2 Comments

1. 

   Diyana on June 11, 2019 at 9:10 am

   Dear Dr Flannigan,
   Great lecture!

   I want to know how would you approach a child who is in compensated warm septic shock?

   I had a 4 months old baby who was so unwell with fever and poor oral intake. He had warm shock, tachycardic up to 190 but BP was always on the high side always above 110/70. O2 sats 100% under room air. He was alert but irritable. He had positive long tract signs that pointed towards meningitis but anterior fontanelle was surprisingly normotensive. He has been having eczema since neonatal period. His labs showed that he had leukocytosis with raised CRP, compensated metabolic acidosis with a lactate of 10mmol/l, SIADH with Na of 125, coagulopathy with APTT of 61/s but no bleeding, albumin of 12g/l and he was oedematous.

   I was worried of the SIADH so i gave bolus of 10cc/kg of NS over 15 mins, then another bolus of 10cc/kg of NS over 15mins. Then the HR reduced to 180. He seemed unsettled still. He was always normoglycaemic. Antibiotics (penicillin and cefotaxime) were given within the 1 hour frame, gave 2/3 maintenance of fluids but did not push further for fluid boluses although he still remained tachycardic until 6 hours later-gradually reduce to 120/130bpm. Lactate seems to gradually reduce and bicarbonate level improved in time. Coagulopathy improved with Vit K. LP was done the next day -delayed due to haemodynamic instability and showed that he had strep pneumoniae in his CSF. His MRI Brain showed right frontal focal encephalitis, no cerebral oedema/midline shifts of any sort to suggest increased ICP

   The questions are:
   1. How would you approach in terms of fluids? Warm compensated shock but with SIADH?
   2. Would you think that this child might need early inotropic support even though the BP was high?

   Thanks
   Diyana, Malaysia

   Reply
   • 

     Christopher Flannigan on June 16, 2019 at 1:59 pm

     Hi Diyana,

     Thanks for getting in touch. It is difficult to give advice without having the child in front of me as although you have provided me with some details (and I don’t have all the information), it is only when you put everything together that you can come up with the best approach and clinical exam is the most important. I’m assuming you diagnosed SIADH on paired serum and urine osmolarity?

     Your case sounds like a baby with meningitis and the high BP it could be related to compensatory mechanisms to preserve cerebral profusion pressure in the setting of raised ICP. Although the fontanelle was soft in the setting of meningitis you need to be concerned bout raised ICP – was the CSF under pressure during the LP the next day? – If this is the case care needs to be taken not to reduce BP too much and you would probably want it in the upper limit for age.

     Your BP sounds a little above this so other factors that could be contributing are – 1) increased sympathetic tone from pain, 2) fluid over load from SIADH. I would be interested to see what happened to heart rate, BP and lactate after a little fluid and some good analgesia.

     When it comes to fluid management in SIADH in general fluid restriction is the aim and I tend to start with 2/3 maintenance initially reducing to 1/2 maintenance if needed. The difficultly is in the shocked patient you may need to give fluid boluses if you think their intravascular compartment is empty (even if they have excessive body water) as is often the situation in septic shock. I would be guided by CVP, swing on a-line, USS IVC and passive leg raising to guide small volume of fluid bolus – in the absence of access to these makers you would need to give a small volume of fluid and reassess just like you did. I would ECHO heart for function (and to exclude tamponade) and use this to guide inotrope use. When it comes to afterload I think adjusting this based on clinical exam (pulse pressure doesn’t look particularly narrow, what was the pulse volume?, were the peripheries cool?), but as your case shows the baby responded well to fluid and analgesia so this wasn’t needed.

     If things hadn’t responded to this and you where worried BP was excessively high causing poor flow to organs and the lactate remained high, after doing the above measure I would intubate and sedate (reducing babies own sympathetic drive and also to allow the invasive lines to help make decisions and allow safe administration of vasodilators if needed (but only starting these if needed as in most cases I would expect things to improve with intubation and sedation and if you do go down this route taking care not to reduce the BP too much). Standard neuroprotective measures should be applied.

     Also given the low sodium and concerns about raised ICP I would have a low threshold to give some hypertonic saline (this will also work as a fluid bolus). Similarly given the very low albumin level, although there is no good evidence of its use, you could consider 20% albumin 5ml/kg given slowly over 4 hours would help draw some fluid back into the circulation as well (but you would need to make sure you wanted to draw more fluid back into the circulation and that your assessment was that the circulating volume was empty rather than too full).

     Sounds like a difficult case, but what you did seems to have worked well.

     Regards
     Chris

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