Shock in the Pediatric Shock in the Pediatric Patient:Patient:

ororOxygen Don’t Go Oxygen Don’t Go

Where the Blood Won’t Where the Blood Won’t Flow!Flow!

James D. Fortenberry MD FAAP, FCCMJames D. Fortenberry MD FAAP, FCCM

Medical Director, PICUMedical Director, PICU

Division of Critical Care MedicineDivision of Critical Care Medicine

Children’s Healthcare of AtlantaChildren’s Healthcare of Atlanta

ObjectivesObjectives Define shock and its different Define shock and its different

categoriescategories Review basic physiologic aspects of Review basic physiologic aspects of

shockshock Describe management of shock Describe management of shock

including:including: oxygen supply and demandoxygen supply and demand fluid resuscitationfluid resuscitation

crystalloid vs. colloid controversycrystalloid vs. colloid controversy vasopressor supportvasopressor support

Definition of ShockDefinition of Shock Uncontrolled blood or fluid lossUncontrolled blood or fluid loss Blood pressure less than 5th Blood pressure less than 5th

percentile for agepercentile for age Altered mental status, low urine Altered mental status, low urine

output, poor capillary refilloutput, poor capillary refill None of the aboveNone of the above

Definition of ShockDefinition of Shock

An acute complex An acute complex pathophysiologic state of pathophysiologic state of circulatory dysfunction which circulatory dysfunction which results in a failure of the results in a failure of the organism to deliver sufficient organism to deliver sufficient amounts of oxygen and other amounts of oxygen and other nutrients to satisfy the nutrients to satisfy the requirements of tissue bedsrequirements of tissue beds

SUPPLY SUPPLY << DEMANDDEMAND

Definition of ShockDefinition of Shock

Inadequate tissue perfusion to Inadequate tissue perfusion to meet tissue demandsmeet tissue demands

Usually result of inadequate blood Usually result of inadequate blood flow and/or oxygen deliveryflow and/or oxygen delivery

Shock is not a blood pressure Shock is not a blood pressure diagnosis!!diagnosis!!

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

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

Arterial Oxygen Arterial Oxygen ContentContent

Hgb 15 gm/100 Hgb 15 gm/100 mLmL

HemoglobinHemoglobin

SaOSaO22 97% 97%

Oxygen Oxygen SaturationSaturation

PaOPaO22 100 mmHg 100 mmHg

Partial PressurePartial Pressure

OO22 bound to Hgb bound to Hgb

100 mm 100 mm HgHg

+

OO22 in in plasmaplasma

+

Oxygen DeliveryOxygen Delivery

DO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x

0.003

OO22OO22OO22OO22OO22OO22 OO22OO22OO22OO22OO22OO22Oxygen ExpressOxygen Express

Ca02

Cardiac OutputCardiac Output

The volume of blood ejected The volume of blood ejected by by the heart in one the heart in one minuteminute

4 - 8 liters / minute4 - 8 liters / minute

Cardiac OutputCardiac Output

C.O.=Heart Rate x Stroke VolumeC.O.=Heart Rate x Stroke Volume

Heart rateHeart rate Stroke volume:Stroke volume:

Preload- volume of blood in Preload- volume of blood in ventricleventricle

Afterload- resistance to contractionAfterload- resistance to contraction Contractility- force appliedContractility- force applied

Cardiac OutputCardiac Output

C.O.=Mean arterial pressure (MAP) - C.O.=Mean arterial pressure (MAP) - CVP/SVRCVP/SVR

To improve CO:To improve CO: MAPMAP CVPCVP SVRSVR

PreloadPreloadAfterloadAfterloadContractilitContractilityy

ResistanResistancece

Stroke Stroke VolumeVolume

Heart RateHeart Rate

Arterial Blood Arterial Blood PressurePressure

OO22 Delivery Delivery

OO22 Content Content Cardiac Cardiac OutputOutput

xx

xx xx

Classification of ShockClassification of Shock

HypovolemicHypovolemic dehydration,burns, dehydration,burns,

hemorrhagehemorrhage

DistributiveDistributive septic, anaphylactic, septic, anaphylactic,

spinalspinal

CardiogenicCardiogenic myocarditis,dysrhythmiamyocarditis,dysrhythmia

ObstructiveObstructive tamponade,pneumothoraxtamponade,pneumothorax

CompensatedCompensated organ perfusion is organ perfusion is

maintainedmaintained

UncompensatedUncompensated Circulatory failure Circulatory failure

with end organ with end organ dysfunctiondysfunction

IrreversibleIrreversible Irreparable loss Irreparable loss

of essential of essential organsorgans

Mechanical Requirements Mechanical Requirements for Adequate Tissue for Adequate Tissue PerfusionPerfusion

FluidFluid

PumpPump

VesselsVessels

FlowFlow

Hypovolemic Shock:Hypovolemic Shock:

Inadequate Inadequate FluidFluid VolumeVolume

(decreased preload)(decreased preload)

Hypovolemic Shock:Hypovolemic Shock:CausesCauses

Fluid Fluid depletiondepletion internalinternal externalexternal

HemorrhageHemorrhage internalinternal externalexternal

Cardiogenic Shock:Cardiogenic Shock:

Pump MalfunctionPump Malfunction

(decreased (decreased contractility)contractility)

Cardiogenic Shock:Cardiogenic Shock:CausesCauses

Electrical FailureElectrical Failure Mechanical Mechanical

FailureFailure CardiomyopathyCardiomyopathy metabolicmetabolic anatomicanatomic hypoxia/ischemiahypoxia/ischemia

Distributive ShockDistributive Shock

Abnormal Vessel Abnormal Vessel ToneTone

(decreased (decreased afterload)afterload)

Distributive ShockDistributive Shock

Vasodilation Venous Pooling

Decreased Preload

Maldistribution of regional blood flow

Distributive Shock:Distributive Shock:

CausesCauses SepsisSepsis AnaphylaxisAnaphylaxis Neurogenesis (spinal)Neurogenesis (spinal) Drug intoxication Drug intoxication

(TCA, calcium, (TCA, calcium, Channel blocker)Channel blocker)

Septic Shock

Decreased Volume

Decreased Pump

Function

Abnormal Vessel Tone

Cardiac OutputCardiac Output

C.O.=Heart Rate x Stroke VolumeC.O.=Heart Rate x Stroke Volume

Heart rateHeart rate Stroke volume:Stroke volume:

Preload- volume of blood in Preload- volume of blood in ventricleventricle

Afterload- resistance to contractionAfterload- resistance to contraction Contractility- force appliedContractility- force applied

Clinical AssessmentClinical Assessment Heart rateHeart rate Peripheral circulationPeripheral circulation

capillary refillcapillary refill pulsespulses extremity temperatureextremity temperature

PulmonaryPulmonary End organ perfusionEnd organ perfusion

brainbrain kidneykidney

Improving Stroke Volume:Improving Stroke Volume:Therapy for Cardiovascular Therapy for Cardiovascular SupportSupport

Preload Volume

Contractility Inotropes

Afterload Vasodilators

Septic ShockSeptic Shock

Early (“Warm”)Early (“Warm”)

Decreased peripheral vascular Decreased peripheral vascular resistanceresistance

Increased cardiac outputIncreased cardiac output

Late (“Cold”)Late (“Cold”)

Increased peripheral vascular Increased peripheral vascular resistanceresistance

Decreased cardiac outputDecreased cardiac output

Assessment of CirculationAssessment of CirculationEarly Late

Heart rate Tachycardia Tachycardia/Bradycardia

Bloodpressure

Normal Decreased

Peripheralcirculation

Warm/CoolDecreased/Increasedpulses

CoolDecreasedpulses

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

Age Heart Rate MAP- CVPTerm

newborn120- 180 55

< 1 120- 180 60

< 2 120- 160 65

< 7 120- 160 65

< 15 90- 140 65

Assessment of CirculationAssessment of CirculationEarly Late

End- organ:Skin

Decreasedcap refill

Very decreasedcap refill

Brain I rritable,restless

Lethargic,unresponsive

Kidneys Oliguria Oliguria, anuria

OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK

OBSTRUCTED OBSTRUCTED FLOWFLOW

Obstructive Shock:Obstructive Shock:CausesCauses

Pericardial tamponadePericardial tamponade

Pulmonary embolismPulmonary embolism

Pulmonary Pulmonary hypertensionhypertension

Hemodynamic Assessment of Hemodynamic Assessment of ShockShock

Type of Shock Preload Afterload Contractility CardiacOutput

Cardiogenic

Hypovolemic Septic

Early

Late

Obstructive

Distributive

Goals of ResuscitationGoals of Resuscitation Overall goal:Overall goal:

increase Oincrease O22 delivery delivery decrease demanddecrease demand

TreatmentTreatment

OO22 contentcontent

CardiaCardiac c outpuoutputt

Blood Blood pressurpressuree

Sedation/Sedation/analgesiaanalgesia

Principles of ManagementPrinciples of Management A: AirwayA: Airway

patent upper airwaypatent upper airway B: BreathingB: Breathing

adequate ventilation and adequate ventilation and oxygenationoxygenation

C: CirculationC: Circulation optimizeoptimize

cardiac functioncardiac function oxygenationoxygenation

Act quickly,Think slowly.

Greek Proverb

Airway Airway ManagementManagement

Patients in shock have:Patients in shock have: OO22 delivery delivery progressive respiratory progressive respiratory

fatigue/failurefatigue/failure energy shunted from vital organsenergy shunted from vital organs afterloadafterload

Airway Airway ManagementManagement

Early intubation provides:Early intubation provides: OO22 delivery and content delivery and content controlled ventilation which:controlled ventilation which:

reduces metabolic demandreduces metabolic demand allows C.O. to vital organsallows C.O. to vital organs

TherapyTherapy

Vagolysis

Chromotropy

V o lum eC V P

P re load

V asodila to rsV asoconstr ic to rs

A fterload

C orrectac idos ishypox ia

hypog lycem ia

Ino trop icagen ts

C on trac tility

S troke V o lum eHeart Rate

Fluid ChoicesFluid Choices

Less FillingLess Filling

Tastes Great !

Tastes Great !

Colloid

Crystalloid

CrystalloidsCrystalloidsHypotonic Fluids (DHypotonic Fluids (D5 5 1/4 1/4 NS)NS) No role in resuscitationNo role in resuscitation Maintenance fluids onlyMaintenance fluids only

Fluids, Fluids, FluidsFluids, Fluids, Fluids

Key to most resuscitative Key to most resuscitative effortsefforts

Give generously and reassessGive generously and reassess

CrystalloidsCrystalloidsIsotonic 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 4x blood volume to restore

hemodynamicshemodynamics

CrystalloidsCrystalloidsIsotonic FluidsIsotonic Fluids

2 trauma studies2 trauma studiescrystalloids = colloids but:crystalloids = colloids but:

4x amount4x amount longer time to resuscitationlonger time to resuscitation

CrystalloidsCrystalloidsComplicationsComplications

Under-resuscitationUnder-resuscitation renal failurerenal failure

Over-resuscitationOver-resuscitation pulmonary edemapulmonary edema peripheral edemaperipheral edema

CrystalloidsCrystalloidsSummarySummary

Crystalloids less effective than Crystalloids less effective than equal volume of colloidsequal volume of colloids

Preferred when 1Preferred when 1oo deficit is water deficit is water and/or electrolytes and/or electrolytes

Good in initial resuscitation to Good in initial resuscitation to restore extracellular volumerestore extracellular volume

Hypertonic solutions however, Hypertonic solutions however, may act as plasma volume may act as plasma volume expandersexpanders

Oncotic pressure (tendency to pull unit) CapillaryCapillary

Hydrostatic pressure (tendency to drive unit)

Fluid Fluid TranspoTransportrt

ColloidsColloidsAlbuminAlbumin

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

ColloidsColloidsHydroxyethyl Starch Hydroxyethyl Starch (Hespan)(Hespan) Synthetic Synthetic Derived from corn starchDerived from corn starch AverageAverage MW = 69,000 MW = 69,000 Stable, nonantigenicStable, nonantigenic Used for volume expansionUsed for volume expansion Renal excretionRenal excretion

t t 1/2 1/2 2-67 hours2-67 hours 90% gone in 42 days90% gone in 42 days

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 Prolongs PT, PTT and clotting

timestimes DosageDosage

20 ml/Kg/day20 ml/Kg/day max 1500 ml/daymax 1500 ml/day

ColloidsColloidsHydroxyethyl Starch Hydroxyethyl Starch (Hespan)(Hespan)

Fluid ChoicesFluid Choices

Based on:Based on: type of deficittype of deficit urgency of repletionurgency of repletion pathophysiology of pathophysiology of

conditioncondition plasma COPplasma COP

Tastes Great !

Tastes Great !

Less FillingLess Filling

Fluid ChoicesFluid Choices

Crystalloids for initial Crystalloids for initial resuscitationresuscitation

PRBC’s to replace blood lossPRBC’s to replace blood loss

Fluid Management in Fluid Management in Pediatric Septic ShockPediatric Septic Shock Emphasis on the golden hourEmphasis on the golden hour Early aggressive use of fluids Early aggressive use of fluids

may improve outcomemay improve outcome Titrate-Reassess!Titrate-Reassess!

Clinical Practice Parameters,Carcillo et al., CCM, 2002

Alpha-Beta Alpha-Beta MeterMeter

ßßDopamineDopamine

EpinephrineEpinephrineNorepinephrine

Norepinephrine Dobutamine

DobutamineNeosynephrine

Neosynephrine

InotropesInotropesAgent Site of action Dose

(g/kg/min)Eff ects

Dopamine Dopaminergic

1- 35- 10

11- 20

Renal vasodilatorInotropeVasoconstrictionIncrease PVR

Dobutamine and 1- 20 InotropeVasodilation

Epinephrine 0.05- 1.0 InotropeTachycardia

Norepinephrine 0.05- 1.0 ProfoundvasoconstrictionInotrope

Nitroprusside VasodilatorArterial >venous

0.5- 1.0 Vasodilation

Milrinone PDE inhibitor 0.5- 0.75 InotropeVasodilator

Dopamine ActivityDopamine Activity

0.5-5.0 mcg/kg/min - dopaminergic 0.5-5.0 mcg/kg/min - dopaminergic receptorsreceptors

2.0-10 mcg/kg/min - beta receptors 2.0-10 mcg/kg/min - beta receptors (inotrope)(inotrope)

10-20 mcg/kg/min - alpha and beta 10-20 mcg/kg/min - alpha and beta receptorsreceptors

Over 20 mcg/kg/min - alpha receptors Over 20 mcg/kg/min - alpha receptors (pressors)(pressors)

A Rational Approach to Shock in the A 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

NO NO pressorspressorsYesYes

A Rational Approach to Pressor A Rational Approach to Pressor Use in the PICUUse in the PICU

NONO

DopamineDopamine

Inadequate MAPInadequate MAP

Dopamine and/or Dopamine and/or NorepinephrineNorepinephrine

Signs of adequate circulationSigns of adequate circulation

Adequate MAPAdequate MAP

A Rational Approach to Pressor A Rational Approach to Pressor Use in the PICUUse in the PICU

Dopamine and/or Dopamine and/or norepinephrinenorepinephrine

Inadequate MAPInadequate MAP

low C.O.low C.O.

epinephrineepinephrine

adequate adequate MAPMAP

Dobutamine Dobutamine or or

MilrinoneMilrinone

tachycardiatachycardia

phenylephrine??phenylephrine??

COCO

““New” Therapies in New” Therapies in Septic ShockSeptic Shock SteroidsSteroids VasopressinVasopressin Activated Protein C (Xigris) in Activated Protein C (Xigris) in

septic shockseptic shock

Management of Pediatric Septic Management of Pediatric Septic Shock: The Golden HourShock: The Golden Hour

First 15 minutes First 15 minutes Emphasis on response to volumeEmphasis on response to volume

Clinical Practice Parameters, Carcillo et al., CCM, 2002

Patients don’t Patients don’t suddenly deteriorate, suddenly deteriorate, healthcare healthcare professionals suddenly professionals suddenly notice!notice!

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