الفهرس | Only 14 pages are availabe for public view |
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. |