الفهرس 
SEPSIS AND SEPTIC SHOCKOnly 14 pages are availabe for public view
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Abstract
Sepsis is defined as life-threatening organ dysfunction
caused by a dysregulated host response to infection and
―septic shock‖ the subset of sepsis with circulatory and
cellular/metabolic dysfunction associated with a higher risk of
mortality.
It is reasonable to begin vasoactive infusions after 40–60
mL/kg of fluid resuscitation if the patient continues to have
evidence of abnormal perfusion, or sooner if fluid overload
develops. Echocardiography is a rapid, noninvasive,
comprehensive cardiac assessment option for patients
presenting with hemodynamic instability. Doppler-based renal
resistive index (RRI) measurement is a rapid and non-invasive
tool that may be useful to detect renal hypoperfusion and to
measure resistance to arterial blood flow in renal vessels in
intensive care unit (ICU) patients.
I-FABP (Intestinal fatty acid-binding protein) is present
in the cytoplasm of mature enterocytes in the small and large
intestine and is released as soon as the cell membrane integrity
is compromised, thus reflecting the extent of gut damage. It is
used as a biomarker of mucosal injury and other diseases
affecting the intestine
The aim of the current study was the assessment of
hemodynamic effects of different vasoactive drugs doapamine, adrenaline and noradrenaline in septic shock in pediatric age
group and comparing their effects on renal artery resistive
index and gut ischemia indicated by IFABP.
This prospective observational study involved 60 patients
with septic shock presented to Pediatric Intensive Care Unit,
Children’s hospital, Ain Shams University who were chosen
after consideration of inclusion and exlusion criteria. They were
divided into three groups according to vasoactive medication
used group 1 received dopamine, group 2 received
noradrenaline and group 3 received adrenaline and evaluated
before starting vasoactive drug and for four point times after
2hours, 6 hours, 12 hours and after twenty four hours. Every
patient received at the start of study fluid bolus on 20 cc/kg and
underwent passive leg raising test for 10 minutes with full
evaluation after each of them.
Bedside full history taking and detailed clinical
examination, functional echocardiography including (cardiac
index, ejection fraction, fractional shortening, systemic vascular
resistance and IVC distensibility index) and renal duplex
measuring renal resistive index and the following laboratory
investigation were performed: CBC, PT, serum creatinine,
albumin, venous blood gases, serum lactate and serum
intestinal fatty acid binding protein.The age of patients ranged from 1months to 18 years
with median 11 to 27 months. The most common cause of
sepsis was pneumonia (63%) followed by gastroenteritis (15%).
pSOFA score was used to assess severity at start of study
and revealed that patient who had received noradrenaline and
adrenaline had higher SOFA score (12.7and 12.3 respectively)
versus who received dopamine 9.4. Mechanical ventilation was
used in 85% of patients who received noradrenaline and 100%
of patients who received adrenaline and only 45% of who
received dopamine.
Mortality rate was high in group who received adrenaline
(85%) and noradrenaline (45%) than those who received
dopamine (25%)
The most common organism causing sepsis in our study
was klebsiella (61%) followed by candidia (26%) and
satphyloccus (18%) and acinetobacter (18%).
VIS score was used to assess dose of vasocative drugs
used. Patients who received adrenaline and noradrenaline had
reached higher VIS score than others.
Noradrenaline and dopamine had caused significant
increase in mean arterial blood pressure that that caused by
adrenaline.Adrenaline and dopamine were found to increase cardiac
index significantly more than noradrenaline however ejection
fraction and fractional shortening were found to be higher in
dopamine compared to noradrenaline.
On the other hand dopamine and noradrenaline were
more significantly effective than adrenaline in increasing
systemic vascular resistance.
Lastly we found IVCCI decrease significantly in groups
who received adrenaline and noradrenaline than those who
received dopamine.
Renal artery resistive index was found to significantly
lower in group who received dopamine than those who received
noradrenaline.
Oxygenation indices were worse in patients who
received adrenaline as we found PaO2/FiO2 ratio was
statistically significant higher in dopamine and noradrenaline
group than adrenaline group also SVO2 was statistically
significant higher in dopamine group than adrenaline and
noradrenaline group.
Lactate levels were significantly higher in patients who
received adrenaline and noradreanline than those who received
dopamine.Serum intestinal fatty acid binding protein (IFABP) was
found elevated at the start of the study and showed dynamic
decrease allover study in three groups but difference didn’t
approach statistical significance.
We found that passive leg raising test is more effective
than fluid bolus in increasing mean arterial pressure (MAP),
central venous pressure (CVP), cardiac index (CI) and
decreasing inferior venacave collapsibility index (IVCCCI)
with statistical significance difference but results doesn’t reach
statistical significance when compared systemic vascular
resisrance index (SVRI) and heart rate.
Thus, further studies on larger scales with longer
duration are warranted to get more detailed data about
hemodynamic effect of different vasoactive medications.