¿CA vs CVC? Involvements.
Dr. Guillermo Luis Montalván González
Paediatric Intensive Care Unit.
Hospital Pediátrico Docente “Eliseo Noel Caamaño” Matanzas Cuba.
Email: gmontalvan.mtz@infomed.sld.cu
The article of Joe Brierley and Mark J. Peters (1) is interesting,
because add new evidences to the hemodynamic patterns that shows the
pediatric patient in septic shock, besides doing it with a noninvasive
cardiac output device ( Doppler ultrasonography).
Each day increases in quantity and quality the publications they improve
the understanding of the initial handling of the pediatric patient with
severe sepsis and septic shock (2,3,4 ) . Recent guidelines and
initiatives show that the progression from sepsis to severe sepsis and
septic shock can be effectively halted and reversed with timely
therapeutic interventions by recognizing the importance of the
reconnaissance early of the sepsis with hypoperfusion.
However, the article is confused in the way that shows the profiles
hemodynamic of the patients according to presenting fluid-resistant
septic shock secondary to central venous catheter-associated infection and
community-acquired sepsis .
I think that the proposed hypothesis not trusts make evident solid
and yes maybe to the personal experience of the investigators and this
takes away you quality to the investigation.
I think that it is very simplistic the analysis of the because of these
finds, in a so complex phenomenon as the sepsis, where many factors as the
genetics, premorbid illness , age, sex, characteristics of infecting
pathogens, source control, patient response to infection, the functional
reserve of the patient, and the degree of dysfunction of organs plays
important roles (5).
For the professional it is important knowledge that the child with septic
shock resistant to fluids can show varied hemodynamic patterns and the
therapeutic employee will depend of these finds, but the hemodynamic
presentation depends of many factors implied, and this article does not
give clarity in the topic. It is important to consider that the sepsis,
severe sepsis and the septic shock does not function as a simple system of
causes-effect, existing much more complex mechanisms implied in the
pathogeny.
Still in the child the signs they correspond to high suspicion of
sepsis + organs dysfunction ( severe sepsis, septic shock), will be the
important elements to value for the professional the capillary refill,
quality of the peripheral pulses, shock index, mental status, central and
peripheral temperatures, urine output and also when results possible the
measurement of the SvO2, lactate levels, anion gap acidosis and cardiac
output(6).
With these tools we show an impressive reduction of the mortality for
sepsis (97% in the late 1960 to as low as 2% in 2003 in previously healthy
children) (7) .
In the middle of the important international effort to foment the
reconnaissance and manage early of the severe sepsis and septic shock, do
you see it code show encouraging results.
I think that the article is a step more in the arduous and important task
to improve the knowledge of the problem.
If see it of this way the article takes importance.
References:
1. Brierley J. , Peters M J. Distinct Hemodynamic Patterns of Septic Shock
at Presentation to Pediatric Intensive Care. Pediatrics 2008 122: 752-759.
2. Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Hemodynamic support in
fluid-refractory pediatric septic shock. Pediatrics. 1998;102(2).
3. De Oliveira CF, de Oliveira DS, Gottschld AF et al.: ACCM/PALS
maemodynamic support guidelines for paediatric septic shock: an outcomes
comparoson with and without monitorinng central venous oxigen saturation.
Intensive Care Med.(2008).
4. Han Y, Carcillo J, Dragotta M, et al. Early reversal of
pediatricneonatal septic shock by community physicians is associated with
improved outcome. Pediatrics. 2003;112(4):793–799
5. R. Scott Watson, Carcillo JA. The Epidemiology of Severe Sepsis in
Children in the United States. Am J Respir Crit Care Med Vol 167.pp
695–701,2003.
6. Carcillo JA et al.Goal-Directed Management of Pediatric Shock in the
Emergency Department. Clin Ped Emerg Med 8:165-175 2007
7. Carcillo JA, Han YY, Kissoon N. Sepsis guidelines and the global
pediatrics sepsis initiative: implications for treatment. Future
Medicine.Therapy (2008) 5(4), 301- 394.
Conflict of Interest:
None declared
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