Fluid management inpediatric shock

Rismala Dewi

Emergency and Pediatric Intensive Care DivisionFMUI-CMH

Pediatric Assessment Triangle

Circulation

Hemodynamics

MyocardialContractility

Stroke Volume Preload

Cardiac Output Afterload

Blood Pressure Heart Rate

Systemic Vascular Resistance

pediatric

Understanding some of physiologicaldifferences will help when working with a

critically ill child

Hypotension is a late

and premorbid sign

StrokeVolume

Afterload

Contractility

Preload

Heart Rate

Cardiac Output

A state in which there is inadequate

tissue perfusion to meet metabolic

demands

It is not LOW BLOOD PRESSURE !!!It is HYPOPERFUSION…..

Hypotension is a late

and premorbid sign

Stages of ShockCOMPENSATED

vital organ function is maintained, BP remainsnormal, tachycardia

UNCOMPENSATEDmicrovascular perfusion is compromised; significantreductions in effective circulating volume

IRREVERSIBLEinadequate perfusion of vital organs; irreparabledamage; death cannot be prevented

“Whatever the cause, the body responds in similar way”

The questions must be answered:

Does the child require emergent therapy?

What kind of fluid should be given?

How much fluid and what rate should fluid begiven initially and then in follow-up?

Management

Volumereplacement

Fluidreplacement

Fluidreplacement

Interstitial

Plasma

Transcellular

14% 5% 1%

Extracellular water20% body weight

Intracellular water40% body weight

Total body water = 60% body weightO

smol

ality

–m

Osm

/L

300

200

100

0

SHOCK

Fluid balance paradigm

Normal heart rate

Normal pulses

Capillary refill time < 2 seconds

Normal blood pressure

Warm extremities

Normal mental status

Urine output >1 mL/kg/hr

Whichfluid?

Cristalloid Colloid

Advantages

Extracellular space expanders

Lactare buffer

Limited plasma volume expansion

Maintain urinee output

Reduced plasma oncotic pressure

Cheap

Advantages

Good intravascular persistence

Reduced resuscicitation time

Moderate volume required

Enhancing microvascular flow

Minor risk of tissue oedem

Moderation of SIRS

Disadvantages

Poor plasma volume support

Reduce plasma COP

Large quantities needed

Risk of overhydration

Risk of hyponatremia

Disadvantages

Risk of volume overload

Adverse effect on haemostasis

Tissue accumulation

Adverse effect on renal function

Risk of anaphylaxis

More expensive

Initial fluid resuscitation with crystalloidminimal 20 mL/Kg in children

Consider addition of albumin in patientrequiring substantial amounts of crystalloid

to maintain adequate MAP

Goaldirected

(targeted)

Don’t give too much Fluid!!

Hepatomegaly

Rales

Increased WOB

↑Jugular venous pressure

Chest X-ray

USCOM

Echocardiography

Fluid responsiveness

Problem to be concern

Metabolicacidosis

Volumeoverload

Electrolyteimbalance

CoagulopathyFluid shiftand raised

ICP

Maintenance fluid

Choong, K et al. Arch Dis Child 2006;91:828-835

Meta- analysis iv fluids in children:-hypotonic vs. isotonic-

Isotonic solutions Hyponatremia

Stablehemodynamic?

Volumeresponsive?

Continue volumereplacement

Cold extremities?

Y

N

NYMonitor

INOTROPIC VASOPRESSOR

Conclusion

Recognize compensated shock quickly-havea high index of suspicion, remembertachycardia is first sign and hypotension islate and ominousAssessment , management of fluid balanceand prescription of appropriate fluidconstitute some of challenges for clinician