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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
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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
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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
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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
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SUPPLY SUPPLY << DEMANDDEMAND
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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!!
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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
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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
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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
+
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Oxygen DeliveryOxygen Delivery
DO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x
0.003
OO22OO22OO22OO22OO22OO22 OO22OO22OO22OO22OO22OO22Oxygen ExpressOxygen Express
Ca02
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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
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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
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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
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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
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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
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Mechanical Requirements Mechanical Requirements for Adequate Tissue for Adequate Tissue PerfusionPerfusion
FluidFluid
PumpPump
VesselsVessels
FlowFlow
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Hypovolemic Shock:Hypovolemic Shock:
Inadequate Inadequate FluidFluid VolumeVolume
(decreased preload)(decreased preload)
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Hypovolemic Shock:Hypovolemic Shock:CausesCauses
Fluid Fluid depletiondepletion internalinternal externalexternal
HemorrhageHemorrhage internalinternal externalexternal
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Cardiogenic Shock:Cardiogenic Shock:
Pump MalfunctionPump Malfunction
(decreased (decreased contractility)contractility)
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Cardiogenic Shock:Cardiogenic Shock:CausesCauses
Electrical FailureElectrical Failure Mechanical Mechanical
FailureFailure CardiomyopathyCardiomyopathy metabolicmetabolic anatomicanatomic hypoxia/ischemiahypoxia/ischemia
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Distributive ShockDistributive Shock
Abnormal Vessel Abnormal Vessel ToneTone
(decreased (decreased afterload)afterload)
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Distributive ShockDistributive Shock
Vasodilation Venous Pooling
Decreased Preload
Maldistribution of regional blood flow
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Distributive Shock:Distributive Shock:
CausesCauses SepsisSepsis AnaphylaxisAnaphylaxis Neurogenesis (spinal)Neurogenesis (spinal) Drug intoxication Drug intoxication
(TCA, calcium, (TCA, calcium, Channel blocker)Channel blocker)
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Septic Shock
Decreased Volume
Decreased Pump
Function
Abnormal Vessel Tone
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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
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Clinical AssessmentClinical Assessment Heart rateHeart rate Peripheral circulationPeripheral circulation
capillary refillcapillary refill pulsespulses extremity temperatureextremity temperature
PulmonaryPulmonary End organ perfusionEnd organ perfusion
brainbrain kidneykidney
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Improving Stroke Volume:Improving Stroke Volume:Therapy for Cardiovascular Therapy for Cardiovascular SupportSupport
Preload Volume
Contractility Inotropes
Afterload Vasodilators
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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
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Assessment of CirculationAssessment of CirculationEarly Late
Heart rate Tachycardia Tachycardia/Bradycardia
Bloodpressure
Normal Decreased
Peripheralcirculation
Warm/CoolDecreased/Increasedpulses
CoolDecreasedpulses
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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
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Assessment of CirculationAssessment of CirculationEarly Late
End- organ:Skin
Decreasedcap refill
Very decreasedcap refill
Brain I rritable,restless
Lethargic,unresponsive
Kidneys Oliguria Oliguria, anuria
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OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK
OBSTRUCTED OBSTRUCTED FLOWFLOW
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Obstructive Shock:Obstructive Shock:CausesCauses
Pericardial tamponadePericardial tamponade
Pulmonary embolismPulmonary embolism
Pulmonary Pulmonary hypertensionhypertension
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Hemodynamic Assessment of Hemodynamic Assessment of ShockShock
Type of Shock Preload Afterload Contractility CardiacOutput
Cardiogenic
Hypovolemic Septic
Early
Late
Obstructive
Distributive
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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
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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
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Act quickly,Think slowly.
Greek Proverb
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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
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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
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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
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Fluid ChoicesFluid Choices
Less FillingLess Filling
Tastes Great !
Tastes Great !
Colloid
Crystalloid
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CrystalloidsCrystalloidsHypotonic Fluids (DHypotonic Fluids (D5 5 1/4 1/4 NS)NS) No role in resuscitationNo role in resuscitation Maintenance fluids onlyMaintenance fluids only
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Fluids, Fluids, FluidsFluids, Fluids, Fluids
Key to most resuscitative Key to most resuscitative effortsefforts
Give generously and reassessGive generously and reassess
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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
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CrystalloidsCrystalloidsIsotonic FluidsIsotonic Fluids
2 trauma studies2 trauma studiescrystalloids = colloids but:crystalloids = colloids but:
4x amount4x amount longer time to resuscitationlonger time to resuscitation
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CrystalloidsCrystalloidsComplicationsComplications
Under-resuscitationUnder-resuscitation renal failurerenal failure
Over-resuscitationOver-resuscitation pulmonary edemapulmonary edema peripheral edemaperipheral edema
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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
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Oncotic pressure (tendency to pull unit) CapillaryCapillary
Hydrostatic pressure (tendency to drive unit)
Fluid Fluid TranspoTransportrt
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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
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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
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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)
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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
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Fluid ChoicesFluid Choices
Crystalloids for initial Crystalloids for initial resuscitationresuscitation
PRBC’s to replace blood lossPRBC’s to replace blood loss
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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
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Alpha-Beta Alpha-Beta MeterMeter
ßßDopamineDopamine
EpinephrineEpinephrineNorepinephrine
Norepinephrine Dobutamine
DobutamineNeosynephrine
Neosynephrine
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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
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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)
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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
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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
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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
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““New” Therapies in New” Therapies in Septic ShockSeptic Shock SteroidsSteroids VasopressinVasopressin Activated Protein C (Xigris) in Activated Protein C (Xigris) in
septic shockseptic shock
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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
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Patients don’t Patients don’t suddenly deteriorate, suddenly deteriorate, healthcare healthcare professionals suddenly professionals suddenly notice!notice!
AnonymouAnonymouss