by analysis of the continuous
arterial pulse contour – uses the area under the
systolic curve for beat-to-beat determination of
stroke volume and their variation over the
respiratory cycle – can also use for determining
volume responsiveness
 > 10% is considered to be responsive

Padang 4 Juli 2017 61

FloTrac/Vigileo
No calibration needed, derives
measurements based on compliance
and patient characteristics (gender, age,
height and weight – derived from experimental
cadaver data)
Measures the pulsitility of the arterial
waveform by calculating the standard
deviation of the arterial pressure wave
over a 20s period – multiplied by the
compliance
The initial software autocalibrated

every 20 minutes, leading to bad ROC

when compared to PACs – however it
now autocalibrates every minute.

Padang 4 Juli 2017 62

 TAKE HOME MESSAGE
Early detection and early intervention is the KEY
THE VERY BASIC MANAGEMENT OF SHOCK
 Stabilize the respiration
 Assess perfusion
 Access vascular: IV or IO
 Fluid resuscitation (avoid overload - GIPS)
(crystalloids and/or colloids) – which one?
 Antibiotic in septic shock
 Inotropes and Vasopressors
 Transfusion: RBC (Hb <7 gr%)
 Electrolyte and Metabolic: hypoglycemia, hypocalcemia
 Steroid
 Closed monitoring – time to time – real time
Padang 4 Juli 2017 63
Kompetensi VS Malpraktek

Terima Kasih
Padang 4 Juli 2017 64
Padang 4 Juli 2017 65
A Need to Change the Paradigm of Current Sepsis Management

Padang 4 Juli 2017 66

Performance Improvement Program

Padang 4 Juli 2017 67

Pediatric Considerations
• Initial resuscitation
• Antibiotics and source control
• Fluid resuscitation
• Inotropes/vasopressors/ vasodilators
• Corticosteroids
• (ECMO)

Padang 4 Juli 2017 68

Terapi inotrop dan vasopresor
 Dopamin merupakan pilihan inotrop pertama
pada syok refrakter cairan pada anak

 Efek dopamin:
dosis rendah –vasodilatasi sirkulasi renal dan
mesenterika
dosis 5-10 mikrogram/kg/menit –inotropik
positif dan kronotropik positif
dosis lebih tinggi -vasokonstriksi perifer
Padang 4 Juli 2017 69
 Syok resisten dopamin
 Cold shock: epinefrin [0,05- 0,3 mcg/kg/menit]
→ efek β-2 adrenergik di p.d perifer
 Warm shock: norepinefrin [1-20 mcg/kg/menit]
→ meningkatkan MAP, SVR, hantaran oksigen ke
jaringan

Dobutamin:
 inotrop pada CO ↓ dan SVR ↑ (ekstremitas dingin,
pengisian kapiler memanjang, produksi urine
berkurang tetapi tekanan darah normal)
 dosis 2,5–20 mcg/kgBB/menit
Padang 4 Juli 2017 70
Memertahankan Jalan Napas
Keputusan intubasi dan ventilasi sebagai
bagian dari dukungan hemodinamik:
pemantauan hemodinamis invasif
dukungan mekanis pada sirkulasi.
memfasilitasi pengontrolan temperatur
mengurangi konsumsi oksigen
gagal napas dan penurunan kesadaran

Padang 4 Juli 2017 71

 Physical Exam
 Orthostatic hypotension – postural pulse increase of
>30 beats/min has a specificity for hypovolemia of
96% (McGee, JAMA, 1999)
 Postural hypotension occurs in up to 10% of
normovolemic patients
 Supine tacycardia is specific (96%), but insensitive
(~10%)
 Supine hypotension is also specific and insensitive

(McGee, JAMA, 1999)

Padang 4 Juli 2017 72
 Dynamic Methods to look at
Hemodynamics and Volume
Status in the PICU
 Take advantage of the Heart-Lung interactions
during positive pressure ventilation.
 Arterial Line Monitoring with dynamic analysis
of the wave form and pulse pressure variability
 Echocardiography to predict volume
responsiveness
 LV, IVC, SVC

Padang 4 Juli 2017 73

 Devices to Automatically analyze
waveforms – for SVV and PPV
 PiCCO
 LiDCO/Pulse Plus
 Flotrac/Vigilo

Padang 4 Juli 2017 74

 Intermittent Contin. Addit'l
Invasive Limits
CO CO Variables

Severe
Femoral
Transpulm. GEDV, Vasc.
PiCCO thermistor
thermodiluti
Every
EVLW, Disease,
Plus -tipped 3s
on SVV, PPV IABP,
catheter
arrythmias

PulseCO/ Regular a- Transpulm.

thermodiluti
Beat to
SVV
SVV/PPV,
IABP,
LiDCO line Beat
on arrythmias

Spont.
FloTrac/ Regular a-
None
Every
SVV
Breathing,
Vigelo line 20s IABP
Padang 4 Juli 2017
arrythmias
75
 FloTrac and Cardiac Output
 FloTrac has been proven to be an
acceptable way of monitoring CO in patients
undergoing CABG (de Waal, CCM, 2007)
 SVV as measured by FloTrac has been
shown to be higher in patients who
responded to fluid loading: 18 vs 4 (p
<0.001) (Cannesson, Eur J of Anesth, 2007)

Padang 4 Juli 2017 76

Positive Pressure and Venous
Return – Taking advantage of
Heart-Lung Interactions
• In a volume
resuscitated
patient:
 Venous return does not
fall during inspiration on
PPV
 Intrathoracic pressure is
positive
 Intrabdominal pressure
also rises
 Pressure gradient
between the abdomen
and thorax is maintained
Padang 4 Juli 2017 77
Positive Pressure and Venous
Return – Taking Advantage of
Heart-Lung Interactions
•In volume depleted
patient on PPV:
Collapse of intra-abdominal
veins and SVC occurs as a
result of positive
intrathoracic pressure
This results in a fall in

venous return RV stroke

volume, LV preload and
cardiac output

Padang 4 Juli 2017 78