Shock in the Pediatric Patient

:
or
Oxygen Don’t Go
Where the Blood Won’t Flow!
James D. Fortenberry MD FAAP, FCCM
Medical Director, PICU
Division of Critical Care Medicine
Children’s Healthcare of Atlanta
Objectives
 Define shock and its different categories
 Review basic physiologic aspects of shock
 Describe management of shock including:
oxygen supply and demand
fluid resuscitation
crystalloid vs. colloid controversy
vasopressor support
Definition of Shock
 Uncontrolled blood or fluid loss
 Blood pressure less than 5th percentile
for age
 Altered mental status, low urine output,
poor capillary refill
 None of the above
Definition of Shock
An acute complex pathophysiologic
state of circulatory dysfunction
which results in a failure of the
organism to deliver sufficient
amounts of oxygen and other
nutrients to satisfy the
requirements of tissue beds
SUPPLY < DEMAND
Definition of Shock
 Inadequate tissue perfusion to meet
tissue demands
 Usually result of inadequate blood flow
and/or oxygen delivery
 Shock is not a blood pressure diagnosis!!
Characteristics of Shock
 End organ dysfunction:
 reduced urine output
 altered mental status
 poor peripheral perfusion
 Metabolic dysfunction:
 acidosis
 altered metabolic demands
Essentials of Life
 Gas exchange capability of lungs
 Hemoglobin
 Oxygen content
 Cardiac output
 Tissues to utilize substrate
Arterial Oxygen Content
Hgb 15 gm/100 mL
Hemoglobin
SaO
2
97%
Oxygen Saturation
PaO
2
100 mmHg
Partial Pressure
O
2
bound to Hgb
100 mm Hg
+
O
2
in plasma
+
Oxygen Delivery
DO
2
=Cardiac Output x 1.34 (Hgb x SaO
2
) + Pa0
2
x 0.003
O
2
O
2
O
2
O
2
O
2
O
2
O
2
O
2
O
2
O
2
O
2
O
2
Oxygen Express
Ca0
2
Cardiac Output
The volume of blood ejected by
the heart in one minute
4 - 8 liters / minute
Cardiac Output

C.O.=Heart Rate x Stroke Volume
 Heart rate
 Stroke volume:
Preload- volume of blood in ventricle
Afterload- resistance to contraction
Contractility- force applied
Cardiac Output


C.O.=Mean arterial pressure (MAP) - CVP/SVR
 To improve CO:
 MAP
 CVP
 SVR

Preload
Afterload
Contractility
Resistance
Stroke Volume Heart Rate
Arterial Blood
Pressure
O
2
Delivery
O
2
Content
Cardiac Output
x
x
x
Classification of Shock
 Hypovolemic
 dehydration,burns,
hemorrhage
 Distributive
 septic, anaphylactic, spinal
 Cardiogenic
 myocarditis,dysrhythmia
 Obstructive
 tamponade,pneumothorax
 Compensated
 organ perfusion is
maintained
 Uncompensated
 Circulatory failure
with end organ
dysfunction
 Irreversible
 Irreparable loss of
essential organs
Mechanical Requirements for
Adequate Tissue Perfusion
 Fluid
 Pump
 Vessels
 Flow
Hypovolemic Shock:
Inadequate Fluid Volume
(decreased preload)
Hypovolemic Shock:
Causes
 Fluid depletion
 internal
 external
 Hemorrhage
 internal
 external
Cardiogenic Shock:
Pump Malfunction
(decreased contractility)
Cardiogenic Shock:
Causes

Electrical Failure
 Mechanical Failure
 Cardiomyopathy
 metabolic
 anatomic
 hypoxia/ischemia
Distributive Shock
Abnormal Vessel Tone
(decreased afterload)
Distributive Shock
Vasodilation
Venous Pooling
Decreased Preload
Maldistribution of regional blood flow
Distributive Shock:
Causes
 Sepsis
 Anaphylaxis
 Neurogenesis (spinal)
 Drug intoxication (TCA,
calcium, Channel blocker)
Septic Shock
Decreased
Volume
Decreased
Pump
Function
Abnormal
Vessel
Tone

Cardiac Output

C.O.=Heart Rate x Stroke Volume
 Heart rate
 Stroke volume:
Preload- volume of blood in ventricle
Afterload- resistance to contraction
Contractility- force applied
Clinical Assessment
 Heart rate
 Peripheral circulation
 capillary refill
 pulses
 extremity temperature
 Pulmonary
 End organ perfusion
 brain
 kidney
Improving Stroke Volume:
Therapy for Cardiovascular Support
Preload Volume
Contractility
Inotropes
Afterload
Vasodilators
Septic Shock
Early (“Warm”)
Decreased peripheral vascular resistance
Increased cardiac output

Late (“Cold”)
Increased peripheral vascular resistance
Decreased cardiac output
Assessment of Circulation
Early Late
Heart rate Tachycardia Tachycardia/
Bradycardia
Blood
pressure
Normal Decreased
Peripheral
circulation
Warm/Cool
Decreased/
Increased
pulses
Cool
Decreased
pulses
Heart Rate and Perfusion Pressure
(MAP-CVP) Parameters by Age
Age Heart Rate MAP-CVP
Term
newborn
120-180 55
< 1 120-180 60
< 2 120-160 65
< 7 120-160 65
< 15 90-140 65
Assessment of Circulation
Early Late
End-organ:
Skin
Decreased
cap refill
Very decreased
cap refill
Brain Irritable,
restless
Lethargic,
unresponsive
Kidneys Oliguria Oliguria, anuria
OBSTRUCTIVE SHOCK
OBSTRUCTED FLOW
Obstructive Shock:
Causes
 Pericardial tamponade
 Pulmonary embolism
 Pulmonary hypertension

Hemodynamic Assessment of Shock
Type of Shock Preload Afterload Contractility Cardiac
Output
Cardiogenic l l ¹ ¹
Hypovolemic ¹ l · ¹
Septic
Early
Late
¹
l
¹
l
·
¹
l
¹
Obstructive ¹ l ¹ ¹
Distributive ¹ ¹ l ·
Goals of Resuscitation
 Overall goal:
 increase O
2
delivery
 decrease demand
Treatment
O
2
content
Cardiac
output
Blood
pressure
Sedation/analgesia
Principles of Management
 A: Airway
patent upper airway
 B: Breathing
adequate ventilation and oxygenation
 C: Circulation
optimize
 cardiac function
 oxygenation
Act quickly,
Think slowly.
Greek Proverb
Airway Management
 Patients in shock have:
 O
2
delivery
 progressive respiratory fatigue/failure
 energy shunted from vital organs
 afterload

Airway Management
 Early intubation provides:
 O
2
delivery and content
 controlled ventilation which:
 reduces metabolic demand
 allows C.O. to vital organs

Therapy
Vagolysis
Chromotropy
Volume
CVP
Preload
Vasodilators
Vasoconstrictors
Afterload
Correct
acidosis
hypoxia
hypoglycemia
Inotropic
agents
Contractility
Stroke Volume
Heart
Rate

Fluid Choices
Colloid
Crystalloid
Crystalloids
Hypotonic Fluids (D
5
1/4 NS)
 No role in resuscitation
 Maintenance fluids only
Fluids, Fluids, Fluids
 Key to most resuscitative
efforts
 Give generously and reassess
Crystalloids
Isotonic Fluids
 Intravascular volume expansion
 Hauser:
crystalloids rapidly redistribute
 Lethal animal model
 NS = good resuscitative fluid
 4x blood volume to restore hemodynamics

Crystalloids
Isotonic Fluids

 2 trauma studies
crystalloids = colloids but:
 4x amount
 longer time to resuscitation
Crystalloids
Complications
 Under-resuscitation
 renal failure
 Over-resuscitation
 pulmonary edema
 peripheral edema
Crystalloids
Summary
 Crystalloids less effective than equal
volume of colloids
 Preferred when 1
o
deficit is water
and/or electrolytes
 Good in initial resuscitation to restore
extracellular volume
 Hypertonic solutions however, may act
as plasma volume expanders
Oncotic pressure
(tendency to pull unit)
Capillary
Hydrostatic pressure
(tendency to drive unit)
Fluid
Transport
Colloids
Albumin
 Hepatic production
 MW = 69,000
 80% of COP
 Serum t
1/2
:
18 hours endogenous
16 hours exogenous
Colloids
Hydroxyethyl Starch (Hespan)
 Synthetic
 Derived from corn starch
 Average MW = 69,000
 Stable, nonantigenic
 Used for volume expansion
 Renal excretion
t
1/2
2-67 hours
90% gone in 42 days
 Greater in COP than albumin
 Longer duration of action
 0.006% adverse reactions
 No effect on blood typing
 Prolongs PT, PTT and clotting times
 Dosage
20 ml/Kg/day
max 1500 ml/day
Colloids
Hydroxyethyl Starch (Hespan)
Fluid Choices
 Based on:
 type of deficit
 urgency of repletion
 pathophysiology of condition
 plasma COP
Fluid Choices
 Crystalloids for initial resuscitation
 PRBC’s to replace blood loss
Fluid Management in Pediatric
Septic Shock
 Emphasis on the golden hour
 Early aggressive use of fluids may
improve outcome
 Titrate-Reassess!
Clinical Practice Parameters,
Carcillo et al., CCM, 2002
Alpha-Beta Meter
Dopamine
Epinephrine
Inotropes
Agent Site of action Dose
(µg/kg/min)
Effects
Dopamine Dopaminergic
|
o > |
1-3
5-10
11-20
Renal vasodilator
Inotrope
Vasoconstriction
Increase PVR
Dobutamine |
1
and |
2
1-20 Inotrope
Vasodilation
Epinephrine
| > o
0.05-1.0 Inotrope
Tachycardia
Norepinephrine
o > |
0.05-1.0 Profound
vasoconstriction
Inotrope
Nitroprusside Vasodilator
Arterial >
venous
0.5-1.0 Vasodilation
Milrinone PDE inhibitor 0.5-0.75 Inotrope
Vasodilator
Dopamine Activity
0.5-5.0 mcg/kg/min - dopaminergic receptors
2.0-10 mcg/kg/min - beta receptors (inotrope)
10-20 mcg/kg/min - alpha and beta receptors
Over 20 mcg/kg/min - alpha receptors (pressors)
A Rational Approach to Shock in the Pediatric
Patient
Shock / Hypotension
Volume Resuscitation
Signs of adequate circulation
Adequate MAP
NO
NO
pressors
Yes
A Rational Approach to Pressor
Use in the PI CU
NO
Dopamine
Inadequate MAP
Dopamine and/or
Norepinephrine
Signs of adequate circulation
Adequate MAP
A Rational Approach to Pressor
Use in the PI CU
Dopamine and/or
norepinephrine
Inadequate MAP
low C.O.
epinephrine
adequate
MAP
Dobutamine
or Milrinone
tachycardia
phenylephrine??
CO
“New” Therapies in Septic
Shock
 Steroids
 Vasopressin
 Activated Protein C (Xigris) in septic
shock
Management of Pediatric Septic
Shock: The Golden Hour
 First 15 minutes
 Emphasis on response to volume
Clinical Practice Parameters,
Carcillo et al., CCM, 2002
Patients don’t suddenly
deteriorate, healthcare
professionals suddenly
notice!
Anonymous

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