Management of septic shock and acquired respiratory distress syndrome in pediatric cancer patients

Septic shock occurs in 6% of paediatric cancer patients with neutropenia and fever. The mortality of the septic shock is 40% in BMT patients and 5% in others. One third of paediatric ARDS cases affect immunocompromised individuals with a total mortality of 45% and 80% after BMT. Septic shock is caused by gramnegative bacteria in more than 75%. ARDS is due to pneumonia in more than 50%, sepsis in about 25%. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hernatology/Oncology (GPOH) for treatment of septic shock and ARDS. Therapy of septic shock includes early antibiotic therapy and volume expansion (>= 40ml/kg initially). Refractory shock requires vasopressors (noradrenaline), followed by a judicious circulatory management. Hydrocortison is indicated in patients with high probability of adrenal insufficiency. Mainstay of ARDS therapy is ventilation with sufficient endexspiratory pressure (PEEP) to prevent loss of functional residual capacity and with limited tidal volumes (<= 6ml/kg) and limited inspiratory pressure (< 35 cmH(2)O) respectively, to minimize ventilator induced lung injury. Volume therapy consists of maintenance of sufficient preload to counteract the impaired venous return, induced by positive pressure ventilation. Diuretics and eventually veno-venous haemofiltration are used to reduce free lung water. Surfactant application may be considered in severe cases. Steroids are indicated in pneurnocystis carinii pneumonia and in engraftment pneumonitis.