LIMITATIONS OF STRATEGIES THAT FOCUS ON RAISING BLOOD PRESSURE
Z Slavik *
Department of Paediatrics, Royal Brompton Hospital, London, UK. *
Definition of systemic hypotension in children with sepsis from Pediatric Sepsis Consensus Conference sparked controversy in recent publication (1, 2). As much as the discussed age variation in systolic blood pressure remains important for the above definition, there is some doubt about systolic blood pressure being the best maker of hemodynamic disturbance in critically ill children with sepsis.

Systemic arterial hypotension in septic shock is related to systemic arterial vasodilatation, relative or absolute hypovolemia and myocardial dysfunction.

Aggressive fluid resuscitation is accepted as the best way to improve end-organ perfusion in the early management of septic shock (3). This effort is not without potential side effects of fluid overload, leading to tissue swelling and subsequent organ dysfunction (e.g. ARDS, ascites with renal impairment, pleural effusions with increased ventilatory support) (4). Hemodilution with hypoalbuminemia and ongoing capillary leak syndrome make tissue oedema even more difficult to treat. Choice of the best resuscitation fluid in each individual patient remains controversial and may depend on the underlying cause of sepsis (3-5). Administration of catecholamines and selective systemic arterial vasoconstrictors, vasopressin or terlipressin may increase systemic blood pressure with unpredictable adverse effects on splanchnic perfusion, renal and myocardial function (6). Phosphodiesterase inhibitors (enoximone, milrinone) and corticosteroids may have a role in management of pediatric fluid and catecholamine resistant septic shock in future (7, 8).
References :
  1. Goldstein B, Giroir B, Randolph A. International Pediatric sepsis consensus conference: Definition for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2-8.
  2. Gebara BM, Letter to the Editor, Pediatr Crit Care Med 2005;6:500.
  3. Sparrow A, Hedderley T, Nadel S., et al. Choice of fluid for resuscitation of septic shock. Emerg Med J 2002;19:114-116.
  4. Ranjit S, Kissoon N, Jayakumar I, Aggressive management of dengue shock syndrome may decrease mortality rate: A suggested protocol. Pediatr Crit Care Med 2005;6:412-419.
  5. Khandelwal P, Bohn D, Carcillo JA, Thomas NJ.Pro/con clinical debate: do colloids have advantages over crystalloids in paediatric sepsis? Crit Care 2002;6:286-288.
  6. Berg RA. A long-acting vasopressin analog for septic shock: Brilliant idea or dangerous folly? Pediatr Crit Care Med 2004;5:188-189.
  7. Ringe HIG, Varnholt V, Gaedicke G. Cardiac rescue with enoximone in volume and catecholamine refractory septic shock. Pediatr Crit Care Med 2003;4:471-475.
  8. Pizzaro CF, Troster EJ, Damiani D, Carcillo JA. Absolute and relative adrenal insufficiency in children with septic shock. Crit Care Med 2005;33:911-912.
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