The Mystery of The Shocked BabyThe Mystery of The Shocked Baby

History

A 10-day-old female infant born at 39 weeks of gestation. She was born by normal spontaneous vaginal delivery and was discharged home.

The mother has a history of primary infertility 3 years.

The mother’s pregnancy, labor were unremarkable.

History This infant was feeding and voiding appropriately

in first days of life.

But parental account that their infant became progressively “fussy”. She breathed faster and required a longer time for each bottle-feeding.

On the day of presentation she fed no more than 30ml of formula and hadn’t voided since the night before.

Vital signs

Temperature 36.8 C Heart rate 190 b/min

CRT = 5 Sec

RR = 69 b/min Blood pressure from the right arm 78/50 mmHg

Sao2 from the right hand is 96% Weight is 3.3 kg

Examination

CNS: conscious but confused with decreased spontaneous movements and weak crying.

CVS: precordium is hyperdynamic, pulmonary component S2 is loud, no murmurs and Lower extremity pulses are difficult to palpate.

Chest: RD Grade ІІ, Equal breath sounds bilaterally with fine rales at both lung bases.

Examination

The liver is palpable 4 cm below the right costal margin.

Her feet are cool to touch.

Baby was pale.

There are no skin lesions.

What is the problem with this baby ?

Shock:Shock:

Shock is the inadequate perfusion Shock is the inadequate perfusion of the body’s vital organsof the body’s vital organs

Indices of tissue perfusion

Pallor & skin mottling Capillary refill time (>3 sec) Heart rate ( > 170 B\min ) Toe-core temperature difference (>2ºC) Urine output (<1 mL/kg/hr) Blood lactate (>2.5 mmol/L)

Which one is shocked ?

Causes of neonatal shock

O2

Pump

Pipes

Circulation

Tank

Non Vital

Vital organs

Remember !!

Once shock is suspected start supportive measures as soon as possible:

airway and assuring its patency. providing oxygen or positive pressure

ventilation. achieving intravascular ( peripheral or

central )or intraosseous access.

Algorithm for management of shock:

Algorithm for management of shock:

Fluid Boluse

Excessive volume expansion may be potentially harmful in Cardiogenic Shock.

Preterm babies can not deal with

Excessive volume expansion which increase likelihood of PDA & NEC.

Why not more than 20ml/kg ?

Clinical signs of hypovolemic shock depend on the degree of intravascular volume depletion:

25% in compensated shock 25-40% in uncompensated shock ( But with myocardial depression)

more than 40% in irreversible shock.

Dopamine Doses

New school Effect Old school

0.5 to 2 μg/kg/min Renal and mesenteric vasodilatation

2.5 to 5 μg/kg/min

2 to 8 μg/kg/min Increased myocardial contractility and heart rate

5 to 10 μg/kg/min

> 8 μg/kg/minSignificant peripheral VC & increase in PVR and blood

pressure10 to 20 μg/kg/min

Dobutamine

Mech: produces vasodilation and increases Cardiac muscle contration.

1st line in: Preterm < 48 hrs PPHN Heart failure

Adrenalin (The most potent inotrope)

Adrenalin results in significant increases in:

Myocardial contractility Cardiac output Peripheral vascular resistance Blood pressure

Milrinone = Primacor

Mech: Improve contractility Improve diastolic function Systemic and pulmonary vasodilation= Decrease

after load & Decrease Pulmonary BP

Indication: Shock post Cardiac Surgery Septic Shock Severe PPHN

When to response ??

Reassess within 10 min of fluid bolus

Reassess every 15–20 min of new dose of Inotropes

Caution !!

Inotropic agents: contraindicated in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is common in IDMs

Caution !!

Catecholamines : Never administer intra-arterially

Dopamine shown to suppress TSH secretion

Remember !!

Correction of negative inotropic factors:

as hypoxia, hypoglycemia, hypocalcemia, acidosisand electrolytes imbalance,

if present.

Digoxin is used in non-critically ill infants.

What about NaHco3 ?

Indications: To correct normal anion gap metabolic acidosis caused

by Renal (RTA) or GI Losses (Diarrhea, Surgery for NEC,ileostomy).

Treatment of life-threatening hyperkalemia.

In significant metabolic acidosis (pH<7.20 or BD > 10), it may be useful to give NaHco3.

(very controversial)

Textbook of Neonatal Resuscitation, 7th Edition

NaHco3 Dose

Dose (in mEq) based on Base Deficit = 0.3 X Base deficit (mEq/L) X weight (kg).

Give ½ dose then assess need for remainder

Dose is given over 30 minutes at least. Sodium Bicarbonate 8.4 % contains 1 mEq NaHCO3 / mL

Incompatible with dobutamine, dopamine, epinephrine, midazolam.

NaHco3 side effects

IVH (with rapid infusion)

Increase PCO2 so decrease pH (if given during inadequate ventilation)

Local tissue necrosis Hypocalcemia Hypernatremia and hypokalemia

Caution !!

Do not treat metabolic acidosis with hyperventilation.

NaHCO3 is not a recommended therapy in NRP

It is best to correct the underlying cause of the metabolic acidosis.

Corticosteroid therapy

Mech: up-regulate adrenergic receptor & as replacement in adrenal insufficiency.

When: in extremely PT with hypotension refractory to volume & vasopressors (high dose dopamine or epinephrine).

Hydrocortisone: 1 mg/kg every 8-12 hrs for 2-3 days.

Dexamethasone: 0.1 mg/kg followed by 0.05 mg/kg IV every 12 H for 5 doses.

Back to our case

Baby was placed on O2 and received one fluid bolus plus Dopamine 10 μg/kg/min + Dobutamine 10 μg/kg/min without any improvement in perfusion.

This bad news was told to the parents in an appropriate way.

Investigations

Serum glucose Blood gases Hematocrit (Hct) Electrolyte CBC, CRP, and cultures Chest x-ray Echocardiography & ECG Renal functions & Liver function tests

Investigations

CBC: Hct 41%, WBC 15 × 103, platelet count 23 × 103.

PH 7.18, CO2 30, NaHCO3 10 mEq/L, BE -16. Na 145 mEq/L, K 5 mEq/L, Ca 9 mg/dl.

RBS = 69 mg/dl. CRP -Ve Urea 40 mg/dl, Creatinine 1.0 mg/dl.

Chest X-ray: Cardiomegaly, increased pulmonary vascularity.

Case progression

Dopamine increased to 20 μg/kg/min + Dobutamine 20 μg/kg/min without any improvement in perfusion.

After senior consultant PGE1 infusion was started and Echocardiogram was being arranged.

Duct dependent systemic circulation

Neonates who present with shock within the first 3 weeks of life are likely to have CHD with duct dependent systemic flow.

It is appropriate to begin PGE-1, even if before A diagnosis made by echocardiography.

PGE1 infusion:

Dose: 0.05-0.1μg/kg/min, start with 0.05μg/kg/min, if no improvement increase to 0.1 μg/kg/min.

Adverse effects: Hypotension, flushing, tachycardia, apnea, fever, and Hypokalemia.

When Baby respond to PGE-1 ?

Maximum effect seen within 30 min in cyanotic lesions,

may take several hours in acyanotic lesions

Echocardiogram: HLHS

Left-sided obstructive heart disease (Duct-dependent systemic circulation)

These diseases include:

Hypoplastic left heart syndrome (HLHS)(most common and severe)

Critical aortic stenosis (AS) Co-arctation of the aorta (COA) Interrupted aortic arch (IAA)

Approaches to HLHS

What about Entral feeding ?

Infants in shock should not be fed.

Intestines will require 2 days or more for recovery before small feedings can be attempted.

Initiate total parenteral nutrition as soon as possible.

Shock & Assisted Ventilation

NCPAP is Contraindicated in Severe cardiovascular instability.

Ventilation is an excellent inotrope

Shock & Ventilatory setting

Refractory Shock

Hypopituitarism Hypoadrenalism (Congenital adrenal hyperplasia, Addison disease)

Large PDA Central line leakage GIT problems (e.g. NEC, perforation)

Drugs ( e.g. muscle relaxants ) Poor myocardial contractility (e.g. cardiomyopathy)

Inborn errors of metabolism (e.g. Organic acidemia )

Refractory Shock:

Hidden Hemorrhage

Subgaleal HemorrhageAdrenal hemorrhage

Refractory Shock:

Hidden Hemorrhage

Fractured Humerus Fractured femur

Refractory Shock:

Periventricular hemorrhage / intraventricular hemorrhage

Refractory Shock:

Pneumothorax

Refractory Shock:

Pneumopericardium

Refractory Shock:

Pneumothorax & Pneumopericardium

Recent Approach :Recent Approach :

Functional Echocardiography and Doppler Flow Velocimetry:

Assessment of global heart contractility

Assessment of superior vena cava flow

Take Home Massage

Once shock is suspected start supportive measures as soon as possible.

Thereafter, treatment is directed by

the underlying pathology.

Take Home Massage

In Shock: Obtain vascular access including arterial line, better through

umbilical vessels.

BP is maintained until very late Hypotension is a pre-terminal sign

Take Home Massage

PGE1 is considered before diagnosis is confirmed if duct-dependent systemic

blood flow is suspected.

NaHCO3 is not a recommended therapy in NRP.

Thank youThank you