Background

The gut is one of the first organs, after skin and kidneys, which experience a loose of blood flow during a shock. Hypoperfusion first damages superficial layers and if the situation is not solved, damage goes deeper. Moreover, reperfusion also plays its own role in gut injury.

Gut barrier dysfunction allows millions of microorganisms and inflammatory products reach the systemic circulation. Thus, transmural necrosis is the open door to peritonitis, multi organ dysfunction syndrome and even a 32-86% of mortality rate. This capacity to initiate and propagate sepsis is the main reason why a rapid diagnosis and intervention is needed. Although this important role, the gut has been the great forgotten.

Physical examination continues to be the main tool for the diagnosis before bloody stools or abdominal hypertension are already present. But what can we do to monitor the gut before that?

Biomarkers as citrulline or intestinal fatty acid-binding protein have been studied but none of them by their own has provide satisfactory results. Microcirculation and near-infrared spectroscopy are promising but they are not routinely widespread and they are under discussion. Image studies as abdominal radiography, echography or computed tomography and intravesical pressure measurements are other options with advantages but disadvantages also.

In conclusion, there is no only a method to assure gut barrier integrity but the most important things are what are we doing to monitor the gut in a shocked child? Is it enough? Can we improve it?

Background

Advanced haemodynamic monitoring is recommended in the 2017 ACCM sepsis guidelines. " For patients with persistent shock...a more accurate measurement of CO may be warranted... pulmonary artery, PiCCO, femoral artery or thermodilution catheters and/or CO estimated by Doppler ultrasound...."; and that haemodynamic support should be "directed to goals of ScvO₂ greater than 70% and cardiac index 3.3–6.0 L/min/m²”.

Objectives

This presentation asks the question - "what is the evidence for these recommendations?"

Methods

Literature review.

Results

There has only been one paediatric RCT of early goal directed therapy (EGDT), which included targeting ScvO₂ > 70%. This was conducted in a single centre in Brazil and showed a significant reduction in mortality. However, three recent large mulitcentre trials of EGDT in adults showed no benefit - consequently EGDT is no longer recommended in the adult sepsis guidelines. There is no trial data to support any specific CO target in children. A recent observational study in paediatric ED showed lactate clearance was associated with decreased organ dysfunction at 48 hours; and in adults, 6 randomized controlled trials evaluating lactate-guided resuscitation of patients with septic shock showed significant reduction in mortality compared to resuscitation without lactate monitoring. A recent single centre RCT of echocardiography guided resuscitation in children showed improvements in both shock reversal and shock reversal time.

Conclusion

There is no convincing trial data to support the use of EGDT or specific ScvO₂ or CO targets in children with septic shock. Lactate clearance and echocardiography guided resuscitation are promising and require further evaluation and clinical trials.