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SHOCK

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SHOCK

SHOCK

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    • 1. SHOCK by: CRISBERT I. CUALTEROS, MD
    • 2. Shock
      • A clinical state characterized by inadequate tissue perfusion resulting in oxygen and substrate delivery that is insufficient to meet tissue metabolic demands.
    • 3. Types of Shock According to Etiology:
      • Hypovolemic shock
      • Cardiogenic shock
      • Distributive shock
    • 4. Hypovolemic Shock
      • Inadequate intravascular volume relative to vascular space.
      • Causes:
        • diarrhea
        • vomiting
        • trauma
    • 5. Cardiogenic Shock
      • Adequate intravascular volume but cardiac dysfunction limits cardiac output.
      • Ex: myocarditis
    • 6. Distributive Shock
      • Inappropriate distribution of blood volume.
      • Causes:
        • Sepsis
        • Anaphylaxis
        • Neurogenic shock
    • 7. Types of Shock According to Its Effect on Blood Pressure:
      • Compensated shock
      • Decompensated shock
    • 8. Signs of Shock:
      • Tachycardia
      • Mottled or pale color
      • Cool skin
      • Diminished peripheral pulses
      • Change in mental status
      • Oliguria
      • Delayed CRT
    • 9. Types of Shock According to Its Effect on Blood Pressure:
      • Compensated shock
      • Decompensated shock
    • 10. P5 Systolic Blood Pressure for Age
      • Age Systolic BP (p5)
      • 0-1 month 60 mmHg
      • > 1 month to 1 yr 70 mmHg
      • >1 yr - 10 yo (age in yrs x 2) + 70
      • > 10 yo 90 mmHg
    • 11. Septic Shock
      • Inflammatory triad
        • Fever
        • Tachycardia
        • Vasodilation
      • Change in mental status
        • Inconsolable irritability
        • Lack of interaction with parents
        • Inability to be aroused
    • 12. Clinical Diagnosis of Septic Shock
      • Suspected infection
      • Decreased perfusion
        • Decreased mental status
        • Decreased urine output
        • Prolonged CRT or flash CR
        • Diminished or bounding peripheral pulses
        • Mottled cool extremities
    • 13. Objectives of Fluid Resuscitation:
      • Rapidly restore effective circulating volume in hypovolemic & distributive shock.
      • Restore oxygen-carrying capacity in hemorrhagic shock states.
      • Correct metabolic imbalances secondary to volume depletion.
    • 14. Types of Fluids:
        • Crystalloids
        • Colloids
        • Blood Products
    • 15. Crystalloids
      • Ex.: Lactated Ringer’s, normal saline
      • Advantages:
        • Readily available
        • Inexpensive
        • No allergic reactions
      • Disadvantage:
        • Remain in intravascular compartment for few minutes.
    • 16. Crystalloids
      • Dextrose-Containing Solution:
        • Osmotic diuresis
        • Hypokalemia
        • Ischemic brain injury
    • 17. Colloids
      • Ex.: Dextran, Haesteril, Gelafundin
      • Advantage:
        • Remain in intravascular compartment longer
      • Disadvantage:
        • Cause sensitivity reactions
    • 18. Blood Products
      • Indications:
        • Replacement of blood loss
        • Correction of coagulopathies
      • Complications:
        • Blood-borne infections
        • Hypothermia
    • 19. Blood Products
      • Recommended for fluid replacement of volume loss in pediatric trauma victims with inadequate perfusion despite 2 to 3 boluses of crystalloid solution.
      • Administer:
        • 10 to 15 ml/kg PRBC
        • 20 ml/kg WB
    • 20. Fluid Bolus Administration
      • General guideline:
      • Administer 20 ml/kg of isotonic crystalloid solution very rapidly (over 5 to 20 minutes).
    • 21. Fluid Bolus Administration
      • If a child has severe signs of hypovolemic shock (severe hemorrhage after trauma, severe dehydration), a 20 ml/Kg bolus is delivered rapidly (< 5 to 10 minutes).
    • 22. Fluid Bolus Administration
      • If the child demonstrates less severe signs of shock or there is some impairment in cardiac function, a bolus of 10 ml/Kg is delivered over 10 to 20 minutes.
    • 23. Fluid Bolus Administration
      • If the child has severe myocardial dysfunction (calcium channel blocker or ß-adrenergic blocker poisoning) , smaller fluid boluses (5 to 10 ml/Kg) is delivered more slowly (over 10 to 20 minutes).
    • 24. Drugs That Support Cardiac Output
      • Inotropes
      • Vasopressors
      • Vasodilators
      • Inodilators
    • 25.
      • Inotropes : increase cardiac contractility and heart rate.
      • Vasopressors : increase vascular resistance and blood pressure
      Drugs That Support Cardiac Output
    • 26.
      • Vasodilators : decrease vascular resistance and cardiac afterload and promote peripheral perfusion
      • Inodilators : increase cardiac contractility and reduce afterload
      Drugs That Support Cardiac Output
    • 27.
      • Dopamine
      • Dobutamine
      • Epinephrine
      • Norepinephrine
      • Sodium nitroprusside
      • Milrinone
      Drugs That Support Cardiac Output
    • 28. Dopamine
      • Indications:
      • Inadequate cardiac output
      • Hypotension
      • Need for enhanced splanchnic blood flow and urine output
    • 29.
      • Dose: 2 to 20 μg/kg/minute
      • Infusion:
        • 6 x body weight = mg to add to diluent to create a total volume of 100 ml.
        • 1 ml/hr delivers 1 μg/kg/min
      Dopamine
    • 30.
      • Premixed solution:
        • Infusion rate (ml/hr):
        • = weight (kg) x desired dose ( μg/kg/min) x 60 min/hr
        • concentration (ug/ml)
        • 200 mg/ 250 ml: conc 800 μg/ml
        • 400 mg/ 250 ml: conc 1600 μg/ml
      Dopamine
    • 31. Dobutamine
      • Indications:
      • Myocardial dysfunction
      • Inadequate cardiac output (elevated systemic or pulmonary vascular resistance)
    • 32. Dobutamine
      • Dose: 2 to 20 μg/kg/minute
      • Infusion:
        • 6 x body weight = mg to add to diluent to create a total volume of 100 ml.
        • 1 ml/hr delivers 1 μg/kg/min
    • 33.
      • Premixed solution:
        • Infusion rate (ml/hr):
        • = weight (kg) x desired dose ( μg/kg/min) x 60 min/hr
        • concentration (ug/ml)
        • 250 mg/ 250 ml: conc 1000 μg/ml
        • 500 mg/ 250 ml: conc 2000 μg/ml
      Dobutamine
    • 34. Epinephrine
      • Indications:
      • Inadequate cardiac output
      • Hypotension
      • Symptomatic bradycardia
      • Pulseless cardiac arrest
      • Septic shock
    • 35.
      • Dose: 0.1 to 1 μg/kg/minute
      • Infusion:
          • 0.6 x body weight = mg to be added to sufficient diluent to create a total volume of 100 ml.
          • 1 ml/hr delivers 0.1 μg/kg/min
      Epinephrine
    • 36. Norepinephrine
      • Indications:
      • Hypotension (especially due to vasodilation)
      • Inadequate cardiac output
      • Spinal shock
      • α-adrenergic blockade
    • 37. Norepinephrine
      • Dose: 0.1 to 2 μg/kg/minute
      • Infusion:
          • 0.6 x body weight = mg to be added to sufficient diluent to create a total volume of 100 ml.
          • 1 ml/hr delivers 0.1 μg/kg/min
    • 38. Sodium Nitroprusside
      • Indications:
      • Hypertensive emergencies
      • Inadequate cardiac output with high systemic or pulmonary vascular resistance
      • Cardiogenic shock
    • 39.
      • Dose: 1 to 8 μg/kg/minute
      • Infusion:
        • 6 x body weight = mg to add to diluent to create a total volume of 100 ml.
        • 1 ml/hr delivers 1 μg/kg/min
      Sodium Nitroprusside
    • 40. Milrinone
      • Indications:
      • Inadequate cardiac output with high systemic or pulmonary vascular resistance
      • Cardiogenic shock
      • Septic shock
    • 41.
      • Loading dose: 50 to 75 μg/kg
      • Infusion: 0.5 to 0.75 μg/kg/min
          • 0.6 x body weight = mg to be added to sufficient diluent to create a total volume of 100 ml.
          • 1 ml/hr delivers 0.1 μg/kg/min
      Milrinone
    • 42. Postarrest shock Fluid bolus (10-20 ml/kg NS or RL, monitor response) Reassess – signs of shock continue What is blood pressure ? Hypotensive (decompensated) shock? Normotensive (compensated) shock?
      • Consider further fluid boluses
      • Epinephrine
      • (0.1 to 1 μg/kg/min)
      • or
      • Dopamine at higher doses
      • (up to 20 μg/kg/min)
      • Norepinephrine
      • (0.1 to 2 μg/kg/min)
      • Consider further fluid boluses
      • Dobutamine (2 to 20 μg/kg/min)
      • or
      • Dopamine (2 to 20 μg/kg/min)
      • or
      • Low-dose epinephrine
      • (0.05 to 0.3 μg/kg/min)
      • Inamrinone: load with 0.75 to 1 mg/kg
      • over 5 mins, may repeat up to 3 mg/kg.
      • Infusion: 5 to 10 μg/kg/min
      • Milrinone: load with 50 to 75 μg/kg.
      • Infusion: 0.5 to 0.75 μg/kg/min.
      Approach to Selection of Vasoactive Medications for Postresuscitation Hemodynamic Stabilization
    • 43.
      • First 5 minutes
      • Recognize altered mental status and perfusion
      • Maintain airway and establish access according to PALS guidelines
      • 5 to 15 minutes
      • Push 20 cc/kg of isotonic crystalloid or colloid boluses up to and over 60 cc/kg
      • Correct hypoglycemia and hypocalcemia
      Fluid responsive ?
      • Observe in PICU
      • Fluid refractory shock
      • Establish central venous access, begin dopamine
      • or dobutamine therapy and establish arterial monitoring
      Proposed Algorithm for Treatment of Septic Shock Yes No
      • Fluid refractory-dopamine/dobutamine resistant shock
      • Titrate epinephrine for cold shock.
      • Norepinephrine for warm shock.
      Catecholamine-resistant shock Is patient at risk for adrenal insufficiency? 0-5 min 15 min Carcillo JA, Fields AI: Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30: 1365-1378
    • 44.
      • Give hydrocortisone
      Normal blood pressure, cold shock, SVC O 2 sat <70% Proposed Algorithm for Treatment of Septic Shock Yes No
      • Add vasodilator or Type III
      • phosphodiesterase inhibitor
      • with volume loading
      Catecholamine-resistant shock Is patient at risk for adrenal insufficiency?
      • Do not give hydrocortisone
      • Observe in PICU
      Patient is stable Patient is unstable Patient is unstable Low blood pressure, cold shock, SVC O 2 sat <70% Low blood pressure, warm shock
      • Titrate volume and
      • epinephrine
      • Titrate volume and norepinephrine
      • Low dose vasopressin or angiotensin?
      60 min Carcillo JA, Fields AI: Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30: 1365-1378
    • 45.
      • Persistent catecholamine-resistant shock
      • Place pulmonary artery catheter and direct fluid,
      • inotrope, vasopressor, vasodilator, and hormonal
      • therapies to attain normal MAP-CVP and CI >3.3
      • and <6L/min/m 2
      Proposed Algorithm for Treatment of Septic Shock
      • Add vasodilator or Type III
      • phosphodiesterase inhibitor
      • with volume loading
      • Observe in PICU
      • Refractory shock
      • Consider ECMO
      • Titrate volume and
      • epinephrine
      • Titrate volume and norepinephrine
      • Low dose vasopressin or angiotensin?
      Patient is stable Patient is unstable Carcillo JA, Fields AI: Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30: 1365-1378
    • 46. Thank You !!!