shock in paeds

8/7/2019 Shock in paeds

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

Oxygen Dont GoOxygen Dont GoWhere the Blood Wont Flow!Where the Blood Wont 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 MedicineChildrens Healthcare of AtlantaChildrens Healthcare of Atlanta


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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


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Definition of ShockDefinition of Shock

Uncontrolled blood or fluid lossUncontrolled blood or fluid loss

Blood pressure less than 5th percentileBlood pressure less than 5th percentilefor agefor age

Altered mental status, low urine output,Altered mental status, low urine output,poor capillary refillpoor capillary refill

None of the aboveNone of the above


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An acute complex pathophysiologicAn acute complex pathophysiologic

state of circulatory dysfunctionstate of circulatory dysfunctionwhich results in a failure of thewhich results in a failure of theorganism to deliver sufficientorganism to deliver sufficientamounts of oxygen and otheramounts of oxygen and other

nutrients to satisfy thenutrients to satisfy therequirements of tissue bedsrequirements of tissue beds


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SUPPLYSUPPLY


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Inadequate tissue perfusion to meetInadequate tissue perfusion to meettissue demandstissue demands

Usually result of inadequate blood flowUsually result of inadequate blood flowand/or oxygen deliveryand/or oxygen delivery

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

Hgb 15 gm/100 mLHgb 15 gm/100 mL

HemoglobinHemoglobin

SaOSaO22 97%97%

Oxygen SaturationOxygen Saturation

PaOPaO22 100 mmHg100 mmHgPartial PressurePartial Pressure

OO22 bound to Hgbbound to Hgb

100 mm Hg100 mm Hg

+

OO22 in plasmain plasma+


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Oxygen DeliveryOxygen DeliveryDO2=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 byThe volume of blood ejected bythe heart in one minutethe heart in one minute

44 -- 8 liters / minute8 liters / minute


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

Heart rateHeart rate

Stroke volume:Stroke volume: PreloadPreload-- volume of blood in ventriclevolume of blood in ventricle

AfterloadAfterload-- resistance to contractionresistance to contraction

Contractility

Contractility-- f

orce appliedforce applied


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

To improveCO:To improveCO:

MAPMAP

CVPCVP

SVRSVR


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PreloadPreloadAfterloadAfterloadContractilityContractility

ResistanceResistance

Stroke VolumeStroke Volume Heart RateHeart Rate

Arterial BloodArterial BloodPressurePressure

OO22 DeliveryDelivery

OO22 ContentContent CardiacOutputCardiacOutput

xx

xx xx


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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 CirculatoryfailureCirculatoryfailure

withend organwithend organ

dysfunctiondysfunction IrreversibleIrreversible

Irreparable loss ofIrreparable loss ofessential organsessential organs


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Mechanical RequirementsforMechanical RequirementsforAdequate Tissue PerfusionAdequate Tissue Perfusion

FluidFluid

PumpPump

VesselsVessels

FlowFlow


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Hypovolemic Shock:Hypovolemic Shock:

InadequateInadequateFluidFluid VolumeVolume(decreased preload)(decreased preload)


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Hypovolemic Shock:Hypovolemic Shock:

CausesCauses FluiddepletionFluiddepletion

internalinternal

externalexternal HemorrhageHemorrhage

internalinternal

externalexternal


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Cardiogenic Shock:Cardiogenic Shock:

Pump MalfunctionPump Malfunction(decreased contractility)(decreased contractility)


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Cardiogenic Shock:Cardiogenic Shock:

CausesCausesElectricalFailureElectricalFailure

MechanicalFailureMechanicalFailure CardiomyopathyCardiomyopathy metabolicmetabolic

anatomicanatomic

hypoxia/ischemiahypoxia/ischemia


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Distributive ShockDistributive Shock

Abnormal Vessel ToneAbnormal Vessel Tone(decreasedafterload)(decreasedafterload)


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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 (TCA,Drug intoxication (TCA,calcium, Channel blocker)calcium, Channel blocker)


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Septic Shock

Decreased

Volume

Decreased

Pump

Function

Abnormal

Vessel

Tone


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C.O.=Heart RatexStroke VolumeC.O.=Heart RatexStroke Volume

Heart rateHeart rate

Stroke volume:Stroke volume: PreloadPreload-- volumeof blood in ventriclevolumeof blood in ventricle

AfterloadAfterload-- resistance to contractionresistance to contraction

Con

tractilityCon

tractility-- fo

rce appliedfo

rce applied


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ClinicalAssessmentClinicalAssessment HeartrateHeartrate

Peripheral circulationPeripheral circulation capillaryrefillcapillaryrefill

pulsespulses extremity temperatureextremity temperature

PulmonaryPulmonary

Endo

rgan perfusionEn

do

rgan perfusion

brainbrain

kidneykidney


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ImprovingStroke Volume:ImprovingStroke Volume:TherapyforCardiovascularSupportTherapyforCardiovascularSupport

Preload Volume

Contractility Inotropes

Afterload Vasodilators


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Septic ShockSeptic ShockEarly (Warm)Early (Warm)

Decreased peripheral vascularresistanceDecreased peripheral vascularresistance

Increased cardiac outputIncreased cardiac output

Late (Cold)Late (Cold)

Increased peripheral vascularresistanceIncreased peripheral vascularresistanceDecreased cardiac outputDecreased cardiac output


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Assessment ofCirculationAssessment ofCirculationarl ate

eart rate ac car ia ac car ia

ra car ia

loo

ressure

ormal ecrea se

eri eralcirculation arm/C

oolecrease /

Increase

ulses

C

oolecrease

ulses


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Heart Rate and Perfusion PressureHeart Rate and Perfusion Pressure(MAP(MAP--CVP) Parameters byAgeCVP) Parameters byAge

Age Heart Rate MAP-CVPerm

ne born

- 8

< - 8 6

< - 6 6

< 7 - 6 6< 9 - 6


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Assessment ofCirculationAssessment ofCirculationarl ate

n or an:kin

ecreaseca refill

er ecreaseca refill

rain Irrita le,

restless

Let ar ic,

unresponsive

Ki nes li uria li uria, anuria


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OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK

OBSTRUCTEDFLOWOBSTRUCTEDFLOW


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Obstructive Shock:Obstructive Shock:CausesCauses

Pericardial tamponadePericardial tamponade

Pulmonary embolismPulmonary embolism

Pulmonary hypertensionPulmonary hypertension


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HemodynamicAssessment of ShockHemodynamicAssessment of Shock

Type of Shock Preload Afterload Contractility Cardiac

Output

Cardiogenic

Hypovolemic Septic

Early

Late

Obstructive

Distributive


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Goals of ResuscitationGoals of Resuscitation Overallgoal:Overallgoal:

increaseOincreaseO22 deliverydelivery

decreasedemanddecreasedemand

TreatmentTreatment

OO22 contentcontent CardiacCardiacoutputoutput

BloodBloodpressurepressure

Sedation/analgesiaSedation/analgesia


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Principles ofM

anagementPrinciples ofM

anagement A: AirwayA: Airway

atent upper airwayatent upper airway

B:BreathingB:Breathing adequate ventilation and oxygenationadequate ventilation and oxygenation

C: CirculationC: Circulation

optimizeoptimize cardiacfunctioncardiacfunction

oxygenationoxygenation


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Act quickly,

Thinkslowly.Greek Proverb


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A

irwayM

anagement

A

irwayM

anagement

Patients in shock have:Patients in shock have: OO22 deliverydelivery

progressive respiratory fatigue/failureprogressive respiratory fatigue/failure energy shunted from vitalorgansenergy shunted from vitalorgans

afterloadafterload


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AirwayManagementAirwayManagement

Early intubation provides:Early intubation provides: OO22 delivery andcontentdelivery andcontent

controlled ventilation which:controlled ventilation which: reduces metabolicdemandreduces metabolicdemand

allows C.O. to vitalorgansallows C.O. to vitalorgans


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TherapyTherapy

Vagolysis

Chromotropy

Volume

CVP

Preload

Vasodilators

Vasoconstrictors

Afterload

Correct

acidosishypoxiahypoglycemia

Inotropic

agents

Contractility

Stroke VolumeHeart

Rate U


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FluidChoicesFluidChoices

Colloid Crystalloid


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CrystalloidsCrystalloids

HypotonicFluids (DHypotonicFluids (D55 1/4 NS)1/4 NS)

No role in resuscitationNo role in resuscitation

Maintenanc

e fluids onlyMai

ntenanc

e fluids only


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Fluids, Fluids, FluidsFluids, Fluids, Fluids Key to mostresuscitativeKey to mostresuscitative

effortsefforts GivegenerouslyandreassessGivegenerouslyandreassess


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IsotonicFluidsIsotonicFluids Intravascular volumeexpansionIntravascular volumeexpansion

Hauser:Hauser:

crystalloids rapidly redistributecrystalloids rapidly redistribute Lethal animal modelLethal animal model

NS = good resuscitative fluidNS = good resuscitative fluid

4x

blood volume to restore hemodynami

cs4

xblood volume to restore hemody

nami

cs


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IsotonicFluidsIsotonicFluids

2 traumastudies2 traumastudies

crystalloids = colloids but:crystalloids = colloids but: 4x amount4x amount

longer time to resuscitationlonger time to resuscitation


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CrystalloidsCrystalloidsComplicationsComplications

UnderUnder--resuscitationresuscitation

renal failurerenal failure

OverOver--resuscitationresuscitation

pulmonaryedemapulmonaryedema

peripheraledemaperipheraledema


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SummarySummary Crystalloids lesseffective thanequalCrystalloids lesseffective thanequalvolume of colloidsvolume of colloids

Preferred when

1Preferred when

1oo

deficit is waterdeficit is waterand/orelectrolytesand/orelectrolytes

Good in initial resuscitation to restoreGood in initial resuscitation to restoreextracellular volumeextracellular volume

Hypertonicsolutions however, may actHypertonicsolutions however, may actas plasma volumeexpandersas plasma volumeexpanders


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Oncotic pressure

(tendency to pull unit) CapillaryCapillaryH

ydrostatic pressure(tendency to drive unit)

FluidFluid

Trans ortTrans ort


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ColloidsColloids

AlbuminAlbumin

Hepatic productionHepatic production

MW = ,000MW = ,000

0% of COP80% of COP

Serum tSerum t1/21/2::18 hours endogenous18 hours endogenous

1 hours1 hours exogenousexogenous


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ColloidsColloids

HydroxyethylStarch (Hespan)HydroxyethylStarch (Hespan) SyntheticSynthetic

Derived from cornstarchDerived from cornstarch

Avera

geAvera

ge MW = ,000MW = ,000 Stable, nonantigenicStable, nonantigenic

Used for volumeexpansionUsed for volumeexpansion

RenalexcretionRenalexcretion tt1/21/2 22-- hours67 hours

90% gone in 42 days90% gone in 42 days


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Greater in COP thanalbuminGreater in COP thanalbumin

Longerdurationof actionLongerdurationof action

0.006% adversereactions0.006% adversereactions Noeffecton blood typingNoeffecton blood typing

Prolongs PT, PTTandclotting timesProlongs PT, PTTandclotting times

DosageDosage 20 ml/Kg/day20 ml/Kg/day

max 1500 ml/daymax 1500 ml/day

ColloidsColloids

HydroxyethylStarch (Hespan)HydroxyethylStarch (Hespan)


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FluidChoicesFluidChoices

Based on:Based on:

type of deficittype of deficit urgency of repletionurgency of repletion

pathophysiology of conditionpathophysiology of condition

plasmaCOPplasmaCOP


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FluidChoicesFluidChoices Crystalloids for initialresuscitationCrystalloids for initialresuscitation

PRBCs toreplace blood lossPRBCs toreplace blood loss


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FluidManagement in PediatricFluidManagement in PediatricSeptic ShockSeptic Shock Em hasis on the golden hourEm hasis on the golden hour

Early aggressive use of fluids mayEarly aggressive use of fluids mayim rove outcomeim rove outcome

TitrateTitrate--Reassess!Reassess!

Clinical Practice Parameters,

Carcillo et al., CCM, 2002


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A

lphaA

lpha--BetaM

eterBetaM

eterEE DopamineDopamineEpinephrineEpinephrine


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DopamineActivityDopamineActivity

0.50.5--5.0 mcg/kg/min5.0 mcg/kg/min -- dopaminergicreceptorsdopaminergicreceptors

2.02.0--10 mcg/kg/min10 mcg/kg/min -- betareceptors (inotrope)betareceptors (inotrope)1010--20 mcg/kg/min20 mcg/kg/min -- al ha and betareceptorsal ha and betareceptors

Over 20 mcg/kg/minOver 20 mcg/kg/min -- al hareceptors (pressors)al hareceptors (pressors)


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A Rational Approach to Shock in the PediatricA Rational Approach to Shock in the Pediatric

PatientPatient

Shock / HypotensionShock / Hypotension

Volume ResuscitationVolume Resuscitation

Signs of adequate circulationSigns of adequate circulation

Adequate MAPAdequate MAP

NONO

NONO

pressorspressorsYesYes


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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


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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

MAPMAPDobutamineDobutamine

or Milrinoneor Milrinone

tachycardiatachycardia

phenylephrine??phenylephrine??

COCO


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New Therapies in SepticNew Therapies in Septic

ShockShock SteroidsSteroids

VasopressinVasopressin

ActivatedProtein C (Xigris) insepticActivatedProtein C (Xigris) insepticshockshock


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Management of Pediatric SepticManagement of Pediatric Septic

Shock: The GoldenHourShock: The GoldenHour

First 15 minutesFirst 15 minutes

Em hasis on response to volumeEm hasis on response to volume

Clinical Practice Parameters,

Carcillo et al., CCM, 2002


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Patients dontsuddenlyPatients dontsuddenlydeteriorate, healthcaredeteriorate, healthcare

professionalssuddenlyprofessionalssuddenlynotice!notice!

AnonymousAnonymous

shock in paeds

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