pediatric shock management

1. Shock in the Pediatric Patient:Shock in the Pediatric Patient:
oror
Oxygen Don’t GoOxygen Don’t Go
Where the Blood Won’t Flow!Where the Blood Won’t Flow!
Dr. Virendra Kumar GuptaDr. Virendra Kumar Gupta
MD PediatricsMD Pediatrics
Fellowship In pediatric Gastroentero-Hepatology & LiverFellowship In pediatric Gastroentero-Hepatology & Liver
TransplantationTransplantation
Assistant ProfessorAssistant Professor
Institute of Paediatric GastroenterologyInstitute of Paediatric Gastroenterology
Nims University Jaipur Nims University Jaipur

2. ObjectivesObjectives
Define shock and its different categoriesDefine shock and its different categories
Review basic physiologic aspects of shockReview basic physiologic aspects of shock
Describe management of shock including:Describe management of shock including:
 oxygen supply and demandoxygen supply and demand
 fluid resuscitationfluid resuscitation
 crystalloid vs. colloid controversycrystalloid vs. colloid controversy
 vasopressor supportvasopressor support

3. IntroductionIntroduction
Shock is a syndrome that results fromShock is a syndrome that results from
inadequate oxygen delivery to meetinadequate oxygen delivery to meet
metabolic demandsmetabolic demands
Oxygen delivery (DOOxygen delivery (DO22 ) is less than) is less than
Oxygen Consumption (< VOOxygen Consumption (< VO22))
Untreated this leads to metabolicUntreated this leads to metabolic
acidosis, organ dysfunction and deathacidosis, organ dysfunction and death

4. Oxygen DeliveryOxygen Delivery
Oxygen delivery = Cardiac Output x ArterialOxygen delivery = Cardiac Output x Arterial
Oxygen ContentOxygen Content
(DO(DO22 = CO x CaO= CO x CaO22))
Cardiac Output = Heart Rate x Stroke VolumeCardiac Output = Heart Rate x Stroke Volume
((CO = HR x SV)CO = HR x SV)
– SV determined by preload, afterload andSV determined by preload, afterload and
contractilitycontractility
Art Oxygen Content = Oxygen content of theArt Oxygen Content = Oxygen content of the
RBC + the oxygen dissolved in plasmaRBC + the oxygen dissolved in plasma
(CaO(CaO22 = Hb X SaO= Hb X SaO22 X 1.34 + (.003 X PaOX 1.34 + (.003 X PaO22))

5. Figure 1. FACTORS AFFECTING OXYGEN DELIVERY
DO2
CaO2
CO
SV
HR
Oxygenation
Hgb
A-a gradient
DPG
Acid-Base Balance
Blockers
Competitors
Temperature
Drugs
Conduction System
Ventricular
Compliance
EDV
ESV Contractility
CVP
Venous Volume
Venous Tone
Afterload Blockers
Temperature Competitors
Drugs Autonomic Tone
Metabolic Milieu
Ions
Acid Base
Temperature
Drugs
Toxins
Influenced By
Influenced By
Influenced By
Influenced By

6. SUPPLYSUPPLY << DEMANDDEMAND

7. Definition of ShockDefinition of Shock
Inadequate tissue perfusion to meetInadequate tissue perfusion to meet
tissue demandstissue demands
Usually result of inadequate blood flowUsually result of inadequate blood flow
and/or oxygen deliveryand/or oxygen delivery
Shock is not a blood pressure diagnosis!!Shock is not a blood pressure diagnosis!!

8. Characteristics of ShockCharacteristics of Shock
End organ dysfunction:End organ dysfunction:
 reduced urine outputreduced urine output
 altered mental statusaltered mental status
 poor peripheral perfusionpoor peripheral perfusion
Metabolic dysfunction:Metabolic dysfunction:
 acidosisacidosis
 altered metabolic demandsaltered metabolic demands

9. Essentials of LifeEssentials of Life
Gas exchange capability of lungsGas exchange capability of lungs
HemoglobinHemoglobin
Oxygen contentOxygen content
Cardiac outputCardiac output
Tissues to utilize substrateTissues to utilize substrate

10. PreloadPreload
AfterloadAfterload
ContractilityContractility
ResistanceResistance
Stroke VolumeStroke Volume Heart RateHeart Rate
Arterial BloodArterial Blood
PressurePressure
OO22 DeliveryDelivery
OO22 ContentContent Cardiac OutputCardiac Output
xx
xx xx

11. Classification of ShockClassification of Shock
HypovolemicHypovolemic
 dehydration,burns,dehydration,burns,
hemorrhagehemorrhage
DistributiveDistributive
 septic, anaphylactic, spinalseptic, anaphylactic, spinal
CardiogenicCardiogenic
 myocarditis,dysrhythmiamyocarditis,dysrhythmia
ObstructiveObstructive
 tamponade,pneumothoraxtamponade,pneumothorax
CompensatedCompensated
 organ perfusion isorgan perfusion is
maintainedmaintained
UncompensatedUncompensated
 Circulatory failureCirculatory failure
with end organwith end organ
dysfunctiondysfunction
IrreversibleIrreversible
 Irreparable loss ofIrreparable loss of
essential organsessential organs

12. Hypovolemic Shock
Most common form of shock world-wide
Results in decreased circulating blood
volume, decrease in preload, decreased
stroke volume and resultant decrease in
cardiac output.
Etiology: Hemorrhage, renal and/or GI
fluid losses, capillary leak syndromes

13. Distributive Shock
Due to an abnormality in vascular tone leading
to peripheral pooling of blood with a relative
hypovolemia.
Etiology
– Anaphylaxis
– Drug toxicity
– Neurologic injury
– Early sepsis
Management
– Fluid
– Treat underlying cause

14. Obstructive Shock
Mechanical obstruction to ventricular
outflow
Etiology: Congenital heart disease, massive
pulmonary embolism, tension pneumothorax,
cardiac tamponade
Inadequate C.O. in the face of adequate
preload and contractility
Treat underlying cause.

15. Dissociative Shock
Inability of Hemoglobin molecule to give up
the oxygen to tissues
Etiology: Carbon Monoxide poisoning,
methemoglobinemia, dyshemoglobinemias
Tissue perfusion is adequate, but oxygen
release to tissue is abnormal
Early recognition and treatment of the cause
is main therapy

16. Cardiogenic ShockCardiogenic Shock
Cardiogenic shock is commonly describedCardiogenic shock is commonly described
as “pump failure” (decreased contractility)as “pump failure” (decreased contractility)
The common causes areThe common causes are
myocarditis, dysrhythmias,and drugsmyocarditis, dysrhythmias,and drugs
with a myocardial depressant action,with a myocardial depressant action,
acidosis, congenital heart lesions andacidosis, congenital heart lesions and
sepsis.sepsis.

17. SIRS/Sepsis/Septic shock
Mediator release:
exogenous & endogenous
Decreased blood
flow
Cardiac
dysfunction
Imbalance of
oxygen
supply and
demand
Alterations in
metabolism
SEPTIC SHOCKSEPTIC SHOCK
Decreased Volume / Decreased Pump Function/Abnormal Vessel
Tone

19. Mechanical Requirements forMechanical Requirements for
Adequate Tissue PerfusionAdequate Tissue Perfusion
FluidFluid
PumpPump
VesselsVessels
FlowFlow

20. Clinical AssessmentClinical Assessment
Heart rateHeart rate
Peripheral circulationPeripheral circulation
 capillary refillcapillary refill
 pulsespulses
 extremity temperatureextremity temperature
PulmonaryPulmonary
End organ perfusionEnd organ perfusion
 brainbrain
 kidneykidney

21. Improving Stroke Volume:Improving Stroke Volume:
Therapy for Cardiovascular SupportTherapy for Cardiovascular Support
Preload Volume
Contractility Inotropes
Afterload Vasodilators

22. Septic ShockSeptic Shock
Early (“Warm”)Early (“Warm”)
Decreased peripheral vascular resistanceDecreased peripheral vascular resistance
Increased cardiac outputIncreased cardiac output
Late (“Cold”)Late (“Cold”)
Increased peripheral vascular resistanceIncreased peripheral vascular resistance
Decreased cardiac outputDecreased cardiac output

23. Assessment of CirculationAssessment of Circulation
Early Late
Heart rate Tachycardia Tachycardia/
Bradycardia
Blood
pressure
Normal Decreased
Peripheral
circulation
Warm/Cool
Decreased/
Increased
pulses
Cool
Decreased
pulses

24. Assessment of CirculationAssessment of Circulation
Early Late
End-organ:
Skin
Decreased
cap refill
Very decreased
cap refill
Brain Irritable,
restless
Lethargic,
unresponsive
Kidneys Oliguria Oliguria, anuria

25. Heart Rate and Perfusion PressureHeart Rate and Perfusion Pressure
(MAP-CVP) Parameters by Age(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

26. Hemodynamic Assessment of ShockHemodynamic Assessment of Shock
Type of Shock Preload Afterload Contractility Cardiac
Output
Cardiogenic ⇑ ⇑ ⇓ ⇓
Hypovolemic ⇓ ⇑ ⇔ ⇓
Septic
Early
Late
⇓
⇑
⇓
⇑
⇔
⇓
⇑
⇓
Obstructive ⇓ ⇑ ⇓ ⇓
Distributive ⇓ ⇓ ⇑ ⇔

27. Goals of ResuscitationGoals of Resuscitation
Overall goal:Overall goal:
 increase Oincrease O22 deliverydelivery
 decrease demanddecrease demand
TreatmentTreatment
OO22 contentcontent CardiacCardiac
outputoutput
BloodBlood
pressurepressure
Sedation/analgesiaSedation/analgesia

28. Principles of ManagementPrinciples of Management
A: AirwayA: Airway
 patent upper airwaypatent upper airway
B: BreathingB: Breathing
 adequate ventilation and oxygenationadequate ventilation and oxygenation
C: CirculationC: Circulation
 optimizeoptimize
 cardiac functioncardiac function
 oxygenationoxygenation

29. Act quickly,
Think slowly.
Greek Proverb

30. Airway ManagementAirway Management
Patients in shock have:Patients in shock have:
 OO22 deliverydelivery
 progressive respiratory fatigue/failureprogressive respiratory fatigue/failure
 energy shunted from vital organsenergy shunted from vital organs
 afterloadafterload

31. Airway ManagementAirway Management
Early intubation provides:Early intubation provides:
 OO22 delivery and contentdelivery and content
 controlled ventilation which:controlled ventilation which:
 reduces metabolic demandreduces metabolic demand
 allows C.O. to vital organsallows C.O. to vital organs

32. TherapyTherapy
Vagolysis
Chromotropy
V o lu m e
C V P
P re lo a d
V a s o d ila to rs
V a s o c o n s tric to rs
A fte rlo a d
C o rre c t
a c id o s is
h y p o x ia
h y p o g ly c e m ia
In o tro p ic
a g e n ts
C o n tra c tility
S tro k e V o lu m e
Heart
Rate 

33. Fluid ChoicesFluid Choices
Less Filling
Less Filling
Tastes Great !
Tastes Great !
Colloid Crystalloid

34. CrystalloidsCrystalloids
Hypotonic Fluids (DHypotonic Fluids (D55 1/4 NS)1/4 NS)
No role in resuscitationNo role in resuscitation
Maintenance fluids onlyMaintenance fluids only

35. Fluids, Fluids, FluidsFluids, Fluids, Fluids
Key to most resuscitativeKey to most resuscitative
effortsefforts
Give generously and reassessGive generously and reassess

36. CrystalloidsCrystalloids
Isotonic FluidsIsotonic Fluids
Intravascular volume expansionIntravascular volume expansion
Hauser:Hauser:
 crystalloids rapidly redistributecrystalloids rapidly redistribute
Lethal animal modelLethal animal model
 NS = good resuscitative fluidNS = good resuscitative fluid
 4x blood volume to restore hemodynamics4x blood volume to restore hemodynamics

37. CrystalloidsCrystalloids
Isotonic FluidsIsotonic Fluids
2 trauma studies2 trauma studies
crystalloids = colloids but:crystalloids = colloids but:
 4x amount4x amount
 longer time to resuscitationlonger time to resuscitation

38. CrystalloidsCrystalloids
ComplicationsComplications
Under-resuscitationUnder-resuscitation
 renal failurerenal failure
Over-resuscitationOver-resuscitation
 pulmonary edemapulmonary edema
 peripheral edemaperipheral edema

39. CrystalloidsCrystalloids
SummarySummary
Crystalloids less effective than equalCrystalloids less effective than equal
volume of colloidsvolume of colloids
Preferred when 1Preferred when 1oo
deficit is waterdeficit is water
and/or electrolytesand/or electrolytes
Good in initial resuscitation to restoreGood in initial resuscitation to restore
extracellular volumeextracellular volume
Hypertonic solutions however, may actHypertonic solutions however, may act
as plasma volume expandersas plasma volume expanders

40. Oncotic pressure
(tendency to pull unit)
CapillaryCapillary
Hydrostatic pressure
(tendency to drive unit)
FluidFluid
TransportTransport

41. ColloidsColloids
AlbuminAlbumin
Hepatic productionHepatic production
MW = 69,000MW = 69,000
80% of COP80% of COP
Serum tSerum t1/21/2::
18 hours endogenous18 hours endogenous
16 hours16 hours exogenousexogenous

42. ColloidsColloids
Hydroxyethyl Starch (Hespan)Hydroxyethyl Starch (Hespan)
SyntheticSynthetic
Derived from corn starchDerived from corn starch
AverageAverage MW = 69,000MW = 69,000
Stable, nonantigenicStable, nonantigenic
Used for volume expansionUsed for volume expansion
Renal excretionRenal excretion
 tt 1/21/2 2-67 hours2-67 hours
 90% gone in 42 days90% gone in 42 days

43. Greater in COP than albuminGreater in COP than albumin
Longer duration of actionLonger duration of action
0.006% adverse reactions0.006% adverse reactions
No effect on blood typingNo effect on blood typing
Prolongs PT, PTT and clotting timesProlongs PT, PTT and clotting times
DosageDosage
 20 ml/Kg/day20 ml/Kg/day
 max 1500 ml/daymax 1500 ml/day
ColloidsColloids
Hydroxyethyl Starch (Hespan)Hydroxyethyl Starch (Hespan)

44. Fluid ChoicesFluid Choices
Based on:Based on:
 type of deficittype of deficit
 urgency of repletionurgency of repletion
 pathophysiology of conditionpathophysiology of condition
 plasma COPplasma COP
Tastes Great !
Tastes Great !
Less Filling
Less Filling

45. Fluid ChoicesFluid Choices
Crystalloids for initial resuscitationCrystalloids for initial resuscitation
PRBC’s to replace blood lossPRBC’s to replace blood loss

46. Fluid Management in PediatricFluid Management in Pediatric
Septic ShockSeptic Shock
Emphasis on the golden hourEmphasis on the golden hour
Early aggressive use of fluids mayEarly aggressive use of fluids may
improve outcomeimprove outcome
Titrate-Reassess!Titrate-Reassess!
Clinical Practice Parameters,
Carcillo et al., CCM, 2002

47. Alpha-Beta MeterAlpha-Beta Meter
ααßßDopamineDopamine
EpinephrineEpinephrine
Norepinephrine
Norepinephrine
Dobutam
ine
Dobutam
ine
Neosynephrine
Neosynephrine

48. InotropesInotropes
Agent Site of action Dose
(µg/kg/min)
Effects
Dopamine Dopaminergic
β
α > β
1-3
5-10
11-20
Renal vasodilator
Inotrope
Vasoconstriction
Increase PVR
Dobutamine β1 and β2 1-20 Inotrope
Vasodilation
Epinephrine β > α 0.05-1.0 Inotrope
Tachycardia
Norepinephrine α > β 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

49. Dopamine ActivityDopamine Activity
0.5-5.0 mcg/kg/min - dopaminergic receptors0.5-5.0 mcg/kg/min - dopaminergic receptors
2.0-10 mcg/kg/min - beta receptors (inotrope)2.0-10 mcg/kg/min - beta receptors (inotrope)
10-20 mcg/kg/min - alpha and beta receptors10-20 mcg/kg/min - alpha and beta receptors
Over 20 mcg/kg/min - alpha receptors (pressors)Over 20 mcg/kg/min - alpha receptors (pressors)

50. A Rational Approach to Shock in theA Rational Approach to Shock in the
Pediatric PatientPediatric Patient
Shock / HypotensionShock / Hypotension
Volume ResuscitationVolume Resuscitation
Signs of adequate circulationSigns of adequate circulation
Adequate MAPAdequate MAP
NONO
NONO
pressorspressors
YesYes

51. A Rational Approach to PressorA Rational Approach to Pressor
Use in the PICUUse in the PICU
NONO
DopamineDopamine
Inadequate MAPInadequate MAP
Dopamine and/orDopamine and/or
NorepinephrineNorepinephrine
Signs of adequate circulationSigns of adequate circulation
Adequate MAPAdequate MAP

52. A Rational Approach to PressorA Rational Approach to Pressor
Use in the PICUUse in the PICU
Dopamine and/orDopamine and/or
norepinephrinenorepinephrine
Inadequate MAPInadequate MAP
low C.O.low C.O.
epinephrineepinephrine
adequateadequate
MAPMAP
DobutamineDobutamine
oror
MilrinoneMilrinone
tachycardiatachycardia
phenylephrine??phenylephrine??
COCO

53. ““New” Therapies in SepticNew” Therapies in Septic
ShockShock
SteroidsSteroids
VasopressinVasopressin
Activated Protein C (Xigris) in septicActivated Protein C (Xigris) in septic
shockshock

54. Management of Pediatric SepticManagement of Pediatric Septic
Shock: The Golden HourShock: The Golden Hour
First 15 minutesFirst 15 minutes
Emphasis on response to volumeEmphasis on response to volume
Clinical Practice Parameters,
Carcillo et al., CCM, 2002

56. Early Goal directed therapy in treatment of sepsis and septic shock- Rivers et al., NEJM, Nov 2001

57. Community-Acquired SepsisCommunity-Acquired Sepsis
 Pneumonia-Quinolone PLUS B-lactamPneumonia-Quinolone PLUS B-lactam
 Abdominal-Carbapenem OR Pip-TazoAbdominal-Carbapenem OR Pip-Tazo
 Skin/Soft Tissue-Vanco PLUS Carbapenem or Pip-TazoSkin/Soft Tissue-Vanco PLUS Carbapenem or Pip-Tazo
 Urinary Tract-Quinolone PLUS Amp/VancoUrinary Tract-Quinolone PLUS Amp/Vanco
 Unknown-Vanco PLUS B-lactamUnknown-Vanco PLUS B-lactam
Health-Care Associated SepsisHealth-Care Associated Sepsis
 Lung-B-lactam PLUS VancoLung-B-lactam PLUS Vanco
 BloodstreamBloodstream -B-lactam PLUS Vanco +/- Antifungal-B-lactam PLUS Vanco +/- Antifungal
 Surgical SiteSurgical Site -B-lactam PLUS Vanco +/- Anaerobic coverage-B-lactam PLUS Vanco +/- Anaerobic coverage
 Suspected Candida-CaspofunginSuspected Candida-Caspofungin
 Unknown-B-lactam PLUS VancoUnknown-B-lactam PLUS Vanco
Antibiotic Guidelines in Sepsis by Suspected SiteAntibiotic Guidelines in Sepsis by Suspected Site

58. Patients don’t suddenlyPatients don’t suddenly
deteriorate, healthcaredeteriorate, healthcare
professionals suddenlyprofessionals suddenly
notice!notice!
THANK YOUTHANK YOU