Difficult Cases

SEPTIC SHOCK
Warren Rodrigues
29th May 2019
 Sepsis

Sepsis is defined as
(a) a life threatening organ dysfunction
that is caused by
(b) a dysregulated host response to infection
 Septic Shock
‘Circulatory and Cellular/Metabolic
abnormalities are profound enough to
substantially increase mortality’.
 DEFINITIONS
• SEPSIS: Systemic inflammatory response to
infection
• SEVERE SEPSIS: Organ Dysfunction,
Hypotension and Hypoperfusion
• SEPTIC SHOCK: Severe Sepsis that persists
despite adequate fluid replacement
• REFRACTORY SEPTIC SHOCK: Shock despite goal- directed
use of inotropes, vasopressors, vasodilators, and
maintenance of metabolic and hormonal homeostasis
2014
update
Nature Reviews/Immunology Volume 17/July 17

Host Response to Infection during Sepsis

 Case - 1
• 4 year old girl, weighing 18 kg attended local hospital with a short history
lethargy & pyrexia.
• Examination: ↑ WOB, Tachycardia, Hypotensive & Mottled.
• Venous gas: Significant metabolic acidosis.
• Fluid boluses given & referred to CATS.
• On Arrival of CATS team:
• A- intubated with using induction (known grade 4 airway)
• B- required high ventilatory pressures 30/10 and FiO2 of 1.0
• C- unable to palpate peripheral pulses, hypotensive - changed from peripheral
dopamine to adrenaline & noradrenaline by CATS team once central access
secured. Initial lactate 8
• D- GCS 15/15 prior to intubation
• Further fluid boluses - 90ml/kg of crystalloid
• 20ml/kg of colloid
• 10ml/kg of FFP
• Repeat gas: pH 7.26, pO2 4.38 pCO2 4.74 BE -10.1 Lact 6.4
 PMHistory
• Pierre Robin Syndrome (Micorgnathia, Glossoptosis, Cleft Palate)
• Cerebro-costo mandibular syndrome (abnormal development of the ribs)
• Bilateral sensorineural hearing loss
• Speech delay
• Large cleft palate (repaired)
• Micrognathia – Grade 4 laryngoscopy
• Regular Medications: Nil
• Well at home
 Admitted to PICU

Plan:
• 1. HFOV
• 2. Inotropes as required
• 3. Continue with steroids
• 4. Microbiology and ID consult
• 5. Resend meningococcal PCR
 Cardiac Arrest-PICU
ABG-pH 7.125 7.34 6.94 7.06
pCO2 5.84 3.03 7.25
pO2 8 6.9 5.7
HCO3 14.5 12.6 16.3
BE -15 -13 -15
Sao2 82% 88% 51% 48%
Lactate 4.14 5.91 10.53 17.98
 Subsequent Clinical Course
• 3 periods of Cardiac Arrest within an hour. APLS algorithm
followed.
• 1st: 8 minute arrest. Good CPR throughout.
• 2nd: 24 minutes. Good quality CPR throughout. Bagged
with ETT in situ. 6 x adrenaline, calcium and bicarbonate.
Echo performed early during 2nd arrest. No ventricular
output. During arrest, ECMO team contacted
• 3rd: 8 minutes. Probably related to hyperkalaemia (K: 7.4)
3 further Adrenaline, Calcium Gluconate and Sodium
bicarbonate. Insulin Dextrose infused.

• Subsequent blood pressure maintained on Adrenaline

1.5mcg/kg/min and Nor-Adrenaline 1.0mcg/kg/min.

• Vasopressin commenced 0.001U/kg/min

Medical Illustration
CXR’s
 Discussion
• Would you place this child on ECMO?
• What type of ECMO support would you
choose ?
• What would be your preferred cannulation
technique?
• How would you counsel the parents?
CXR VA ECMO
 Diagnosis
• Streptococcal toxic shock syndrome (Group A Streptococcus)
• Multiple cardiac arrests downtime approximately 40 minutes.
• VA ECMO (12 days).
• Renal failure requiring renal replacement therapy (CVVH).
• Left sided empyema.
• Right common carotid artery pseudo-aneurysm.
• Ischaemic left foot (post ECMO) - improving.
What criteria would you use to deploy
ECMO in Sepsis?
• Epinephrine > 1mic/kg/min (Inotrope score
>100)
• Aggressive fluid replacement/
pharmacological strategies
• Deterioration despite treatment (hypotension,
↑ lactate or rapidly progressive MOD)
 What contraindications would you consider for
use of ECMO in Paediatric Sepsis?
• Severe pre-existing neurological dysfunction
• Incurable Malignancy
• Allogenic Bone Marrow- dismal
• Stem Cell Transplant- 10%
• Neutropenic sepsis- not a contra-indication
but outcomes guarded
• Organism: beware of these- Bordetella & HSV
How does Cardiac Failure manifest in Sepsis?
Haemodynamic Alterations
Phase Overlap: Parker etal.
 Paediatric Refractory Septic Shock
Haemodynamics Age bracket
• Right Heart Failure (+/- • Neonates
VV PPHN)
• Left Heart failure with Poor • Infants and children (cold)
VA DO2 SWITCH
• Distributive Shock with Poor
?CVA • Late Adolescence (warm)
PVA VO2 (extraction)
What advantages do these cannulation
strategies/ ECMO modes offer?
• VV
• Central VA
 ADVANTAGES OF VV ECMO
• Avoids systemic embolization & arterial
trauma
• Avoids increased LV afterload; preserves
pulmonary blood flow
• Pulsatile Systemic Flow, Oxygenation of
blood in Systemic Ventricle and better
coronary oxygenation
Central Cannulation
• ADVANTAGES:
 High Flow Rates → Faster Resolution of Shock & MODS
 Avoids Differential Cyanosis
 Complete Cardiac & Pulmonary Support

• DISADVANTAGES:
 Specialty Cardiac Services
 Risk of Mediastinitis
 Risk of local Haemorrhage greater than percutaneous
technique
• 18 year period, ECMO: 441 patients

• 1988-2006

• Refr’ Septic Shock ECMO: 45 (10%)

• Cardiac Arrest: 18

• More than 3 organ failure: 41 (91%)

• Survival to hospital discharge: 21 (47%)

• Survival: Aortic Cannulation versus

Peripheral VA: 73% versus 44% (p:0.05)

• No survivors had disability at long term

follow up.
Period: 2000-2009; 9 year period (246 runs)

Patients: 23 with C VA ECMO

Patients with atleast 2 organ failure: 22 (96%)

(all with high inotrope score)

Cardiac Arrest: 8 (35%)

Flow: 150mls/kg and 2.4L/min for <10 & >10kg

respectively

Decannulated: 18 (78%)

Survival to discharge: 17 (74%)

Higher Pre ECMO lactate associated with

mortality
 What ECMO flow rates would you consider in
Sepsis? Why is the term ‘full flow’ misleading?
• Goal directed
• Sepsis: 150-200mls/kg/minute
• ‘Reverse shock and restore tissue oxygenation’
 On an ECMO flow of 200mls/kg/min,
observation is that the Urine is now Rosé!

• Haemolysis!
• Plasma Free Hb monitoring
• Maximise canullae size
• Minimize presence of low flow zones (circuit
bridges, number of taps and access points)
 Outcomes in Sepsis
• Neonatal Sepsis: 75%
• Neonatal HSV infection: 25%
• Bordetella pertussis: lower than HSV
• Children with isolated Bacterial and Viral Pneumonia: 59% & 65%
• Adults with isolated Bacterial and Viral Pneumonia: 61% & 66%.
• Combined Survival in Adults and Children with ARDS: 54% (all ARDS)
• Sepsis induced ARDS more or less similar to above
• Paediatric Septic Shock: Survival to hospital discharge is 50%
• Paediatric High Flow C VA ECMO: 75%
• Allogenic Bone Marrow Transplant: Dismal outcomes
• Stem cell transplantation: 10% to hospital discharge
 Case – 2
• 2 ½ year old female, 12 kg.
• ECMO referral for hypercapnic respiratory failure (Influenza B, RSV
positive, bilateral pneumothoces and pleural effusions)
• Presented to local unit with 7 days history of worsening breathing
difficulties, fever and cough.
• Treated with Optiflow, CoAmoxiclav, Ceftriaxone, Clarithromicin and
Hydrocortisone.
• Respiratory Deterioration requiring intubation and ventilation and
transfer to tertiary PICU where she continued to deteriorate
requiring increasing oxygen and ventilatory pressures.
• Pulmonary air leak syndrome
• She had multiple chest drain insertions with manipulations, bilateral
pneumothorax and pleural effusion, 3 drains on suction (1 left and 2
right)
• Inotropy: Nor Adrenaline 0.05mics/kg/minute
Radiology
 Consultant Note
• Explained ECMO offers lung rest with chance of healing.
Children in X’s situation on ECMO have around 75% chance of
recovery. There is a risk of bleeding, brain injury but
emphasised that there are also considerable risks with
conventional treatment and it is difficult for her lungs to heal
on high pressure ventilation.
• After discussions parents said they want to go ahead with
ECMO.
 CXR

VA ECMO:
12 Fr R carotid,
17Fr RIJV.
 ECMO Course & Update
• Infection: Severe necrotising pneumonia with RSV, Flu B, Candida and PCR positive for
Pneumococcus. No history of recurrent infections, poor growth.
• Days prior to ECMO- No known frank collapse or hypotension, Prolonged hypoxia –
• Fairly stable on ECMO, but poor lung recovery - SaO2 in mid- 70s
• Sedated - slowly weaning of Opiods.
• No spontaneous eye opening
• Coughing and moving all limbs
• EEG "encephalopathy“, CT Head Normal
• Ciprofloxacin, Piptazobactam, Oseltamivir
• Anti-coagulation: as per protocol

• Echo normal
• Renal function and LFT normal
• Lactate 1.9-2.5
• Day 28
CT Chest
 Decision?
• 4 weeks- VA ecmo- 160-170% ECMO Flows
• CT Thorax
• Manipulation of chest drain as intermittently blocked
• Cannulae re- positioned
• Flexible bronchoscopy -> tube obstructed
• High Plasma free Hb (3.8) - No end organ damage
• Air leak - ?Bronchopleural fistula - Improved
• Airway occlusion by secretions - Improved after Bronchoscopy
• White out lungs - Necrotising pneumonia LLL, RLL, R middle lobe & lingula,
sparing upper lobes.
• Abdominal distension (spleen and liver displaced vs enlarged), Medical Pancreatitis
• CRP>270, but negative cultures and Pro-Calcitonin 0.1ng/ml
• She failed to make significant clinical improvement despite
prolonged mechanical support for 4 weeks
After 4 week of V-A ECMO
 What was done and how?
• Consensus opinion was that conversion to VV ECMO
was the next sensible step.
• Staged approach VA→VAV→VV
Plan
• Perfusion
• Surgeon/ Interventional Cardiologist
• Fluroscopy/ Echocardiography
• Deep Hypothermia
• Avalon Canulla
• Y connector
• Gate Clamp
• Flow probes
Fluoroscopy
Fluoroscopy
Avalon Canulla Inserted

A
CXR
 VAV

With thanks to Mr N Muthialu for medical illustration

CXR (VAV → VV) over 3 days
CXR ( on VV lasting 18 days)

VV ( Avalon): Facilitated Physiotherapy & Regular Repositioning

CXR
 VV
Avalon
TRIPLE CANNULATION
 TRIPLE CANNULATION NOMENCLATURE
• Canulla 1: Draining a vein
• Canulla 2: Supplying an artery
• Canulla 3: May be draining or supplying with
completely different consequences
Rule:
• Since A is a supplying canulla→ all
following/subsequent letters denote supplying
canullas.
• VAV: V: Draining; A: Supplying; V: Supplying
• VVA: V: Draining; V: Draining; A: Supplying
 When to consider Triple Cannulation?
‘ An Upgrade’
VVA
• Insufficient unloading
during VA- ECMO
• Left Ventricular Distention
during VA- ECMO (after
trying LA venting)
VAV
• Respiratory Failure during
VA-ECMO (especially Femoral Cannulation)
• Cardiogenic Shock during
VV- ECMO
• Provides benefits of VA &
VV ECMO
• Respiratory support is
strong – lung protective
strategy
• Circulatory support is lower
The “Watershed Phenomenon”
Seen in Femoral Cannulation

Imperative to have a Right

Radial Arterial Line
 GOSH ECMO for Sepsis
Neonates Alive = 19 RIP = 19 VV= 3 → VA VA = 35
(n=38) VV Roller pump
All: RIP (Survival
Diagnosis 50%)
PPHN Sepsis
Pertussis
HSV

Paediatrics Alive = 12 RIP = 8 VV= 1 VA = 19

(n=20) (VV = 1) (all VA) Diagnosis
Group A Strep (Survival
60%)

With thanks to Lynn Pereira