{"id":25495,"date":"2018-02-27T00:00:00","date_gmt":"2018-02-26T21:00:00","guid":{"rendered":"https:\/\/tatd.org.tr\/blog\/2018\/02\/27\/pediatrik-sepsiste-guncelleme-derleme\/"},"modified":"2021-11-20T03:04:41","modified_gmt":"2021-11-20T00:04:41","slug":"pediatrik-sepsiste-guncelleme-derleme","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/en\/haber-ve-duyuru\/pediatrik-sepsiste-guncelleme-derleme\/","title":{"rendered":"Pediatrik Sepsiste G\u00fcncelleme: Derleme"},"content":{"rendered":"

Kawasaki T. Update on pediatric sepsis: a review.<\/strong><\/p>\n

J Intensive Care 2017<\/strong> Jul 20,5:47<\/strong> doi: 10.1186\/s40560-017-0240-1.<\/p>\n

Haz\u0131rlayan: Dr. \u00d6zge Duman Atilla<\/strong><\/p>\n

\u00d6zet <\/strong><\/p>\n

Giri\u015f: <\/strong>Sepsis, d\u00fcnyada \u00e7ocuklar aras\u0131nda mortalitenin \u00f6nde gelen sebeplerinden biridir. Ne yaz\u0131k ki, buna ra\u011fmen, g\u00fcvenilir kan\u0131tlar pediatrik sepsiste yetersizdir ve klinik uygulamadaki pek \u00e7ok husus uzman g\u00f6r\u00fc\u015f\u00fcne ve yeti\u015fkin sepsisuygulamalar\u0131ndaki kan\u0131tlara dayanmaktad\u0131r. Surviving Sepsis Campaign 2012 k\u0131lavuzu yay\u0131nland\u0131\u011f\u0131ndan beri en g\u00fcncel bulgular pediatrik sepsisin derinlemesine anla\u015f\u0131lmas\u0131n\u0131 sa\u011flad\u0131.<\/p>\n

Ana metin: <\/strong>Hemodinamik y\u00f6netim ve antimikrobiyallerin zaman\u0131nda kullan\u0131m\u0131 ile ilgili bilgiler eklendi. Pediatrik \u201csepsis bundles (demet)\u201d kalite iyile\u015ftirme giri\u015fimlerinin, bir\u00e7ok merkez taraf\u0131ndan klinik sonu\u00e7larda ba\u015far\u0131l\u0131 oldu\u011fu rapor edildi.\u00a0 Dahas\u0131, k\u0131sa bir s\u00fcre \u00f6nce yay\u0131nlanan k\u00fcresel bir epidemiyolojik \u00e7al\u0131\u015fma (SPROUT \u00e7al\u0131\u015fmas\u0131) sadece demografik, terap\u00f6tik giri\u015fimler ve prognostik sonu\u00e7lar\u0131 ortaya koymakla kalmad\u0131, ayn\u0131 zamanda \u00e7ocuk pediatrik sepsis tan\u0131m\u0131 konusundaki uygunsuzlu\u011fu da ayd\u0131nlatt\u0131.<\/p>\n

Sonu\u00e7lar: <\/strong>G\u00fcncellenmi\u015f bu bilgilerle pediatrik sepsisin daha da ilerleme kaydedece\u011fi d\u00fc\u015f\u00fcn\u00fclmektedir. Buna ek olarak, gelecekteki ara\u015ft\u0131rmalar\u0131n dayand\u0131\u011f\u0131 temel verilerin SPROUT \u00e7al\u0131\u015fmas\u0131 yoluyla olu\u015fturulmas\u0131 anlaml\u0131d\u0131r.<\/p>\n

Anahtar kelimeler: <\/strong>sepsis, septic shock, pediatric, child, epidemiology, surviving sepsis campaign, antibiotics, hemodynamic management, algorithm, prognosis<\/p>\n

Giri\u015f<\/strong><\/p>\n

Sepsis, altta yatan sa\u011fl\u0131k problemine bakmaks\u0131z\u0131n bir\u00e7ok \u00e7ocu\u011fu etkileyen hayat\u0131 tehdit eden bir durumdur (1). Sepsis, geli\u015fmi\u015f \u00fclkelerde bile \u00e7ocuklar aras\u0131nda \u00f6nde gelen \u00f6l\u00fcm nedenlerinden biri olarak an\u0131lmaktad\u0131r. Demografik veriler a\u00e7\u0131k\u00e7a g\u00f6stermese de, di\u011fer nedenlerden dolay\u0131 \u00f6ld\u00fc\u011f\u00fc rapor edilen bir\u00e7ok \u00e7ocuk do\u011frudan do\u011fruya sepsisten \u00f6lmektedir.<\/p>\n

Pediatrik sepsis y\u00f6netimi, 2008 (2) ve 2012 (3) y\u0131llar\u0131nda Surviving Sepsis Campaign k\u0131lavuzlar\u0131nda (SSCK) sistematik derlemeler yoluyla kapsaml\u0131 olarak savunuldu. Ne yaz\u0131k ki buna ra\u011fmen, bir\u00e7ok \u00f6neri ve destekleme halen d\u00fc\u015f\u00fck kaliteli kan\u0131t ve uzman g\u00f6r\u00fc\u015f\u00fc ve zaman zaman da yaln\u0131zca eri\u015fkin sepsis kan\u0131tlar\u0131na dayanmaktad\u0131r. Dahas\u0131 SSCK\u2019nun son s\u00fcr\u00fcm\u00fc, pediatrik sepsis y\u00f6netiminin \u00f6zel tan\u0131mlamalar\u0131n\u0131 i\u00e7ermemektedir (4). Bu derleme SSCK 2012’den sonra yay\u0131nlanan pediatrik sepsis ile ilgili g\u00fcncellenmi\u015f bilgi ve en \u00e7ok konu\u015fulan konular \u00fczerine odaklanmaktad\u0131r (3).<\/p>\n

Pediatrik sepsis tan\u0131m\u0131<\/strong><\/p>\n

Son iki dekat, sepsis hem eri\u015fkinler hem \u00e7ocuklar i\u00e7in \u201cenfeksiyonun neden oldu\u011fu sistemik inflamatuar cevap sendromu (SIRS)\u201d olarak tan\u0131mlanm\u0131\u015ft\u0131r (5-7). Bu tan\u0131mlama ne yaz\u0131k ki, herhangi bir organ i\u015flev bozuklu\u011funun olmad\u0131\u011f\u0131 influenzaenfeksiyonu gibi hafif durumlar\u0131 bile \u00e7ok geni\u015f kapsad\u0131\u011f\u0131 i\u00e7in uzun s\u00fcredir ele\u015ftirilmektedir. Ger\u00e7ekte,\u00a0 Churpek ve arkada\u015flar\u0131 hastaneye yat\u0131r\u0131lan eri\u015fkin hastalar\u0131n neredeyse yar\u0131s\u0131n\u0131n, hastanede kald\u0131klar\u0131 s\u00fcre i\u00e7erisinde en az bir kez iki veya daha fazla SIRS kriteri g\u00f6sterdi\u011fini ortaya koyarken (8), Kaukonen ve arkada\u015flar\u0131 baz\u0131 enfeksiyonlu ve en az bir organ i\u015flev bozuklu\u011fu olan yeti\u015fkin yo\u011fun bak\u0131m hastalar\u0131n\u0131n yakla\u015f\u0131k% 12’sinin SIRS kriterleri a\u00e7\u0131s\u0131ndan negatif oldu\u011funu, ancak mortalite oranlar\u0131n\u0131n halen \u00f6nemli oldu\u011funu g\u00f6stermi\u015ftir (9). \u00a0Bu bulgular, SIRS kriterlerinin, risk alt\u0131ndaki hastalar\u0131 taramak i\u00e7in uygun bir ara\u00e7 olmad\u0131\u011f\u0131n\u0131 ve organ i\u015flev bozuklu\u011funun \u015fiddetinin, mortalite riski y\u00fcksek olan hastalar\u0131 tan\u0131mlamak i\u00e7in SIRS\u2019\u0131n yerine ge\u00e7ebilece\u011fini ima etmektedir.<\/p>\n

Bu konular dikkate al\u0131narak, yeni sepsis kriterleri, sepsisi bir veya daha fazla organ i\u015flev bozuklu\u011fu ile komplike olan enfeksiyon olarak tan\u0131mlayarak 2017\u2019de \u201cSepsis-3\u201d de savunuldu (10).Organ sistemleri i\u015flev bozuklu\u011fu SOFA (Sequential Organ FailureAssessment) skorunda 2 veya daha fazla art\u0131\u015fla de\u011ferlendirilmektedir. Bu ge\u00e7i\u015fin ana amac\u0131 gelecekteki tedavi \u00e7al\u0131\u015fmalar\u0131nda iyile\u015ftirme i\u00e7in daha a\u011f\u0131r hastalara odaklanmakt\u0131r (10).<\/p>\n

Ne yaz\u0131k ki, sepsis tan\u0131m\u0131ndaki bu de\u011fi\u015fiklik \u015fu an i\u00e7in sadeceyeti\u015fkin n\u00fcfusa uygulanmaktad\u0131r (10). \u00c7ocuklarda uzla\u015f\u0131 tan\u0131m\u0131na gelince (7), \u00f6zellikle pediatrik SIRS ve organ i\u015flev bozuklu\u011fu kriterleri ile ilgili yeti\u015fkin tan\u0131m\u0131na benzer ele\u015ftirilere ek olarak di\u011fer konular da belirtilmi\u015ftir.\u00a0 Pediatrik SIRS kriterlerinde takipne e\u015fi\u011fi, \u00f6rne\u011fin eri\u015fkinlerdeki normal aral\u0131kla bile\u00e7ak\u0131\u015fabilir (6-12 ya\u015f \u00e7ocuklar i\u00e7in 18 soluk\/dk, 13-18\u00a0 ya\u015f ad\u00f6lesanlar i\u00e7in 14 soluk\/dk) (7). Her organ yetmezli\u011fi i\u00e7in standardize edilmi\u015f kriterler (7) klinik sonu\u00e7larla ilgili kan\u0131tlara dayanmamaktad\u0131r. Dahas\u0131, birka\u00e7 \u00e7al\u0131\u015fma, doktorun klinik karar\u0131 ve uzla\u015f\u0131 kriterleri aras\u0131nda \u015fiddetli sepsis tan\u0131s\u0131nda yaln\u0131zca yakla\u015f\u0131k 2\/3 oran\u0131nda orta d\u00fczey bir uyum oldu\u011funu ortaya koydu [11-13], a\u00e7\u0131k\u00e7as\u0131 SIRS konseptine dayanan pediatrik sepsis g\u00fcncel uzla\u015f\u0131 kriterleri klinik olarak tehlikeli hastalar\u0131n belirlenmesinde etkili bir rol oynamamaktad\u0131r. Pediatrik sepsisin, yak\u0131n gelecekte eri\u015fkin Sepsis-3\u2019e g\u00f6re organ i\u015flev bozuklu\u011fu skorlamas\u0131 temelinde yeniden tan\u0131mlanmas\u0131 \u015fiddetle arzulanmaktad\u0131r (13,14).<\/p>\n

Epidemiyoloji <\/strong><\/p>\n

Pediatrik sepsis epidemiyolojisi farkl\u0131 ya\u015f, pop\u00fclasyon ve tan\u0131sal kriterler nedeni ile \u00e7al\u0131\u015fmadan \u00e7al\u0131\u015fmaya de\u011fi\u015fir. Watson ve arkada\u015flar\u0131 ilk olarak 1995 y\u0131l\u0131nda ABD’de yedi eyalette 19 ya\u015f\u0131n alt\u0131ndaki \u00e7ocuklarda \u015fiddetli sepsisin n\u00fcfusa dayal\u0131 insidans ve sonu\u00e7lar\u0131n\u0131 bildirdi(1).\u0130nsidans her y\u0131l 1000 \u00e7ocuk ba\u015f\u0131na 0.56 vaka (1000’de 5.16) ve ya\u015fla \u00e7arp\u0131c\u0131 bir d\u00fc\u015f\u00fc\u015f g\u00f6sterdi (10-14 ya\u015f grubunda 1000\u2019de 0.20). Hastane mortalitesi% 10.3, ya\u015fla birlikte \u00e7ok az farkl\u0131l\u0131k g\u00f6sterdi ve komorbiditesi bulunan \u00e7ocuklar aras\u0131nda daha y\u00fcksekti.<\/p>\n

Son zamanlarda ABD\u2019den yap\u0131lan birka\u00e7 \u00e7al\u0131\u015fma yeni bulgular ekledi. Watson’un \u00e7al\u0131\u015fmas\u0131 ile ayn\u0131 pop\u00fclasyonun takibinde (1), Hartman ve arkada\u015flar\u0131 1995\u2019den 2005\u2019e prevelans\u0131n %81 oran\u0131nda s\u00fcrekli artt\u0131\u011f\u0131n\u0131, 2005\u2019de 1000 \u00e7ocukta 0.89 vakaya ula\u015ft\u0131\u011f\u0131n\u0131 bildirdi (15).Di\u011fer taraftan vaka-\u00f6l\u00fcm oran\u0131 bu on y\u0131l boyunca % 10.3\u2019ten % 8.9\u2019a d\u00fc\u015ft\u00fc (15). Balamuth ve arkada\u015flar\u0131, ABD’deki 44 \u00e7ocuk hastanesinin veri taban\u0131na dayanarak, 2004-2012 y\u0131llar\u0131 aras\u0131nda hastaneye yat\u0131r\u0131lan t\u00fcm \u00e7ocuklarda (18 ya\u015f veya alt\u0131nda) ciddi sepsisprevelans\u0131n\u0131n\u00a0 % 3.7’den % 4.4’e y\u00fckseldi\u011fini buldu (16). \u015ea\u015f\u0131rt\u0131c\u0131 bir \u015fekilde, biri ciddi sepsis\/septik \u015fok i\u00e7in Uluslararas\u0131 Hastal\u0131k S\u0131n\u0131flamas\u0131 9.bask\u0131 Klinik Modifikasyon (ICD-9) kodlar\u0131, di\u011feri en az bir organ i\u015flev bozuklu\u011fu ve enfeksiyon i\u00e7in ICD-9 kodu (modifiyeAngus kriterleri (17) olan iki tan\u0131sal pop\u00fclasyon aras\u0131nda mortalite oran\u0131 \u00f6nemli derecede farkl\u0131 idi (%21.2\u2019ye kar\u015f\u0131 %8.2) (16). Ayn\u0131 veri taban\u0131n\u0131 kullanarak, Ruth ve arkada\u015flar\u0131 %14.4 mortalite oran\u0131 (2004\u2019de %18.9, 2012\u2019de %12; do\u011fumdan 19 ya\u015fa kadar)\u00a0 ile ili\u015fkili bu hastanelerin pediatrik yo\u011fun bak\u0131mlar\u0131nda,\u00a0 ciddi sepsisprevelans\u0131n\u0131\u00a0 %7.7 (2004\u2019de %6.2, 2012 \u2018de %7.7) olarak g\u00f6sterdi (18).<\/p>\n

Ge\u00e7ti\u011fimiz g\u00fcnlerde 9 pediatrik yo\u011fun bak\u0131m ve 22 genel yo\u011fun bak\u0131m \u00fcnitesinden olu\u015fan Avusturalya ve Yeni Zelanda Pediatrik Yo\u011fun Bak\u0131m kay\u0131tlar\u0131ndan b\u00fcy\u00fck \u00f6l\u00e7ekli bir epidemiyolojik veri \u00e7\u0131kt\u0131. Schlapbach ve arkada\u015flar\u0131, 2002 ve 2013 y\u0131llar\u0131 aras\u0131nda geriye d\u00f6n\u00fck olarak kay\u0131tlar\u0131 (<16 ya\u015f) ara\u015ft\u0131rd\u0131; invazif enfeksiyon, sepsis ve septik \u015foklu hastalar\u0131n toplam yo\u011fun bak\u0131m yat\u0131\u015flar\u0131n\u0131n s\u0131ras\u0131yla %6.9, %2.9 ve %2.1\u2019ini olu\u015fturdu\u011funu g\u00f6sterdi. \u00c7ocuklarda yo\u011fun bak\u0131m genel mortalite oran\u0131 %3\u2019den y\u00fcksekti, her tan\u0131 grubu i\u00e7in yo\u011fun bak\u0131m mortalite oranlar\u0131 %3.9, %5.6 ve %17 idi. Ek olarak, \u00e7al\u0131\u015fman\u0131n ilk ve ikinci yar\u0131s\u0131 kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda septik \u015fok i\u00e7in de\u011fil\u00a0 (OR 0.79, %95 GA 0.61-1.01) ancak invazifenfeksiyon (OR 0.72, %95 GA 0.56-0.94) ve sepsis (OR 0.66, %95 GA 0.47-0.93) i\u00e7in riske g\u00f6re ayarlanm\u0131\u015f mortalite \u00f6nemli \u00f6l\u00e7\u00fcde azalm\u0131\u015ft\u0131 (19).<\/p>\n

2013 y\u0131l\u0131nda, k\u00fcresel \u00e7apraz kesitsel \u00e7al\u0131\u015fma (SPROUT \u00e7al\u0131\u015fmas\u0131) geli\u015fmi\u015fve geli\u015fmekte olan \u00fclkeler dahil, 26 \u00fclke ve 128 merkezde yap\u0131ld\u0131 (20). Bu d\u00f6n\u00fcm noktas\u0131 \u00e7al\u0131\u015fma %25 hastane mortalitesi ile ili\u015fkili ciddi sepsis prevelans\u0131n\u0131 yo\u011fun bak\u0131mdaki \u00e7ocuklar aras\u0131nda (< 18 ya\u015f) %8.2 olarak g\u00f6sterdi ki, geli\u015fmi\u015f ve geli\u015fmekte olan \u00fclkeler aras\u0131nda ve ya\u015fa g\u00f6re fark yoktu (20). Di\u011fer taraftan, bu \u00e7al\u0131\u015fma hasta demografikleri, enfeksiy\u00f6z hastal\u0131\u011f\u0131n karakteristikleri ve terap\u00f6tik m\u00fcdahalelerin ayr\u0131nt\u0131lar\u0131n\u0131 da a\u00e7\u0131klad\u0131 (20). Dahas\u0131, Avrupa PYB\u00dc (pediatrik yo\u011fun bak\u0131m \u00fcnitesi) ve ABD PYB\u00dc hastalar\u0131n\u0131 kar\u015f\u0131la\u015ft\u0131ran SPROUT \u00e7al\u0131\u015fmas\u0131 alt grup analizleri, PYB\u00dc yata\u011f\u0131n\u0131n bulunabilirli\u011finin eri\u015fkin septik hastalardaki bulgulara benzer olarak (22) geli\u015fmi\u015f \u00fclkelerde ciddi sepsisli \u00e7ocuklar\u0131n mortalitesinietkiledi\u011fini destekledi (21). Tablo 1, Japon ve \u0130talyan PYB\u00dc\u2019den gelen verileri de i\u00e7eren geli\u015fmi\u015f \u00fclkelerin g\u00fcncel pediatrik sepsis epidemiyolojik \u00e7al\u0131\u015fmalar\u0131n\u0131 g\u00f6stermektedir (24).<\/p>\n

Bu yeni yay\u0131nlanan epidemiyolojik ara\u015ft\u0131rmalar ayr\u0131ca altta yatan durumlar ve enfeksiyon b\u00f6lgelerini de bildirmektedir. Hartman ve arkada\u015flar\u0131, 2000 ve 1995 ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda 2005\u2019de, altta yatan komorbiditesi olan ciddi sepsisli \u00e7ocuklar\u0131n oran\u0131nda azalma bildirdi (2005\u2019de %49.7; 2000\u2019de %58.8; 1995\u2019de %63.3). N\u00f6romusk\u00fcler, kardiyovask\u00fcler ve respiratuar hastal\u0131klar o y\u0131llarda en s\u0131k komorbiditeler idi. \u00d6zellikle yenido\u011fanlar aras\u0131nda, 2000 ve 1995\u2019e g\u00f6re 2005\u2019de enfeksiyon b\u00f6lgeleri \u00e7ok daha az tespit edilmi\u015fti (2005\u2019de %54, 2000\u2019de %74 ve 1995\u2019de %80; p<0.001).\u00a0 Respiratuar enfeksiyonlar, bakteriyeminin ard\u0131ndan (2005\u2019de %18.1, 2000\u2019de %26.6 ve 1995\u2019de %20.7) t\u00fcm belirlenen vakalar\u0131n neredeyse yar\u0131s\u0131ndan fazlas\u0131n\u0131 olu\u015fturarak (2005\u2019de %48.9, 2000\u2019de %45 ve 1995\u2019de %47.1) en s\u0131k enfeksiyon b\u00f6lgesi oldu (15). Ruth ve arkada\u015flar\u0131, bu \u00e7ok merkezli veritaban\u0131na g\u00f6re,\u00a0 bir komorbiditesi olan ciddi sepsisli \u00e7ocuklar\u0131n oran\u0131n\u0131n, ABD\u2019de \u00f6nceki ulusal tahminlerden (%49) \u00e7ok daha y\u00fcksek olarak 2002\u2019de %64.9 dan 2012\u2019de %76.6\u2019a y\u00fckseldi\u011fini g\u00f6sterdi(p<0.001) ve bu \u00e7ocuklar\u0131n mortalite oranlar\u0131 herhangi bir komorbiditesi olmayan \u00e7ocuklara g\u00f6re \u00e7ok daha y\u00fcksekti (%15.8\u2019e kar\u015f\u0131 %10.4, p<0.001). Ya\u015f ve organ i\u015flev bozuklu\u011funa g\u00f6re d\u00fczenleme yap\u0131ld\u0131ktan sonra, malignitesi olan \u00e7ocuklarda, malignitesi olmayan \u00e7ocuklara g\u00f6re mortalite riskinin \u00e7ok daha y\u00fcksek oldu\u011fu kan\u0131tland\u0131 (OR 1.93, %95 GA 1.79-2.08). Benzer olarak, hematolojik\/imm\u00fcnolojik hastal\u0131klar (OR 1.49, %95 GA 1.35-1.64) ve kardiyovask\u00fcler bozukluklar (OR 1.41, %95 GA 1.33-1.5) mortalite riskleri olarak bulundu. Varsay\u0131lan enfeksiyon alan\u0131, en s\u0131k kan dola\u015f\u0131m\u0131 ve respiratuar sistem (%67.8 ve %57.2) olmak \u00fczere hastalar\u0131n %91.5\u2019de saptand\u0131 (18). Schlapbach ve arkada\u015flar\u0131, \u00e7ok de\u011fi\u015fkenli analizler sonucunda, pediatrik sepsiste mortalite ile \u00f6nemli \u00f6l\u00e7\u00fcde ili\u015fkili fakt\u00f6rler olarak onkolojik durumlar (OR 1.95, %95 GA 1.41-2.69), kemik ili\u011fi transplantasyonu (OR 2.80, %95 GA 1.76-4.44), kronik n\u00f6rolojik hastal\u0131klar (OR 1.76, %95 GA 1.23-2.52), kronik b\u00f6brek yetmezli\u011fi (OR 3.22, %95 GA 1.43-7.24) ve a\u011f\u0131rl\u0131k belirte\u00e7lerini g\u00f6sterdi. A\u011f\u0131rl\u0131k belirte\u00e7leri, PYB\u00dc\u2019e kabulden sonraki ilk saat i\u00e7inde mekanik ventilasyon uygulamas\u0131 (OR 3.77, %95 GA 2.97-4.77), ekstrakorporeal membran oksijenasyon (ECMO) kullan\u0131m\u0131 (OR 2.47, %95 GA 1.46-4.16) ve renal replasman tedavisi (OR 4.68, %95 GA 3.43-6.40) ve akut respiratuar distres sendromu komplikasyonunu (OR 1.53, %95 GA 1.01-2.32) i\u00e7ermektedir (19). Bu bulgular\u0131n aksine, SPROUT \u00e7al\u0131\u015fmas\u0131 herhangi bir komorbiditenin varl\u0131\u011f\u0131n\u0131n PYB\u00dc mortalitesini \u00f6nemli \u00f6l\u00e7\u00fcde etkilemedi\u011fini g\u00f6sterdi (p=0.35). Mortalite oran\u0131 ise solid organ\/k\u00f6k h\u00fccre transplant\u0131 (%48.2), malignite (%41.4), renal hastal\u0131k (%38.2) ve hematolojik\/imm\u00fcnolojik hastal\u0131\u011f\u0131 (%37.7) olan \u00e7ocuklarda daha y\u00fcksekti. Bu \u00e7al\u0131\u015fma ayr\u0131ca respiratuar sistem (%40) ve kan dola\u015f\u0131m\u0131n\u0131 (%19) en s\u0131k enfeksiyon b\u00f6lgesi olarak g\u00f6sterdi (20).<\/p>\n

Bu \u00e7al\u0131\u015fmalarda epidemiyolojik veriler ve risk fakt\u00f6rleri aras\u0131ndaki farkl\u0131l\u0131klar\u0131n \u00e7al\u0131\u015fma pop\u00fclasyonu, tan\u0131sal tan\u0131mlamalar ve veri tabanlar\u0131n\u0131n do\u011frulu\u011fugundan kaynaklanm\u0131\u015f olabilece\u011fi d\u00fc\u015f\u00fcn\u00fclmektedir.<\/p>\n

Antimikrobialler<\/strong><\/p>\n

Antibiyotiklerin erken verilmesi ve s\u0131v\u0131 resusitasyonu ve vazopress\u00f6r\/inotropik ajanlarla hemodinamik stabilizasyon, sepsisin ba\u015flang\u0131\u00e7 y\u00f6netimi i\u00e7in bir arac\u0131n iki tekeri gibidir. Kumar ve arkada\u015flar\u0131, bu geriye d\u00f6n\u00fck kohort \u00e7al\u0131\u015fmada uygun antibiyotiklerin erken verilmesinin diren\u00e7li veya tekrarlayan hipotansiyon ba\u015flad\u0131ktan sonra eri\u015fkin septik \u015foklu hastalarda daha y\u00fcksek sa\u011f kal\u0131m oranlar\u0131 ile ili\u015fkili oldu\u011funu g\u00f6sterdi (25). Pediatrik sepsiste, Weiss ve arkada\u015flar\u0131 son zamanlarda benzer sonu\u00e7lar bildirmi\u015flerdir (26). PYB\u00dc\u2019de tedavi edilmekte olan ciddi sepsis veya septik \u015foklu 130 \u00e7ocu\u011fu geriye d\u00f6n\u00fck olarak incelediler ve sepsis tan\u0131s\u0131 konduktan sonra uygun antibiyotik tedavisinin 3 saatten daha fazla gecikmesinin PYB\u00dc mortalitesinde ciddi art\u0131\u015fla ili\u015fkili oldu\u011funu (OR 3.92, %95 GA 1.27-12.06) ve organ i\u015flev bozuklu\u011fu olmadan ge\u00e7irilen g\u00fcn say\u0131s\u0131n\u0131n daha az (16\u2019a kar\u015f\u0131 20 g\u00fcn; p=0.04) oldu\u011funu buldular. Bu ili\u015fki, kar\u0131\u015ft\u0131r\u0131c\u0131 fakt\u00f6rler eklendikten sonra dahi devam etti (26). Ancak, ak\u0131lda tutulmas\u0131 gerekir ki, birinci uygun antibiyotik uygulamas\u0131nda ilk 3 saat i\u00e7indeki gecikme Kumar\u2019\u0131n eri\u015fkin \u00e7al\u0131\u015fmas\u0131ndan (25) farkl\u0131 olarak mortalite art\u0131\u015f\u0131na yol a\u00e7mam\u0131\u015ft\u0131r (26).<\/p>\n

Hemodinamik Y\u00f6netim<\/strong><\/p>\n

Erken hedefe y\u00f6nelik tedavi<\/strong><\/p>\n

Rivers ve arkada\u015flar\u0131n\u0131n 2001\u2019de septik \u015foklu eri\u015fkinler i\u00e7in \u00e7arp\u0131c\u0131 mortalite azalmas\u0131 ile \u201cerken hedefe y\u00f6nelik tedavi (EGDT)\u201dyi (%30.5 \u2018a kar\u015f\u0131 %46.5; p=0.009) tan\u0131mlad\u0131\u011f\u0131 yay\u0131ndan beri (27), septik \u015foklu \u00e7ocuklarda ilk hemodinamik y\u00f6netimin k\u00f6\u015feta\u015f\u0131 agresif s\u0131v\u0131 resusitasyonu ve sonras\u0131nda s\u0131v\u0131ya diren\u00e7li \u015fok hastalar\u0131 i\u00e7in\u00a0 inotropik\/vasoaktif destek olmu\u015ftur (2,28,29). De Oliveira ve ark. ciddi sepsis veya s\u0131v\u0131ya diren\u00e7li septik \u015foklu (1 ay-18 ya\u015f) 102 \u00e7ocukda yapt\u0131klar\u0131 RK\u00c7 ile Rivers\u2019\u0131n orijinal EGDT\u2019e benzeyen s\u00fcrekli SCVO2 monitorizasyonu ve ERT transf\u00fczyonunu i\u00e7eren Amerikan Kritik Bak\u0131m Cemiyeti (American College of Critical Care Medicine-ACCM)- Pediatrik \u0130leri Ya\u015fam Deste\u011fi (PALS) algoritmas\u0131n\u0131 ara\u015ft\u0131rd\u0131 ve tedavi grubunda sa\u011f kal\u0131m oranlar\u0131n\u0131n d\u00fczeldi\u011fini (28 g\u00fcnl\u00fck mortalite %11.8\u2019e kar\u015f\u0131 %39.2; p=0.002) bildirdi (30). Ayr\u0131ca Sankar ve arkada\u015flar\u0131 s\u0131v\u0131ya diren\u00e7li septik \u015foku (<17 ya\u015f) olan 120 \u00e7ocukta yapt\u0131klar\u0131 ileriye d\u00f6n\u00fck kohort \u00e7al\u0131\u015fmas\u0131yla SCVO2'nin aral\u0131kl\u0131 \u00f6l\u00e7\u00fcm\u00fcn\u00fcn bile, SCVO2 izlemi yap\u0131lmamas\u0131na g\u00f6re sa\u011f kal\u0131m\u0131n artmas\u0131na katk\u0131da bulunabilece\u011fini \u00f6ne s\u00fcrd\u00fc [31].<\/p>\n

Bununla beraber, son birka\u00e7 y\u0131ld\u0131r, 3 \u00e7ok merkezli RK\u00c7 [ProCESS (32), ARISE (33) ve ProMISe (34)] ve 1 meta-analiz (35) s\u00fcrekli SCVO2 hedefi olmadan standart hemodinamik y\u00f6netimin septik \u015foklu eri\u015fkinlerde EGDT\u2019e e\u015fit etkinlikte oldu\u011funu g\u00f6sterdi. Eri\u015fkin kritik bak\u0131mda son trendler g\u00f6z\u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda, EGDT\u2019nin orijinal formu art\u0131k pediatrik sepsisde uygulanamayacakt\u0131r.<\/p>\n

Hemodinamik de\u011ferlendirme ve monitorizasyon<\/strong><\/p>\n

2012\u2019den beri Surviving Sepsis Campaign demetinin par\u00e7as\u0131 olan laktat klerensinin, yedek monitorizasyon i\u00e7in eri\u015fkinlerde septik \u015fokun neden oldu\u011fu doku hipoksisinin geriye d\u00f6nd\u00fcr\u00fclmesini de\u011ferlendirmede SCVO2 monitorizasyonundan a\u015fa\u011f\u0131 olmad\u0131\u011f\u0131 desteklenmektedir (3). Bu, septik \u00e7ocuklarda da ge\u00e7erli olabilir. Scott ve arkada\u015flar\u0131 yak\u0131n zamanda ciddi sepsisli 77 \u00e7ocu\u011fun (<18 ya\u015f) ileriye d\u00f6n\u00fck kohortunda,\u00a0 serum laktat\u0131 ilk \u00f6l\u00e7\u00fcmden sonraki 2-4 saat i\u00e7inde normalize (<2 mmol\/L) olan hastalarda 48 saatten daha uzun s\u00fcren diren\u00e7li organ i\u015flev bozuklu\u011fu riskinin \u00f6nemli oranda d\u00fc\u015f\u00fck oldu\u011funu (relatif risk (RR) 0.46, %95 GA 0.29-0.73) ortaya koymu\u015ftur (38). Di\u011fer taraftan, ba\u015flang\u0131\u00e7 seviyesinin yaln\u0131zca\u00a0 %10\u2019undan daha fazla laktat klerensi ba\u015far\u0131lan hastalarda organ i\u015flev bozuklu\u011funda ciddi azalma g\u00f6r\u00fclmemi\u015ftir (38).<\/p>\n

\u00d6te yandan, sepsisle ili\u015fkili miyokardial disfonksiyon daha yayg\u0131n bilindi\u011finden, transtorasik ekokardiyografi septik \u00e7ocuklarda hemodinamiyi tekrar tekrar de\u011ferlendirmek i\u00e7in noninvazif bir ara\u00e7 olarak \u00e7ok dikkat \u00e7ekmektedir (39,40). Sankar ve arkada\u015flar\u0131 s\u0131v\u0131ya diren\u00e7li septik \u015foklu 56 \u00e7ocukta (3 ay-7 ya\u015f) sol ventrik\u00fcl diastolik disfonksiyonu prevelans\u0131n\u0131n %41 ve mortalite oran\u0131n\u0131n %43 oldu\u011funu bildirmi\u015ftir (42). Raj ve arkada\u015flar\u0131 30 septik \u015foklu \u00e7ocuk ve ad\u00f6lesan\u0131 ara\u015ft\u0131rd\u0131 (1 ay-21 ya\u015f) ve sol ventrik\u00fcl sistolik, diastolik ve her iki disfonksiyon prevelans\u0131n\u0131 s\u0131ras\u0131yla %37, %33 ve %17 olarak g\u00f6sterdi (42). Dahas\u0131, Abdel-Hady ve arkada\u015flar\u0131, sepsisli 20 miad\u0131nda yenido\u011fan kohortu ile doku doppler g\u00f6r\u00fcnt\u00fclemesinin kullan\u0131m\u0131n\u0131n miyokardial disfonksiyonu saptamada konvansiyonel ekokardiyografiye g\u00f6re daha sensitif oldu\u011funu destekledi (43). Basu ve arkada\u015flar\u0131, septik \u015foklu \u00e7ocuklarda (1-13 ya\u015f) normal ejeksiyon fraksiyonu ve fraksiyonel k\u0131salmaya ra\u011fmen bozulmu\u015f miyokardial performans\u0131 saptamada strain ekokardiyografinin etkinli\u011fini g\u00f6sterdi (44).<\/p>\n

B\u00fcy\u00fck ilgi uyand\u0131ran t\u00fcm bu bulgular ne yaz\u0131k ki ekokardiyografi k\u0131lavuzlu y\u00f6netimin klinik \u00f6nemini, \u00f6zellikle de prognozda, hen\u00fcz tam olarak ara\u015ft\u0131rmam\u0131\u015ft\u0131r. Ranjit ve arkada\u015flar\u0131 septik \u015foklu 48 \u00e7ocu\u011fun (1 ay-16 ya\u015f) ileriye d\u00f6n\u00fck kohortunda, sepsisle ili\u015fkili miyokardial disfonksiyonun ve d\u00fczeltilmemi\u015f hipovoleminin tan\u0131nmas\u0131nda arteryel bas\u0131n\u00e7 monitorizasyonu ile beraber yatakba\u015f\u0131 ekokardiyografinin etkinli\u011fini ve sonras\u0131nda s\u0131v\u0131 ve inotrop\/vasopressorlerin titrasyonunu desteklemektedir (45). Haileselassie ve arkada\u015flar\u0131 yak\u0131n zamanda PYB\u00dc\u2019de sepsisli 23 \u00e7ocukta (<19 ya\u015f) yapt\u0131klar\u0131 geriye d\u00f6n\u00fck kohort \u00e7al\u0131\u015fmada, i\u00e7 kontrol gruplar\u0131na k\u0131yasla septik hastalar\u0131n YB\u00dc\u2019de kal\u0131\u015f s\u00fcreleriyle ili\u015fkili olmayan ancak daha y\u00fcksek laktat d\u00fczeyleri ile korelasyonu olan hem longitudinal hem de sirk\u00fcmferensiyal ciddi y\u00fcklenmesi oldu\u011funu bildirmi\u015ftir (46). Bu \u00e7al\u0131\u015fmalar ka\u00e7\u0131n\u0131lmaz bir bias riski ta\u015f\u0131d\u0131\u011f\u0131ndan pediatrik sepsiste ekokardiyografi k\u0131lavuzlu hemodinamik y\u00f6netimin etkinli\u011fini belirlemek i\u00e7in daha iyi tasarlanm\u0131\u015f b\u00fcy\u00fck \u00e7al\u0131\u015fmalar gerekmektedir.<\/p>\n

S\u0131v\u0131ya yan\u0131t verme durumu<\/strong><\/p>\n

Eri\u015fkin kritik bak\u0131mda, s\u0131v\u0131 cevab\u0131 vol\u00fcm y\u00fck\u00fcnden ka\u00e7\u0131narak bolus s\u0131v\u0131n\u0131n etkinli\u011fini tahminde \u00f6n y\u00fck\u00fcn (intravask\u00fcler vol\u00fcm veya ventrik\u00fcler diastol sonu vol\u00fcm) kendisinden \u00e7ok daha \u00f6nemlidir. Ventile edilen eri\u015fkinlerde sistolik bas\u0131n\u00e7 de\u011fi\u015fimi (SPV), nab\u0131z bas\u0131n\u00e7 de\u011fi\u015fimi (PPV) ve strok vol\u00fcm de\u011fi\u015fimi (SVV) gibi \u00e7e\u015fitli dinamik parametreler s\u0131v\u0131 cevab\u0131n\u0131 de\u011ferlendirmede umut vericidir. Bunlar\u0131n t\u00fcm\u00fc, mekanik ventilasyon siklusundan kaynaklanan arteryel dalga formunun varyasyon analizinden t\u00fcretilir. K\u0131sa s\u00fcre \u00f6nce yay\u0131nlanan SSCK 2016, sepsisli eri\u015fkin hastalarda s\u0131v\u0131 ihtiyac\u0131n\u0131 de\u011ferlendirmek i\u00e7in dinamik indekslerin yararl\u0131 oldu\u011funu ileri s\u00fcrmektedir (4). Di\u011fer taraftan, Gan ve ark., ROC (receiver operating characteristic) e\u011frisi alt\u0131nda kalan alanlar\u0131 kar\u015f\u0131la\u015ft\u0131rarak, ventile edilen \u00e7ocuklarda s\u0131v\u0131 cevab\u0131n\u0131 de\u011ferlendirmede \u00e7e\u015fitli statik ve dinamik indekslerin sistematik bir derlemesini ger\u00e7ekle\u015ftirmi\u015ftir (47). Neredeyse kalp h\u0131z\u0131, sistolik arteryel bas\u0131n\u00e7 ve santral ven\u00f6z bas\u0131n\u00e7 dahil olmak \u00fczere t\u00fcm statik indekslerin, s\u0131v\u0131 cevab\u0131n\u0131 tahmin etmede yararl\u0131 olmad\u0131\u011f\u0131n\u0131 g\u00f6stermi\u015flerdir. Dahas\u0131, hayal k\u0131r\u0131kl\u0131\u011f\u0131 yaratan, arteryel dalga formuna (SPV, PPV ve SVV), inferior vena kava \u00e7ap\u0131na ve pletismografiye dayananlar da dahil olmak \u00fczere dinamik indekslerin \u00e7o\u011funlu\u011funun prediktif de\u011feri yoktu ve eri\u015fkinlerdeki bulgularla uyu\u015fmuyordu. Tek g\u00fcvenilir parametre, 10 ml\/kg bolus s\u0131v\u0131 ile %15\u2019den daha fazla strok vol\u00fcm art\u0131\u015f\u0131 \u00f6ng\u00f6ren Doppler ekokardiyografi ile \u00f6l\u00e7\u00fclen aortik kan ak\u0131m\u0131 tepe h\u0131z\u0131n\u0131n (\u2206Vpeak) solunumsal varyasyonuydu. Yazarlar, dinamik de\u011fi\u015fkenlerin etkinli\u011findeki farkl\u0131l\u0131\u011f\u0131n g\u00f6\u011f\u00fcs duvar\u0131 y\u00fcksekli\u011fi ve akci\u011fer komplians\u0131, eri\u015fkinlerle k\u0131yasland\u0131\u011f\u0131nda \u00e7ocuklarda daha kompliant arteryel damar yata\u011f\u0131 ve d\u00fc\u015f\u00fck kardiyak ventrik\u00fcler kompliansdan etkilenebilece\u011fini d\u00fc\u015f\u00fcnmektedir (47). S\u0131v\u0131 cevab\u0131n\u0131 \u00f6ng\u00f6rmede \u2206Vpeak g\u00fcvenilirli\u011fi, Desgranges ve arkada\u015flar\u0131 taraf\u0131ndan di\u011fer bir sistematik derleme ile mekanik ventilasyondaki \u00e7ocuklarda do\u011frulanm\u0131\u015ft\u0131r (48). Ne yaz\u0131k ki \u015fimdiye kadar \u2206Vpeak de\u011feri dahil edilen 6 \u00e7al\u0131\u015fmada %7-20 aras\u0131nda de\u011fi\u015fti\u011finden, cevap verenleri cevap vermeyenlerden ay\u0131rmada optimal cut-off de\u011feri tespit edilememi\u015ftir (48).<\/p>\n

Pasif bacak kald\u0131rma (PLR), alt ekstremitelerden ven\u00f6z d\u00f6n\u00fc\u015f\u00fc kolayla\u015ft\u0131rarak \u201cger\u00e7ek\u201d s\u0131v\u0131 sorunununda, s\u0131v\u0131 cevab\u0131n\u0131 de\u011ferlendiren basit bir manevrad\u0131r. Yak\u0131n zamanda 3 iyi tasarlanm\u0131\u015f sistematik derleme PLR\u2019nin, spontan solunumda veya mekanik ventilasyonda oldu\u011funa bak\u0131lmaks\u0131z\u0131n,\u00a0 dola\u015f\u0131m yetmezlikli eri\u015fkin hastalarda s\u0131v\u0131 cevab\u0131n\u0131 tahmin etmede olduk\u00e7a ge\u00e7erli oldu\u011funu kan\u0131tlad\u0131 (49-51). Ek olarak, PLR yap\u0131ld\u0131\u011f\u0131nda kardiyak out-put, strok vol\u00fcm ve aortik kan ak\u0131m\u0131 gibi de\u011fi\u015fkenlerdeki de\u011fi\u015fiklikler nab\u0131z bas\u0131nc\u0131ndan \u00e7ok daha do\u011fru olarak s\u0131v\u0131 cevab\u0131n\u0131 tahmin etmi\u015ftir (50,51). Di\u011fer taraftan, PLR \u00e7ocuklarda \u015fimdiye kadar yaln\u0131zca bir \u00e7al\u0131\u015fmada test edilmi\u015ftir (52). Lukito ve arkada\u015flar\u0131 mekanik ventilasyonda veya spontan solunumdaki, \u00e7e\u015fitli tan\u0131lar\u0131 olan PYB\u00dc\u2019deki 40 \u00e7ocukta (1-8 ya\u015f) \u00e7al\u0131\u015fm\u0131\u015f ve PLR manevras\u0131ndan sonra kardiyak indeks art\u0131\u015f\u0131n\u0131n s\u0131v\u0131 cevab\u0131 ile anlaml\u0131 ili\u015fkisi oldu\u011funu g\u00f6stermi\u015ftir (52).\u00a0<\/p>\n

Sepsisli \u00e7ocuklar\u0131n bu \u00e7al\u0131\u015fmalardaki kat\u0131l\u0131mc\u0131lar\u0131n s\u0131n\u0131rl\u0131 bir y\u00fczdesini olu\u015fturdu\u011funu belirtmek gerekir ki (47,48,52), bu dinamik indeksler pediatrik sepsisin hemodinamik y\u00f6netiminde hen\u00fcz netle\u015fmemi\u015ftir. Dahas\u0131, hem eri\u015fkin hem pediatrik kritik bak\u0131mda, bu dinamik indeksler konsepti tart\u0131\u015fmas\u0131z olarak statik hemodinamik parametrelere g\u00f6re s\u0131v\u0131 cevab\u0131n\u0131 \u00e7ok daha iyi \u00f6ng\u00f6rebilir, ancak bu dinamik indekslere dayanan hemodinamik y\u00f6netimin \u015fimdiye kadar hastalar\u0131n klinik sonu\u00e7lar\u0131n\u0131 iyile\u015ftirmede ge\u00e7erlili\u011fi sa\u011flanmam\u0131\u015ft\u0131r.<\/p>\n

S\u0131v\u0131 y\u00f6netimi <\/strong><\/p>\n

S\u0131v\u0131 res\u00fcsitasyonu a\u00e7\u0131s\u0131ndan bak\u0131ld\u0131\u011f\u0131nda, a\u011f\u0131r enfeksiyonu ve bozulmu\u015f perf\u00fczyonu olan Afrikal\u0131 3141 \u00e7ocukta (60 g\u00fcn ve 12 ya\u015f aras\u0131)\u00a0 bolus s\u0131v\u0131 tedavisini elen alan b\u00fcy\u00fck randomize kontroll\u00fc FEAST \u00e7al\u0131\u015fmas\u0131 (53) 2011 de yay\u0131nland\u0131\u011f\u0131ndan beri \u00e7ok tart\u0131\u015fma yaratt\u0131. Beklenenin tersine, bu \u00e7al\u0131\u015fma ilk yakla\u015f\u0131mda herhangi bir bolus s\u0131v\u0131, salin ya da %5 albumin alan hastalar\u0131n, bolus s\u0131v\u0131 almayan gruba g\u00f6re anlaml\u0131 olarak daha fazla 48 saatlik mortaliteye sahip oldu\u011funu g\u00f6sterdi (RR 1.45; %95 GA 1.13\u20131.86)(53).\u00a0 Bu \u015fok edici sonucun makul sebepleri olarak y\u00fcksek malaria prevelans\u0131 (%57) veya \u00e7al\u0131\u015fma populasyonu i\u00e7inde ciddi anemi (hemoglobin <5 g\/dL, 32%) ve s\u0131v\u0131 y\u00fcklenmesinin yeterince tan\u0131nmamas\u0131 a\u00e7\u0131kland\u0131 (54).\u00a0 Bununla birlikte, a\u015f\u0131r\u0131 mortalite mekanizmas\u0131n\u0131n post-hoc analizleri (55) ve \u00f6nceden belirlenmi\u015f alt grup analizleri (53) bu a\u00e7\u0131klamayla \u00e7eli\u015fti.\u00a0 Bolus grubundaki bu olumsuz sonu\u00e7lar i\u00e7in daha mant\u0131kl\u0131 sebepler olarak sempatik ba\u011f\u0131ml\u0131 dola\u015f\u0131m kompansasyonunda ani d\u00fc\u015f\u00fc\u015f, iskemi -reperf\u00fczyon hasar\u0131 veya ilk s\u0131v\u0131 res\u00fcsitasyonundan sonra kaynak s\u0131n\u0131rl\u0131 durumlarda ileri monit\u00f6rizasyon, mekanik ventilasyon ve\/veya inotrop\/vazoaktif deste\u011fin eksikli\u011fi belirtildi (56-59). Daha sonras\u0131nda yap\u0131lan pediatrik sepsiste bolus s\u0131v\u0131 tedavisinin sistematik derlemesi, bolus s\u0131v\u0131n\u0131n zararl\u0131 etkilerini ortaya koyan FEAST \u00e7al\u0131\u015fmas\u0131ndan \u00e7ok etkilenmi\u015ftir (60). Son olarak Gelbart ve arkada\u015flar\u0131 malaria ve dang hummas\u0131 gibi tropikal patojenleri ekarte ederek, hastaneye yat\u0131r\u0131lan ciddi sepsis veya septik \u015foklu \u00e7ocuklarda (29 g\u00fcn-18 ya\u015f) bolus s\u0131v\u0131 tedavisi \u00e7al\u0131\u015fmalar\u0131n\u0131 sistematik olarak g\u00f6zden ge\u00e7irdi (61). Sadece ikisi Hindistan ve biri Brezilya\u2019dan (30) 3 RK\u00c7 ve b\u00fcy\u00fck oranda geriye d\u00f6n\u00fck 8 g\u00f6zlemsel \u00e7al\u0131\u015fma buldular.\u00a0 Ne yaz\u0131k ki, bu \u00e7al\u0131\u015fmalar\u0131n metodolojileri \u00e7ok heterojendi ve t\u00fcm bulgular\u0131 meta-analiz yap\u0131lmas\u0131n\u0131 engelleyen k\u00fc\u00e7\u00fck \u00f6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fcndeydi (61).\u00a0<\/p>\n

Resusitasyon s\u0131v\u0131s\u0131n\u0131n t\u00fcr\u00fcne gelince, SSCK 2012 isotonik kristalloidler veya kolloidlerin \u00fcst\u00fcnl\u00fc\u011f\u00fcn\u00fc belirtmedi (3). Ancak, sa\u011f kal\u0131mda isotonik kristalloidler ile kolloidlerin e\u015fde\u011ferlili\u011fi, geli\u015fmi\u015f \u00fclkelerdeki durumdan daha farkl\u0131 olarak, dang \u015fok sendromlu \u00e7ocuklardaki 3 RK\u00c7\u2019a dayand\u0131r\u0131lm\u0131\u015ft\u0131r (62-64).\u00a0 B\u00fcy\u00fck oranda malarial\u0131 \u00e7ocuklar\u0131n dahil edildi\u011fi FEAST \u00e7al\u0131\u015fmas\u0131nda, alb\u00fcmin bolus ve salin bolus gruplar\u0131 aras\u0131nda 48 saatlik ve 4 haftal\u0131k mortalitede fark yoktu (48 saatlik mortalite %10.6\u2019a kar\u015f\u0131 %10.5, RR 1.00, %95 GA 0.78-1.29; 4 haftal\u0131k mortalite %12.2\u2019e kar\u015f\u0131 %12, RR 1.01, %95 GA 0.8-1.28). Yukar\u0131da da a\u00e7\u0131kland\u0131\u011f\u0131 gibi, her iki bolus grubu bolus almayanlara g\u00f6re anlaml\u0131 olarak daha y\u00fcksek mortaliteye sahipti (53), yine de bu durum geli\u015fmi\u015f \u00fclkelerden daha farkl\u0131d\u0131r. Jian ve arkada\u015flar\u0131 yak\u0131n zamanda,\u00a0 sepsisli farkl\u0131 gruplarda s\u0131v\u0131 resusitasyonunda alb\u00fcmin ve di\u011fer s\u0131v\u0131lar\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 RK\u00c7\u2019\u0131n bir meta-analizini yay\u0131nlad\u0131. Sepsisli \u00e7ocuklarda t\u00fcm nedenlere ba\u011fl\u0131 mortalitede alb\u00fcm\u00fcnin di\u011fer s\u0131v\u0131 tiplerine \u00fcst\u00fcnl\u00fc\u011f\u00fc olmad\u0131\u011f\u0131n\u0131 g\u00f6sterdiler (sabit etki modeli, RR 0.92, %95 GA 0.74-1.14; random etki modeli, RR 0.55, %95 GA 0.21-1.45)(65). Bununla beraber,\u00a0 ne yaz\u0131k ki bu meta-analize al\u0131nan t\u00fcm RK\u00c7\u2019lar\u0131n b\u00fcy\u00fck oranda FEAST \u00e7al\u0131\u015fmas\u0131n\u0131n da yap\u0131ld\u0131\u011f\u0131 (53), \u00e7ok say\u0131da malaria hastas\u0131n\u0131n oldu\u011fu geli\u015fmekte olan \u00fclkelerde yap\u0131ld\u0131\u011f\u0131 ak\u0131lda tutulmal\u0131d\u0131r (65). Di\u011fer taraftan, SPROUT \u00e7al\u0131\u015fmas\u0131 ya\u015f, cinsiyet, a\u011f\u0131rl\u0131k skoru, co\u011frafik b\u00f6lge ve komorbiditelerin say\u0131s\u0131na ba\u011fl\u0131 olarak alb\u00fcmin kullan\u0131m\u0131n\u0131 PYB\u00dc mortalitesinde anlaml\u0131 bir risk fakt\u00f6r\u00fc olarak saptam\u0131\u015ft\u0131r (d\u00fczeltilmi\u015f OR 2.5, %95 GA 1.54-4.05)(20). Sepsisli \u00e7ocuklarda alb\u00fcmin kullan\u0131m\u0131na dair bu negatif bulgular, anlaml\u0131 olmamakla beraber tercih edilebilir yeti\u015fkin sepsis bulgular\u0131 ile tezat olu\u015fturmaktad\u0131r (4,66). \u00d6te yandan, eri\u015fkin sepsiste \u00f6nerilen (4) sentetik kolloidlerden, b\u00f6brek hasar\u0131 nedeni ile \u00e7ocuklarda ka\u00e7\u0131n\u0131lmas\u0131 \u00f6nerilir (67-69).<\/p>\n

Bu bulgular g\u00f6z \u00f6n\u00fcnde bulunduruldu\u011funda, pediatrik sepsis y\u00f6netiminde resusitasyon s\u0131v\u0131s\u0131n\u0131n tipi ve optimal dozuna ili\u015fkin herhangi bir \u00f6neri veya destek g\u00f6stermek \u00e7ok zor. Bununla beraber, en az\u0131ndan geli\u015fmi\u015f \u00fclkelerde, alb\u00fcminin dikkatli kullan\u0131m\u0131n\u0131n yan\u0131 s\u0131ra SSCK 2012\u2019de (3) desteklenen g\u00fcncel uygulamaya devam edilmesi mant\u0131kl\u0131 olacakt\u0131r. Geli\u015fmi\u015f \u00fclkelerde pediatrik sepsiste optimal resusitasyon s\u0131v\u0131s\u0131 ve dozunu a\u00e7\u0131kl\u0131\u011fa kavu\u015fturmak i\u00e7in iyi tasarlanm\u0131\u015f pragmatik RK\u00c7\u2019lara kesinlikle ihtiya\u00e7 vard\u0131r.\u00a0<\/p>\n

A\u015f\u0131r\u0131 pozitif s\u0131v\u0131 balans\u0131n\u0131n eri\u015fkin ve \u00e7ocuk kritik hastalar\u0131n her iki grubunda da k\u00f6t\u00fc sonu\u00e7lara yol a\u00e7t\u0131\u011f\u0131 belirtilmi\u015ftir (70). Bununla beraber Abulebda ve arkada\u015flar\u0131 ABD kaynakl\u0131 \u00e7ok merkezli pediatrik septik \u015fok vaka-kontrol \u00e7al\u0131\u015fmas\u0131nda (10 ya\u015f veya daha gen\u00e7), PYB\u00dc\u2019e yat\u0131\u015ftan sonra hem ilk 24 saat hem de 7 g\u00fcnl\u00fck k\u00fcm\u00fclatif pozitif s\u0131v\u0131 balans\u0131n\u0131n yeni geli\u015ftirilen pediatrik sepsis biobelirte\u00e7 risk modeli ile tabakaland\u0131r\u0131lm\u0131\u015f (72)\u00a0 orta ve y\u00fcksek risk gruplar\u0131nda \u00e7oklu organ i\u015flev bozuklu\u011fu veya mortalite ile ili\u015fkili olmad\u0131\u011f\u0131n\u0131 g\u00f6stermi\u015ftir (71).<\/p>\n

\u0130notropik\/vazoaktif ajanlar<\/strong><\/p>\n

Septik \u015fok i\u00e7in inotropik\/vazoaktif ajanlar a\u00e7\u0131s\u0131ndan, noradrenalin daha az aritmik etkisi olmas\u0131 nedeni ile yak\u0131n zamanda eri\u015fkinler i\u00e7in ilk tercih olarak \u00f6nerilmi\u015ftir (3,73,74). Pediatrik septik \u015fokta, herhangi bir inortopik\/vazoaktif ajan\u0131 belirtmeyen 2012 SSCK\u2019da (3) kar\u015f\u0131la\u015ft\u0131rmal\u0131 yay\u0131nlar eksikti. Neyseki, son birka\u00e7 y\u0131ld\u0131r ilk tercih olarak adrenalin ile dopamini kar\u015f\u0131la\u015ft\u0131ran 2 RK\u00c7 yay\u0131nland\u0131 (75,76).\u00a0 Ventura ve arkada\u015flar\u0131, s\u00fcrekli dopamin veya adrenalin inf\u00fczyonu i\u00e7in s\u0131v\u0131ya diren\u00e7li septik \u015foklu 120 \u00e7ocu\u011fu randomize etti (75). \u00c7al\u0131\u015fma ila\u00e7lar\u0131 her 20 dakikada bir daha \u00f6nceden saptanan hemodinamik stabilizasyon kriterleri sa\u011flan\u0131ncaya kadar artt\u0131r\u0131ld\u0131 (dopamin 5, 7.5, 10 mcg\/kg\/dk, adrenalin 0.1, 0.2, 0.3 mcg\/kg\/dk) ve maksimum dozdan sonra doktorun takdirine g\u00f6re di\u011fer bir katekolamin ile de\u011fi\u015ftirildi. Birincil sonu\u00e7 dopamin grubuna g\u00f6re adrenalin grubunda anlaml\u0131 derecede daha d\u00fc\u015f\u00fck bulunan 28 g\u00fcnl\u00fck mortalite idi (%7\u2019e kar\u015f\u0131 %21, p=0.033). Ek olarak, dopamin \u00e7ok varyasyonlu analizde \u00f6l\u00fcm (OR 6.5, %95 GA 1.1-37.8) ve hastane kaynakl\u0131 enfeksiyonla (OR 67.7, %95 GA 5.0-910.8) ili\u015fkili bulundu (75). Narayanan ve arkada\u015flar\u0131 ayr\u0131ca, s\u0131v\u0131ya diren\u00e7li hipotansif “so\u011fuk” septik \u015foklu 60 \u00e7ocukda (3 ay-12 ay) birinci tercih tedavi olarak dopamin ile adrenalinin farkl\u0131 tedavi rejimlerini\u00a0 (dopamin 10, 15, 20 mcg\/kg\/dk, adrenalin 0.1, 0.2, 0.3 mcg\/kg\/dk, her 10 dakikada) kar\u015f\u0131la\u015ft\u0131rd\u0131klar\u0131 pilot RK\u00c7 ger\u00e7ekle\u015ftirdi. Birincil sonu\u00e7, resusitasyonun ilk saatinde \u015fok rezolusyon h\u0131z\u0131yd\u0131 ve adrenalin grubunda anlaml\u0131 oranda daha y\u00fcksekti (%41’e kar\u015f\u0131 %15, p=0.0019), ancak mortalite anlaml\u0131 farkl\u0131l\u0131k g\u00f6stermemekteydi (adrenalin grubunda %48, dopamin grubunda %58, p=0.605) (76). Bu RK\u00c7’lar g\u00f6r\u00fcn\u00fc\u015fe g\u00f6re pediatrik septik \u015fok y\u00f6netiminde birinci tercih olarak dopaminin yerine adrenalinin ge\u00e7ti\u011fini destekleyebilir, ancak iki ajan yerine hemodinami y\u00f6netiminde iki tedavi rejiminin kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131n\u0131 s\u00f6ylemek daha do\u011fru olur. Ger\u00e7ekten de, Deep ve arkada\u015flar\u0131 s\u0131v\u0131ya diren\u00e7li septik \u015foklu neonatallerin d\u0131\u015fland\u0131\u011f\u0131, ileriye d\u00f6n\u00fck olarak 36 \u00e7ocukda yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada ba\u015fvuru s\u0131ras\u0131nda 2 farkl\u0131 hemodinamik patern oldu\u011funu ortaya \u00e7\u0131kard\u0131 (77). Genelde, toplum k\u00f6kenli septik \u015foklu \u00e7ocuklar\u0131n \u00e7o\u011funlu\u011funda “so\u011fuk \u015fok” g\u00f6r\u00fcl\u00fcrken, hastane k\u00f6kenli septik \u015foklu \u00e7ocuklar\u0131n t\u00fcm\u00fcnde “s\u0131cak \u015fok” g\u00f6r\u00fcl\u00fcr. Bununla beraber, “so\u011fuk \u015fok”ta ba\u015flang\u0131\u00e7ta adrenaline ba\u015flanm\u0131\u015f olan baz\u0131 hastalarda noradrenalin gerekmi\u015f veya daha sonra milrinona \u00e7evrilmi\u015ftir, buna kar\u015f\u0131n “s\u0131cak \u015fok”ta ba\u015flang\u0131\u00e7ta noradrenaline yan\u0131t veren baz\u0131 hastalarda d\u00fc\u015f\u00fck kardiyak output geli\u015fmi\u015f ve adrenalin gerekmi\u015ftir (77). Bu ger\u00e7ekler g\u00f6z \u00f6n\u00fcnde bulunduruldu\u011funda, ilk tercih olarak tek bir ajan\u0131n evrensel olarak uygulanmas\u0131 tehlikeli olabilir ve hemodinamik deste\u011fin ard\u0131\u015f\u0131k olarak titizlikle optimizasyonu septik \u015foklu \u00e7ocuklar\u0131n y\u00f6netiminde ka\u00e7\u0131n\u0131lmazd\u0131r.<\/p>\n

Katekolamine diren\u00e7li vasodilat\u00f6r hipotansiyonlu eri\u015fkin septik \u015fok vakalar\u0131nda, vasopresin ve uzun etkili analogu terlipresin SSCK 2012’den beri optimal perf\u00fczyon bas\u0131nc\u0131n\u0131n sa\u011flanmas\u0131nda alternatif olarak desteklenmektedir (3,78). Di\u011fer taraftan, bu ajanlar\u0131n \u00e7ocuklarda kullan\u0131m\u0131 belirgin klinik yarar\u0131n\u0131n eksikli\u011fi nedeni ile desteklenmemi\u015ftir (3,79,80). Son olarak Masarwa ve arkada\u015flar\u0131 t\u00fcm nedenlere ba\u011fl\u0131 diren\u00e7li \u015fok durumundaki \u00e7ocuklarda (0-18 ya\u015f) konvansiyonel tedavi ile vasopresin ve terlipresini kar\u015f\u0131la\u015ft\u0131ran sistematik bir derleme yay\u0131nlad\u0131 (81). \u00dc\u00e7 RK\u00c7\u2019a at\u0131fta bulundular ve vasopresin\/terlipresin kullan\u0131m\u0131 ve mortalite aras\u0131nda ili\u015fki bulamad\u0131lar (RR 1.19; %95 GA 0.71-2.0; I2<\/sup>=%28). Ayr\u0131ca vasopresin\/terlipresin ile tedavi edilen hastalarda anlaml\u0131 olmayan ancak ili\u015fkili olan daha fazla doku iskemisine e\u011filim oldu\u011funa dikkat \u00e7ektiler (RR 1.48; %95 GA 0.47-4.62; I2<\/sup>=%0) (81). Etkinlikteki bu farkl\u0131l\u0131klar, eri\u015fkin hastalardaki g\u00f6receli vasopresin eksikli\u011finin tersine, septik \u015foklu \u00e7ocuklarda intrensek vasopresin ve kopeptin d\u00fczeylerinin de\u011fi\u015fkenli\u011finden kaynaklanabilir (83). Di\u011fer taraftan, metilen mavisi katekolamine diren\u00e7li vasodilat\u00f6r \u015fokta di\u011fer bir vasokonstrikt\u00f6r olarak \u00f6nerilmi\u015ftir (84), ancak hen\u00fcz yeterince de\u011ferlendirilmemi\u015ftir.<\/p>\n

Yard\u0131mc\u0131 tedaviler <\/strong><\/p>\n

SSCK 2012\u2019deki pediatrik de\u011ferlendirmelerde, s\u0131v\u0131ya diren\u00e7li katekolamin rezistans septik \u015fok ve \u015f\u00fcpheli veya kan\u0131tlanm\u0131\u015f mutlak (klasik) adrenal yetmezlikli \u00e7ocuklarda hidrokortizonun zaman\u0131nda verilmesi GRADE 1A, yeterince g\u00fc\u00e7l\u00fc \u00e7al\u0131\u015fmalar olmasa dahi, y\u00fcksek kaliteli kan\u0131tlarla g\u00fc\u00e7l\u00fc \u00f6neri olarak (3,85,86) desteklenmi\u015ftir. Di\u011fer taraftan, pediatrik septik \u015fokta kritik hastal\u0131\u011fa ba\u011fl\u0131 kortikosteroid yetersizli\u011finin daha yayg\u0131n oldu\u011fu durumda kortikosteroidlerin etkinli\u011fi konusunda iyi tasarlanm\u0131\u015f ara\u015ft\u0131rmalar son derece azd\u0131r (85,86). Menon ve arkada\u015flar\u0131 yak\u0131n zamanda RK\u00c7’lar\u0131n sistematik bir g\u00f6zden ge\u00e7irmesini yapt\u0131lar ancak bunlar\u0131n \u00e7o\u011funun 1996’dan \u00f6nce, geli\u015fmekte olan \u00fclkelerde dang \u015foku konusunda yay\u0131nland\u0131\u011f\u0131n\u0131 saptad\u0131lar (87). Meta-analizleri, kortikosteroid almayanlarla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda alanlarda sa\u011f kal\u0131mda bir yarar sa\u011flamad\u0131\u011f\u0131n\u0131 g\u00f6sterdi (87). Diper taraftan SPROUT \u00e7al\u0131\u015fmas\u0131nda, kortikosteroidlerin kullan\u0131m\u0131 \u00e7ok de\u011fi\u015fkenli analizde mortalite ile anlaml\u0131 \u015fekilde ili\u015fkiliydi (d\u00fczeltilmi\u015f OR 1.58; %95GA 1.01-2.49)(20). Yeterli d\u00fczeyde kan\u0131t eksikli\u011fine ra\u011fmen, son zamanlarda yap\u0131lan bir Kanada \u00e7al\u0131\u015fmas\u0131nda, hemen hemen t\u00fcm pediatrik yo\u011fun bak\u0131mc\u0131lar\u0131n (%91.4) 60 ml\/kg s\u0131v\u0131 ve 2 veya daha fazla vasoaktif ila\u00e7 alan diren\u00e7li \u015foktaki hastalara kortikosteroid uygulad\u0131\u011f\u0131n\u0131 g\u00f6sterdi (88). Bu ankette, kat\u0131lanlar\u0131n %80\u2019den fazlas\u0131, gelecekteki RK\u00c7\u2019lara diren\u00e7li \u015fok hastalar\u0131n\u0131 dahil etmeye istekli olduklar\u0131n\u0131, fakat ayn\u0131 zamanda, hastalar\u0131 k\u00f6t\u00fcle\u015firse kortikosteroid uygulayaca\u011f\u0131n\u0131 belirtti ki, bu da etkili bir RK\u00c7 ger\u00e7ekle\u015ftirmek i\u00e7in potansiyel zorluklar oldu\u011funu g\u00f6stermektedir (89). Mevcut ara\u015ft\u0131rma bulgular\u0131ndan (90-95) ve eri\u015fkinler i\u00e7in SSCK 2012\u2019deki (3) \u00f6nerilerden yola \u00e7\u0131karak, d\u00fc\u015f\u00fck doz hidrokortizon uygulamas\u0131n\u0131 yaln\u0131zca s\u0131v\u0131ya diren\u00e7li katekolamin rezistans septik \u015foklu \u00e7ocuklarda yapmak mant\u0131kl\u0131 olacakt\u0131r. Pragmatik hedef pop\u00fclasyon, spesifik dahil etme\/d\u0131\u015flama kriterleri, olumsuz olaylar\u0131n raporlanmas\u0131 ve ger\u00e7ek\u00e7i sonlan\u0131m noktalar\u0131 ile pediatrik septik \u015fokta kortikosteroidlerin etkinli\u011fini de\u011ferlendirmek i\u00e7in iyi tasarlanm\u0131\u015f, b\u00fcy\u00fck \u00f6l\u00e7ekli RK\u00c7\u2019lara kesinlikle ihtiya\u00e7 vard\u0131r (89) (tablo 2).<\/p>\n

Di\u011fer yard\u0131mc\u0131 tedavilerle beraber, pediatrik sepsiste ekstrakorporeal ya\u015fam deste\u011fi (ECLS), renal replasman tedavisi (RRT) ve plasma de\u011fi\u015fimini (PE) i\u00e7eren ekstrakorporeal tedavilerin etkinli\u011fi birka\u00e7 y\u0131ld\u0131r ara\u015ft\u0131r\u0131lmaktad\u0131r. ECLS\u2019nin dikkate al\u0131nmas\u0131, hemodinamik y\u00f6netimin son \u00e7aresi olarak diren\u00e7li septik \u015foklu \u00e7ocuklarda SSCK 2012\u2019de (3) \u00f6nerildi, ancak bu \u00f6neri yaln\u0131zca s\u0131n\u0131rl\u0131 say\u0131da merkezin tecr\u00fcbesine dayanmaktad\u0131r (96-98). Son olarak, Ruth ve arkada\u015flar\u0131 ABD\u2019deki \u00e7ok merkezli PYB\u00dc veritaban\u0131ndan, septik \u00e7ocuklarda, \u00f6zellikle 2004 ile 2012 y\u0131llar\u0131 aras\u0131nda 3 veya daha fazla organ i\u015flev bozuklu\u011fu olanlarda (%6,9-10,3), ECLS kullan\u0131m\u0131n\u0131n artt\u0131\u011f\u0131n\u0131 g\u00f6sterdi (t\u00fcm ciddi sepsislerde 2004-2008\u2019de %3.6\u2019a kar\u015f\u0131 2009-2012\u2019de %4). Ayr\u0131ca, mortalite oran\u0131n\u0131n, ECLS uygulanan \u00e7ocuklarda kademeli d\u00fc\u015fme e\u011filimi ile %47.8 oldu\u011funu bildirdiler (99). Smith ve arkada\u015flar\u0131, %44 sa\u011f kal\u0131mla n\u00f6tropenik sepsisli 9 \u00e7ocukta ECLS tecr\u00fcbelerini bildirdi ki, k\u00f6t\u00fcmser prognoz nedeni ile daha \u00f6nceden kontrendikeydi (100). RRT\u2019e gelince, Ruth ve arkada\u015flar\u0131 \u00e7ok merkezli PYB\u00dc veritaban\u0131ndan, RRT\u2019nin septik \u00e7ocuklar\u0131n (0-18ya\u015f) %19\u2019una uyguland\u0131\u011f\u0131n\u0131, ancak RRT\u2019nin kullan\u0131m\u0131n\u0131n 2004\u2019den 2012\u2019e kadar \u00f6nemli oranda azald\u0131\u011f\u0131n\u0131 g\u00f6sterdi. \u0130li\u015fkili mortalite oran\u0131 RRT\u2019de %32.3 ve ECLS ve RRT\u2019nin her ikisi beraber %58 idi (99). SSCK 2012, esas olarak tek merkezli geriye d\u00f6n\u00fck bir \u00e7al\u0131\u015fmaya dayananarak (101), total v\u00fccut a\u011f\u0131rl\u0131\u011f\u0131n\u0131n %10\u2019undan daha fazla s\u0131v\u0131 y\u00fcklenmesini \u00f6nlemede di\u00fcretikler ve RRT\u2019nin kullan\u0131m\u0131n\u0131 \u00f6nerdi (3). Ne yaz\u0131k ki bu \u00f6neri, \u00f6zellikle s\u0131v\u0131 y\u00fck\u00fcn\u00fcn e\u015fik de\u011feri, septik \u00e7ocuklarda hen\u00fcz onaylanmam\u0131\u015ft\u0131r (102-104). Pediatrik sepsiste PE\u2019nin etkinli\u011fi belirsizdir. Kawai ve arkada\u015flar\u0131, organ i\u015flev bozuklu\u011fu ve hemodinamik durumun d\u00fczelmesinde, ECLS uygulanan 14 \u00e7ocukta PE\u2019nin olas\u0131 etkinli\u011fini destekledi (105), Rimmer ve arkada\u015flar\u0131 taraf\u0131ndan yap\u0131lan meta-analizde ise septik \u00e7ocuklarda PE\u2019nin sa\u011f kal\u0131ma faydas\u0131 olmad\u0131\u011f\u0131 g\u00f6sterildi (n=66, RR 0.96; %95 GA 0.28-3.38) (106). Ne yaz\u0131k ki, bu meta-analizin g\u00fcc\u00fc yetersizdi.<\/p>\n

\u201cSepsis demeti\u201d yakla\u015f\u0131m\u0131 (ACCM\/PALS algoritmas\u0131)<\/strong><\/p>\n

SSCK 2012\u2019de, eri\u015fkin sepsis bak\u0131m\u0131n\u0131n performans kalitesini artt\u0131rmak i\u00e7in ba\u015flang\u0131\u00e7 y\u00f6netim demeti savunulmaktad\u0131r (3). Yak\u0131n zamanda ger\u00e7ekle\u015ftirilen k\u00fcresel ileriye d\u00f6n\u00fck g\u00f6zlemsel \u00e7al\u0131\u015fmada (IMPreSS \u00e7al\u0131\u015fmas\u0131) ciddi sepsis veya septik \u015foklu eri\u015fkinlerde demet yakla\u015f\u0131m\u0131 ile uyumun sa\u011f kal\u0131m yarar\u0131 g\u00f6sterildi (107). Pediatrik sepsiste SSCK paneli, 2008-2012 (2,3) y\u0131llar\u0131 aras\u0131nda septik \u015fokun ba\u015flang\u0131\u00e7 y\u00f6netiminde ACCM-PALS algoritmas\u0131 (\u015fekil 2) (29) ile uyumu \u00f6nermeye devam etti. Bu algoritman\u0131n birka\u00e7 \u00e7al\u0131\u015fmada etkili oldu\u011fu kan\u0131tland\u0131 (30,108-110) ve klinik durumlardaki uyumu son zamanlarda daha g\u00fc\u00e7l\u00fc bir \u015fekilde ara\u015ft\u0131r\u0131ld\u0131. Paul ve arkada\u015flar\u0131, 5 algoritmik zamana \u00f6zel hedefe uyumu acil serviste ileriye d\u00f6n\u00fck olarak ara\u015ft\u0131rd\u0131; erken tan\u0131, damar yolu, intraven\u00f6z s\u0131v\u0131lar 60 mls\/kg, s\u0131v\u0131ya diren\u00e7li \u015fokta vasopres\u00f6rler ve antibiyotik uygulanmas\u0131 (111). T\u00fcm algoritma i\u00e7in yaln\u0131zca %19\u2019la d\u00fc\u015f\u00fck uyum oran\u0131nda, yeterli s\u0131v\u0131 resusitasyonu ve zaman\u0131nda vasopres\u00f6r ba\u015flanmas\u0131n\u0131 ise s\u0131ras\u0131yla %37 ve %35 oran\u0131nda buldular. Ayr\u0131ca, uyumsuz grupla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda uyumlu grupta hastane yat\u0131\u015f s\u00fcrelerinin anlaml\u0131 oranda k\u0131sa oldu\u011funu g\u00f6sterdiler (6.8\u2019e kar\u015f\u0131 10.9 g\u00fcn; p=0.009) (111). Daha sonra ACCM-PALS algoritmas\u0131na daha fazla uyum i\u00e7in, \u00f6zellikle 60 dk i\u00e7inde 60 mls\/kg kadar zamanl\u0131 s\u0131v\u0131 resusitasyonuna odaklanarak kalite geli\u015ftirme giri\u015fimleri ba\u015flatt\u0131lar (112). Acil servis ekibine yapt\u0131klar\u0131 yo\u011fun m\u00fcdahale ile s\u0131v\u0131lara, vasoaktif ajanlara ve total demetin t\u00fcm\u00fcne uyum d\u00fczeldi ve sonunda %100\u2019e ula\u015ft\u0131 ve sonras\u0131nda yakla\u015f\u0131k\u00a0 %100 kald\u0131 (112). Long ve arkada\u015flar\u0131 ileriye d\u00f6n\u00fck olarak ven\u00f6z kan gaz\u0131 \u00f6rneklemesi, zaman\u0131nda s\u0131v\u0131 resusitasyonu ve antibiyotik uygulanmas\u0131na odaklanan, ayn\u0131 nitelikte kalite geli\u015ftirme m\u00fcdahale \u00e7al\u0131\u015fmas\u0131n\u0131 ger\u00e7ekle\u015ftirdi (113). Damar yolu, antibiyotik verilmesi ve s\u0131v\u0131 uygulanmas\u0131 s\u00fcrelerinde belirgin azalma sa\u011flad\u0131lar ve daha \u00f6nemlisi, hastane yat\u0131\u015f s\u00fcreleri \u00f6nemli oranda k\u0131sald\u0131 (m\u00fcdahale \u00f6ncesinde 96 saat, m\u00fcdahale sonras\u0131nda 80 saat; hazard ratio 1.36, %95 GA 1.04-1.8) (113). Di\u011fer geriye d\u00f6n\u00fck kohort \u00e7al\u0131\u015fmalar\u0131n bir \u00e7iftinde akut b\u00f6brek hasar\u0131 (114) ve baz\u0131 organ i\u015flev bozuklu\u011fu komplikasyon oranlar\u0131n\u0131n azalt\u0131lmas\u0131nda prokollerle belirlenmi\u015f ba\u015flang\u0131\u00e7 y\u00f6netiminin yararl\u0131 etkileri g\u00f6sterildi. T\u00fcm bu \u00e7al\u0131\u015fmalar\u0131n tek merkezli, \u00f6nce-sonra veya geriye d\u00f6n\u00fck tasar\u0131mda oldu\u011funu belirtmek gerekir, ancak \u201csepsis demetleri\u201dne uymak i\u00e7in sarfedilen her \u00e7aban\u0131n septik \u00e7ocuklar\u0131n y\u00f6netiminde performans\u0131 d\u00fczeltme olas\u0131l\u0131\u011f\u0131 y\u00fcksektir.\u00a0<\/p>\n

Yo\u011fun bak\u0131m sonras\u0131 sekeller<\/strong><\/p>\n

Yukar\u0131da da belirtildi\u011fi gibi, pediatrik sepsis mortalitesi son 10 y\u0131lda kademeli olarak azalmaktad\u0131r. Di\u011fer taraftan, pediarik sepsiste sa\u011f kalanlarda uzun d\u00f6nem sekeller hen\u00fcz iyi ara\u015ft\u0131r\u0131lmam\u0131\u015ft\u0131r.<\/p>\n

RESOLVE \u00e7al\u0131\u015fmas\u0131n\u0131n post-hoc analizi (116) hem vasoaktif ajanlar hem de mekanik ventilasyon gerekmi\u015f 28 g\u00fcnl\u00fck pediatrik sepsisten sa\u011f kal\u0131mlar\u0131n (d\u00fczeltilmi\u015f gebelik haftas\u0131 38-17 ya\u015f) %34 kadar\u0131nda, fonksiyonel durumda gerileme\u00a0 g\u00f6sterdi ve %18\u2019inin en az\u0131ndan orta dereceli engelli oldu\u011funu bildirdi (117). Ayr\u0131ca k\u00f6t\u00fc fonksiyonel sonu\u00e7larla ili\u015fkili risk fakt\u00f6rlerini de buldular; santral sinir sistemi ve intra-abdominal enfeksiyon kayna\u011f\u0131, yeni travma, ba\u015fvuru \u00f6ncesinde kardiyopulmoner resusitasyon uygulanmas\u0131 ve y\u00fcksek a\u011f\u0131rl\u0131k indeksi (117). SPROUT \u00e7al\u0131\u015fmas\u0131nda ciddi sepsisli pediatrik sa\u011f kalanlar\u0131n %17 kadar\u0131n\u0131n en az\u0131ndan orta dereceli engellilikle komplike olurken, %28\u2019inin en az\u0131ndan hafif engellilikle komplike oldu\u011fu g\u00f6sterildi (20).\u00a0<\/p>\n

Aspesberro ve arkada\u015flar\u0131 yak\u0131n zamanda pediatrik kritik bak\u0131m sa\u011f kalanlar\u0131nda (0-18 ya\u015f) sa\u011fl\u0131kla ilgili ya\u015fam kalitesine (HRQoL) g\u00f6re literat\u00fcr\u00fcn odaklanm\u0131\u015f incelemesini yapt\u0131 (118). YB\u00dc\u2019e kab\u00fclde sepsisin zay\u0131f HRQoL\u2019de anahtar belirleyicilerden biri oldu\u011funu saptad\u0131lar. Ayr\u0131ca, meningokokkal septik \u015foktan sa\u011f kalanlarda davran\u0131\u015fsal ve emosyonel \u00f6l\u00e7\u00fcm skalalar\u0131n\u0131 d\u00fc\u015f\u00fck skorlu ve meningoensefalit ve sepsisli \u00e7ocuklarda n\u00f6ropsikolojik fonksiyonlar\u0131 azalm\u0131\u015f buldular (118). A\u00e7\u0131k\u00e7as\u0131, sepsisten sa\u011f kurtulan \u00e7ocuklar hastal\u0131k \u00f6ncesi performanslar\u0131 i\u00e7in m\u00fccadele etmektedirler. \u00a0<\/p>\n

Sonu\u00e7lar <\/strong><\/p>\n

SSCK \u00f6ncesi d\u00f6nemle kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda, son 10 y\u0131lda pediatrik sepsiste daha fazla kan\u0131t birikmi\u015ftir. En \u00f6nemlisi, SPROUT \u00e7al\u0131\u015fmas\u0131 k\u00fcresel epidemiyolojik veriye dayanarak pediatrik sepsiste gelecekteki ara\u015ft\u0131rmalar hakk\u0131nda \u00f6nemli etkiler sa\u011flam\u0131\u015ft\u0131r (20,119). SSCK\u2019nun daha geni\u015f \u00e7apta kabul\u00fc sayesinde, e\u011filim hen\u00fcz kesin olarak do\u011frulanmam\u0131\u015f olsa da, mortalitenin kademeli olarak azald\u0131\u011f\u0131 g\u00f6r\u00fclmektedir. Pediatrik yo\u011fun bak\u0131mc\u0131lar, t\u00fcm sepsisten sa\u011f kalanlar\u0131n hastal\u0131k \u00f6ncesi performanslar\u0131n\u0131 sa\u011flayamayaca\u011f\u0131n\u0131 ak\u0131lda tutmal\u0131d\u0131r (120). Pediatrik sepsis ge\u00e7irenlerde multidisipliner longitudinal takibin koordine edilmesi arzu edilir. Ek olarak, sepsisli \u00e7ocuklarda gelecekteki klinik \u00e7al\u0131\u015fmalar\u0131n sonu\u00e7 \u00f6l\u00e7\u00fctleri olarak, yaln\u0131zca mortalite de\u011fil ayn\u0131 zamanda sepsisin \u00e7ocuklar\u0131n ya\u015fam\u0131 \u00fczerindeki etkisinde uzun d\u00f6nem HRQoL de de\u011ferlendirilmelidir.<\/p>\n

Kaynaklar\u00a0 <\/strong><\/p>\n

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    \n","protected":false},"excerpt":{"rendered":"

    Kawasaki T. Update on pediatric sepsis: a review. J Intensive Care 2017 Jul 20,5:47 doi: 10.1186\/s40560-017-0240-1. Haz\u0131rlayan: Dr. \u00d6zge Duman Atilla \u00d6zet Giri\u015f: Sepsis, d\u00fcnyada \u00e7ocuklar aras\u0131nda mortalitenin \u00f6nde gelen…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[10011],"tags":[],"class_list":["post-25495","post","type-post","status-publish","format-standard","hentry","category-haber-ve-duyuru"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/posts\/25495","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/comments?post=25495"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/posts\/25495\/revisions"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/media?parent=25495"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/categories?post=25495"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/tags?post=25495"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}