Pediatric Cardiogenic Shock Management

Casey Culbertson MD
Cardiac Intensivist
Co-Founder MD1World
Pediatric Cardiogenic Shock
Diagnosis, Medical and Mechanical Support Management

Overview
Definition / Etiologies of Cardiogenic Shock
Clinical Symptoms, PE/Labs
Medical Management
Mechanical Support
Outcomes
Summary

Ann Intensive Care 2016 Dec;6(1):14. doi: 10.1186/s13613-016-0111-2. Epub 2016 Feb 16
Experts' recommendations for the management of cardiogenic shock in children.
Brissaud O1, Botte A2, Cambonie G3, Dauger S4, de Saint Blanquat L5, Durand P6, Gournay V, Guillet E8, Laux D9, Leclerc F, Mauriat
P10, Boulain T11, Kuteifan K12.
Abstract
Cardiogenic shock which corresponds to an acute state of circulatory failure due to impairment of myocardial contractility is a very
rare disease in children, even more than in adults. To date, no international recommendations regarding its management in critically
ill children are available. An experts' recommendations in adult population have recently been made (Levy et al. Ann Intensive Care
5(1):52, 2015; Levy et al. Ann Intensive Care 5(1):26, 2015). We present herein recommendations for the management of
cardiogenic shock in children, developed with the grading of recommendations' assessment, development, and evaluation system by
an expert group of the Groupe Francophone de Réanimation et Urgences Pédiatriques (French Group for Pediatric Intensive Care
and Emergencies). The recommendations cover four major fields of application such as: recognition of early signs of shock and the
patient pathway, management principles and therapeutic goals, monitoring hemodynamic and biological variables, and circulatory
support (indications, techniques, organization, and transfer criteria). Major principle care for children with cardiogenic shock is
primarily based on clinical and echocardiographic assessment. There are few drugs reported as effective in childhood in the medical
literature. The use of circulatory support should be facilitated in terms of organization and reflected in the centers that support these
children. Children with cardiogenic shock are vulnerable and should be followed regularly by intensivist cardiologists and
pediatricians. The experts emphasize the multidisciplinary nature of management of children with cardiogenic shock and the
importance of effective communication between emergency medical assistance teams (SAMU), mobile pediatric emergency units
(SMUR), pediatric emergency departments, pediatric cardiology and cardiac surgery departments, and pediatric intensive care units.

Abstract
Cardiogenic shock can be a major and frequently fatal, complication of both acute and chronic disorders that aaect
the function of heart to maintain adequate tissue perfusion. Despite advances in the management of shock,
cardiac failure with cardiogenic shock continues to be challenging clinical problem. Rapid and eecient treatment
approach is needed to prevent morbidity and mortality associated with it. Decompensated Cardiogenic shock is
defined as decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular
volume (1). Hemodynamic criteria for cardiogenic shock are sustained hypotension (systolic blood pressure <2SD
for age for at least 30 min) and a reduced cardiac index (<2.2 L/min/m 2) in the presence of elevated pulmonary
capillary occlusion pressure (>15 mm Hg). Cardiogenic shock can be diagnosed clinically at bedside by the
presence of clinical signs suggestive of poor tissue perfusion, which include oliguria, cyanosis, cold extremities,
altered mentation and hypotension. In most patients these signs may persist after attempts have been made to
correct hypovolemia, arrhythmia, hypoxia, and acidosis.
Cardiogenic Shock in Children (PDF Download Available). Available from:
https://www.researchgate.net/publication/278021324_Cardiogenic_Shock_in_children
Cardiogenic Shock in Children
Sachdev M, Argarwal N, Joshi R, Raja J

Definition
“The inability of the heart to meet the metabolic demands of the body”
Uncommon form of shock occurs in 5-13% of
pediatric emergencies
Cardiogenic shock however is up to 20% of
PICU admissions
“Shock” = wide spectrum of LV dysfunction (various etiologies)
Cardiogenic Shock = most severe expression
of LV failure
In children, cardiogenic shock can mimic
other common forms of shock (SEPSIS)
Early evaluation and management can
significantly improve outcomes

Definition / Presentation (The 3 “T’s”)
Symptoms Poor appetite, increased work of breathing
(Tachypnea), exercise intolerance / fatigue,
lethargy, altered metal status, poor urine
output, recent viral syndrome
Vital Signs Tachycardia, arrhythmia, heart block,
hypotension, Tachypnea
Clinical Signs Murmur, gallop, dysrhythmia, decreased
peripheral pulses, JVD, hepatomegaly,
abdominal distention, edema, respiratory
distress, crackles

Etiologies of decompensated HF and cardiogenic shock
Primary LV Failure Congenital Heart disease, dilated cardiomyopathy,
fulminant viral myocarditis, rejection post heart transplant
Ischemia Post-cardiopulmonary bypass, cardiac arrest
Arrhythmia Tachyarrhythmia, bradyarrhythmia, heart block
Cardiac tamponade Post-operative bleeding, post-pericardiotomy syndrome,
pericarditis
Acute valvular dysfunction Endocarditis, papillary muscle rupture, post-catheterization
or post-surgical
Coronary insufficiency ALCAPA, coronary osteal stenosis / atresia, coronary
thromboembolism (MI), coronary vasospasm
Metabolic disorders Long-chain fatty acid oxidation disorders
Toxic stress Thyrotoxicosis, drug ingestion / inhalation

Patho-physiology (“cascade”) of evolving acute decompensated heart failure (ADHF)

PE on presentation when ADHF vs. sepsis is suspected in setting of hypo-perfusion
Acute
decompensated HF
with highest
mortality
40%
22%
“Early” compensated
septic shock
“Late”
uncompensated
septic shock
Normal LV systolic function but
abnormal diastolic function
Abnormal LV systolic
function AND abnormal
diastolic function

Initial (EMERGENT) evaluation upon presentation (ER/ICU)
History (Viral prodrome) / PE (Cold or
warm and wet or dry)
ECG (R/O dysrhythmia)
CXR (Cardiomegaly)
Labs (CBC, CRP, LFT’s, lactate, ABG
(Cardiac focus-BNP)
ECHO

ECG examples (Child presents with vomiting)
Sinus Tachycardia
Normal pr-rp intervals
“Warm / dry”
PJRT
Prolonged RP interval
“Cold / dry”

CXR examples (Child presents with vomiting)
Sepsis
(Pneumonia but small heart)
“Warm / dry”
Cardiogenic Shock
(Cardiomegaly / Pulmonary Edema)
“Cold / Wet”

ECHO examples (Child presents with vomiting)
Normal LV size and function
“Warm / dry”
Dilated LV with decreased EF%
“Cold / Wet”

Problem with Acute Decompensated Heart Failure
ADHF
CO
Preload
CO

Medical Interventions for Acute Decompensated Heart Failure
CO
Overall Goals
• Optimize preload and afterload
• Careful administration of isotonic fluid boluses and/or
diuretics depending on type of ADFH (“wet vs. cold”)
• Limit myocardial 02 demand
• Use of supplemental 02
• Non-invasive positive pressure ventilation
• Mechanical Ventilation
• Augment systolic and diastolic function
• Inotropic / luscitropic Support
• Milrinone / Dobutamine
• Epinephrine/Vasopressin
• Levosimendan for patient refractory to inotropes
• Correct / control any dysrhythmias
• Control fevers
• Careful sedation

CO

Various shock Hemodynamics and Treatments
CO
CO

Medical Interventions for ADCH (“Cold + Dry”)
CO
Overall Goals
• Careful administration of isotonic fluid boluses
• 5-10 cc/kg to augment preload
• Watch for signs of fluid overload
• Tachypnea
• Bibasilar crackles
• Hepatomegaly
• Epinephrine / Vasopressin
• Manipulation of SVR (Afterload)
• Vasodialators

Medical Interventions for ADCH (“Cold + Wet”)
CO
Overall Goals
• Careful administration of diuretic therapy
• Volume would result in worsening respiratory
failure and worsening cardiac output
• Epinephrine / Vasopressin
• Manipulation of SVR (afterload)
• Vasodialators

Treatment success with Acute Decompensated Heart Failure
CO
CO
Preload Diuretic
Inotropic
Support

Physical / laboratory signs of success with ADHF
Physical Signs
• Warm, well perfused with good capillary refill
• Decreased respiratory effort
• Decreased tachycardia
• Less Hepatomegaly
• Better mentation (alertness)
Laboratory Signs
• Increased urine output
• Decreased lactate levels
• Resolution of Base deficit
• Decreased anion gap

Medications NOT to be use in Acute Decompensated Heart Failure
Use of IV ACE inhibitors – not to use in ADHF

Overall Survival for ADHF

Signs of “Failure” of medical therapy for ADHF
Signs
• Ongoing Hypotension
• Persistent Acidosis
• Low Urine Output
• Clinical evidence of poor
perfusion despite maximal
inotropic support

Management of “failure” of medical therapy for ADHF

Acute Management of “failure” of medical therapy for ADHF
Acute Support

ECMO Mechanical therapy for ADHF
To lower the risks of mortality and neurological morbidity, we strongly recommend implementing ECMO when
pH ≥ 7.2 and lactate < 9 mmol/L and using low-to-moderate inotrope support (strong agreement).

ECMO Survival for ADHF
Ann Intensive Care 2016 Dec;6(1):14. doi: 10.1186/s13613-016-0111-2. Epub 2016 Feb 16
We strongly recommend using ECMO in patients with cardiogenic shock refractory to conventional
therapy (strong agreement).
“Two main indications are for ECMO are observed: severe heart
failure or cardiogenic shock and cardiac arrest. Delayed use of
ECMO in patients with cardiogenic shock increases the risk of
cardiac arrest. Numerous retrospective studies, as well as data from
the ELSO registry (https://www.elso.org/), show that when ECMO is
used the mean patient survival is >40 % for cardiogenic shock and
>35 % for cardiac arrest. The prognosis for myocarditis is very good
if ECMO is started prior to cardiac arrest.”

ECMO Survival for ADHF

Long-Term Management of “failure” of medical therapy for ADHF
Long Term
Support

Pediatric ventricular assist devices
• Infants with severe congestive heart failure
who require mechanical ventilation as part of
heart failure management are placed on a
Berlin Heart EXCOR VAD (Berlin Heart, The
Woodland, TX).
• Larger children with a body surface area (BSA)
>0.7 m2 who may be eligible for an implantable
continuous-flow VAD (e.g., HeartMate II and
HeartWare HVAD) at a center with significant
experience are often considered for a VAD if
they are inotrope-dependent and awaiting
transplantation.
• Pediatric VAD patients have clearly
demonstrated that the single most important
predictor of patient mortality is the degree of
end-organ dysfunction, specifically renal and
hepatic dysfunction, at the time of VAD
implantation

J Thorac Dis 2015 Dec; 7(12): 2194–2202
Pediatric ventricular assist devices
Abstract
The domain of pediatric ventricular assist device (VAD) has recently gained considerable attention. Despite the fact that,
historically, the practice of pediatric mechanical circulatory support (MCS) has lagged behind that of adult patients, this gap
between the two groups is narrowing. Currently, the Berlin EXCOR VAD is the only pediatric-specific durable VAD
approved by the U.S Food and Drug Administration (FDA). The prospective Berlin Heart trial demonstrated a
successful outcome, either bridge to transplantation (BTT), or in rare instances, bridge to recovery, in approximately
90% of children. Also noted during the trial was, however, a high incidence of adverse events such as embolic stroke, bleeding
and infection. This has incentivized some pediatric centers to utilize adult implantable continuous-flow devices, for instance the
HeartMate II and HeartWare HVAD, in children. As a result of this paradigm shift, the outlook of pediatric VAD support has
dramatically changed: Treatment options previously unavailable to children, including outpatient management and even
destination therapy, have now been becoming a reality. The sustained demand for continued device miniaturization and
technological refinements is anticipated to extend the range of options available to children—HeartMate 3 and
HeartWare MVAD are two examples of next generation VADs with potential pediatric application, both of which are
presently undergoing clinical trials. A pediatric-specific continuous-flow device is also on the horizon: the redesigned Infant
Jarvik VAD (Jarvik 2015) is undergoing pre-clinical testing, with a randomized clinical trial anticipated to follow thereafter. The
era of pediatric VADs has begun. In this article, we discuss several important aspects of contemporary VAD therapy, with a
particular focus on challenges unique to the pediatric population.
Ika Adachi, Sarah Burki, Farhan Zafar, David Luis Simon Morales

J Thorac Dis 2015 Dec; 7(12): 2194–2202
Pediatric VAD’s – Short Term
Patients with relatively short-lived etiologies, such as viral
myocarditis and acute rejection of cardiac grafts, may experience
a recovery of cardiac function when the inflammatory/immune
storm subsides; thus VAD therapy simply supports the circulation
as the underlying process runs its course. In such circumstances,
temporary devices are a preferred mode of support
Rotary or centrifugal pump, such as CentriMag/PediMag
(Thoratec Corp.; Pleasanton, CA) and Jostra Rotaflow (MAQUET
Cardiovascular; Wayne, NJ) can be used for short-term VAD
support. This type of extracorporeal VAD system is a device of
choice in patients with critical cardiogenic shock.
CentriMag
Rotaflow

J Thorac Dis 2015 Dec; 7(12): 2194–2202
Pediatric VAD’s – Long Term
Etiology of heart failure is chronic in nature,
hence less prone to recovery, the patient will
most likely need durable support in the form of a
long-term VAD. The EXCOR (Berlin Heart, Inc.;
The Woodlands, TX) is the only pediatric-
specific device that enjoys global acceptance.
Adult continuous-flow devices are being
increasingly used in children driven by
significantly better complication profiles of
continuous-flow devices compared to pediatric
pulsatile pumps, and the option of discharge to
home.

Pediatric VAD’s – Long Term Survivial

Summary
• Pediatric Cardiogenic Shock is often non-specific,
challenging clinical scenario of ADHF and possible
cardiovascular collapse
• Presence of persistent signs / symptoms of ADHF
(myocardial distress (3 T’s) and end-organ hypo-perfusion)
warrants immediate evaluation and treatment
• Treatment includes therapies to manipulate and improve
preload, afterload and myocardial contractility
• ADHF medical management ‘failures’ will require either short
term support (ECMO) or longer term support (VAD)
• Mechanical support has been associated with improved
survival
• Overall, mortality from Pediatric ADHF still remains high

Thank You for your Attention

Pediatric Cardiogenic Shock Management

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