1Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
2Blizard Institute, Queen Mary University of London, London, UK
Correspondence to
Dr Constantinos Kanaris, Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; ckanaris@doctors.net.uk
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With a variety of vasoactive agents available with differing modes of action and little in the way of high-quality evidence from the paediatric population, starting and choosing the right inotrope in children with severe sepsis can be a difficult decision. In this paper we discuss basic pharmacology and physiology as well as a reasoned approach on when and how to use inotropes in a general paediatric and emergency department setting until the paediatric critical care retrieval team arrives.
Cardiovascular physiological considerations in children with septic shock
There are numerous types of shock in paediatric patients, each meriting a different approach to management. What is universal across the spectrum of managing shock is that the main goal is to restore oxygen delivery to vital organs. Improving the balance between oxygen delivery and utilisation is of essence. It is also worth considering that cardiovascular management of a term newborn with septic shock is slightly different as clinicians have to ascertain whether the patient is in transitional circulation or not. Transitional circulation includes patent ductus arteriosus and haemodynamic change once the duct is closed. Echocardiographic assessment can help but this requires a high level of skill. The remit of this paper addresses the clinical management of septic shock in infants and children without transitional circulation as discussed above; the latter are managed differently usually within the setting of the neonatal intensive care unit (NICU).
Consider the following oxygen delivery equation:
A more detailed version of this formula is:
This formula dictates that for oxygen to be efficiently delivered, there needs to be adequate haemoglobin and that it is well saturated with oxygen (arterial saturations). Oxyhaemoglobin subsequently needs to be pumped around the circuit effectively (cardiac output (CO)) and for this to be achieved we need adequate blood pressure (BP).
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