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  1. 1. Shock in the Pediatric Patient:Shock in the Pediatric Patient: oror Oxygen Don’t GoOxygen Don’t Go Where the Blood Won’t Flow!Where the Blood Won’t 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
  2. 2. 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
  3. 3. Definition of ShockDefinition of Shock Uncontrolled blood or fluid lossUncontrolled blood or fluid loss Blood pressure less than 5th percentileBlood pressure less than 5th percentile for 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
  4. 4. Definition of ShockDefinition of Shock An acute complex pathophysiologicAn acute complex pathophysiologic state of circulatory dysfunctionstate of circulatory dysfunction which results in a failure of thewhich results in a failure of the organism to deliver sufficientorganism to deliver sufficient amounts of oxygen and otheramounts of oxygen and other nutrients to satisfy thenutrients to satisfy the requirements of tissue bedsrequirements of tissue beds
  6. 6. Definition of ShockDefinition of Shock Inadequate tissue perfusion to meetInadequate tissue perfusion to meet tissue demandstissue demands Usually result of inadequate blood flowUsually result of inadequate blood flow and/or oxygen deliveryand/or oxygen delivery Shock is not a blood pressure diagnosis!!Shock is not a blood pressure diagnosis!!
  7. 7. 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
  8. 8. 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
  9. 9. Arterial Oxygen ContentArterial Oxygen Content Hgb 15 gm/100 mLHgb 15 gm/100 mL HemoglobinHemoglobin SaOSaO22 97%97% Oxygen SaturationOxygen Saturation PaOPaO22 100 mmHg100 mmHg Partial PressurePartial Pressure OO22 bound to Hgbbound to Hgb 100 mm Hg100 mm Hg + OO22 in plasmain plasma+
  10. 10. Oxygen DeliveryOxygen Delivery DO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x 0.003 OO22OO22OO22OO22OO22OO22 OO22OO22OO22OO22OO22OO22Oxygen ExpressOxygen Express Ca02
  11. 11. Cardiac OutputCardiac Output The volume of blood ejected byThe volume of blood ejected by the heart in one minutethe heart in one minute 4 - 8 liters / minute4 - 8 liters / minute
  12. 12. 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 ventriclePreload- volume of blood in ventricle  Afterload- resistance to contractionAfterload- resistance to contraction  Contractility- force appliedContractility- force applied
  13. 13. Cardiac OutputCardiac Output C.O.=Mean arterial pressure (MAP) - CVP/SVRC.O.=Mean arterial pressure (MAP) - CVP/SVR To improve CO:To improve CO: MAPMAP CVPCVP SVRSVR
  14. 14. PreloadPreload AfterloadAfterload ContractilityContractility ResistanceResistance Stroke VolumeStroke Volume Heart RateHeart Rate Arterial BloodArterial Blood PressurePressure OO22 DeliveryDelivery OO22 ContentContent Cardiac OutputCardiac Output xx xx xx
  15. 15. 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  Circulatory failureCirculatory failure with end organwith end organ dysfunctiondysfunction IrreversibleIrreversible  Irreparable loss ofIrreparable loss of essential organsessential organs
  16. 16. Mechanical Requirements forMechanical Requirements for Adequate Tissue PerfusionAdequate Tissue Perfusion FluidFluid PumpPump VesselsVessels FlowFlow
  17. 17. Hypovolemic Shock:Hypovolemic Shock: InadequateInadequate FluidFluid VolumeVolume (decreased preload)(decreased preload)
  18. 18. Hypovolemic Shock:Hypovolemic Shock: CausesCauses Fluid depletionFluid depletion  internalinternal  externalexternal HemorrhageHemorrhage  internalinternal  externalexternal
  19. 19. Cardiogenic Shock:Cardiogenic Shock: Pump MalfunctionPump Malfunction (decreased contractility)(decreased contractility)
  20. 20. Cardiogenic Shock:Cardiogenic Shock: CausesCauses Electrical FailureElectrical Failure Mechanical FailureMechanical Failure  CardiomyopathyCardiomyopathy  metabolicmetabolic  anatomicanatomic  hypoxia/ischemiahypoxia/ischemia
  21. 21. Distributive ShockDistributive Shock Abnormal Vessel ToneAbnormal Vessel Tone (decreased afterload)(decreased afterload)
  22. 22. Distributive ShockDistributive Shock Vasodilation Venous Pooling Decreased Preload Maldistribution of regional blood flow
  23. 23. Distributive Shock:Distributive Shock: CausesCauses SepsisSepsis AnaphylaxisAnaphylaxis Neurogenesis (spinal)Neurogenesis (spinal) Drug intoxication (TCA,Drug intoxication (TCA, calcium, Channel blocker)calcium, Channel blocker)
  24. 24. Septic Shock Decreased Volume Decreased Pump Function Abnormal Vessel Tone
  25. 25. 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 ventriclePreload- volume of blood in ventricle  Afterload- resistance to contractionAfterload- resistance to contraction  Contractility- force appliedContractility- force applied
  26. 26. Clinical AssessmentClinical Assessment Heart rateHeart rate Peripheral circulationPeripheral circulation  capillary refillcapillary refill  pulsespulses  extremity temperatureextremity temperature PulmonaryPulmonary End organ perfusionEnd organ perfusion  brainbrain  kidneykidney
  27. 27. Improving Stroke Volume:Improving Stroke Volume: Therapy for Cardiovascular SupportTherapy for Cardiovascular Support Preload Volume Contractility Inotropes Afterload Vasodilators
  28. 28. Septic ShockSeptic Shock Early (“Warm”)Early (“Warm”) Decreased peripheral vascular resistanceDecreased peripheral vascular resistance Increased cardiac outputIncreased cardiac output Late (“Cold”)Late (“Cold”) Increased peripheral vascular resistanceIncreased peripheral vascular resistance Decreased cardiac outputDecreased cardiac output
  29. 29. Assessment of CirculationAssessment of Circulation Early Late Heart rate Tachycardia Tachycardia/ Bradycardia Blood pressure Normal Decreased Peripheral circulation Warm/Cool Decreased/ Increased pulses Cool Decreased pulses
  30. 30. Heart Rate and Perfusion PressureHeart Rate and Perfusion Pressure (MAP-CVP) Parameters by Age(MAP-CVP) Parameters by Age Age Heart Rate MAP-CVP Term newborn 120-180 55 < 1 120-180 60 < 2 120-160 65 < 7 120-160 65 < 15 90-140 65
  31. 31. Assessment of CirculationAssessment of Circulation Early Late End-organ: Skin Decreased cap refill Very decreased cap refill Brain Irritable, restless Lethargic, unresponsive Kidneys Oliguria Oliguria, anuria
  33. 33. Obstructive Shock:Obstructive Shock: CausesCauses Pericardial tamponadePericardial tamponade Pulmonary embolismPulmonary embolism Pulmonary hypertensionPulmonary hypertension
  34. 34. Hemodynamic Assessment of ShockHemodynamic Assessment of Shock Type of Shock Preload Afterload Contractility Cardiac Output Cardiogenic ⇑ ⇑ ⇓ ⇓ Hypovolemic ⇓ ⇑ ⇔ ⇓ Septic Early Late ⇓ ⇑ ⇓ ⇑ ⇔ ⇓ ⇑ ⇓ Obstructive ⇓ ⇑ ⇓ ⇓ Distributive ⇓ ⇓ ⇑ ⇔
  35. 35. Goals of ResuscitationGoals of Resuscitation Overall goal:Overall goal:  increase Oincrease O22 deliverydelivery  decrease demanddecrease demand TreatmentTreatment OO22 contentcontent CardiacCardiac outputoutput BloodBlood pressurepressure Sedation/analgesiaSedation/analgesia
  36. 36. Principles of ManagementPrinciples of Management A: AirwayA: Airway  patent upper airwaypatent upper airway B: BreathingB: Breathing  adequate ventilation and oxygenationadequate ventilation and oxygenation C: CirculationC: Circulation  optimizeoptimize  cardiac functioncardiac function  oxygenationoxygenation
  37. 37. Act quickly, Think slowly. Greek Proverb
  38. 38. Airway ManagementAirway Management Patients in shock have:Patients in shock have:  OO22 deliverydelivery  progressive respiratory fatigue/failureprogressive respiratory fatigue/failure  energy shunted from vital organsenergy shunted from vital organs  afterloadafterload
  39. 39. Airway ManagementAirway Management Early intubation provides:Early intubation provides:  OO22 delivery and contentdelivery and content  controlled ventilation which:controlled ventilation which:  reduces metabolic demandreduces metabolic demand  allows C.O. to vital organsallows C.O. to vital organs
  40. 40. TherapyTherapy Vagolysis Chromotropy V o lu m e C V P P re lo a d V a s o d ila to rs V a s o c o n s tric to rs A fte rlo a d C o rre c t a c id o s is h y p o x ia h y p o g ly c e m ia In o tro p ic a g e n ts C o n tra c tility S tro k e V o lu m e Heart Rate 
  41. 41. Fluid ChoicesFluid Choices Less Filling Less Filling Tastes Great ! Tastes Great ! Colloid Crystalloid
  42. 42. CrystalloidsCrystalloids Hypotonic Fluids (DHypotonic Fluids (D55 1/4 NS)1/4 NS) No role in resuscitationNo role in resuscitation Maintenance fluids onlyMaintenance fluids only
  43. 43. Fluids, Fluids, FluidsFluids, Fluids, Fluids Key to most resuscitativeKey to most resuscitative effortsefforts Give generously and reassessGive generously and reassess
  44. 44. CrystalloidsCrystalloids Isotonic 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 hemodynamics4x blood volume to restore hemodynamics
  45. 45. CrystalloidsCrystalloids Isotonic FluidsIsotonic Fluids 2 trauma studies2 trauma studies crystalloids = colloids but:crystalloids = colloids but:  4x amount4x amount  longer time to resuscitationlonger time to resuscitation
  46. 46. CrystalloidsCrystalloids ComplicationsComplications Under-resuscitationUnder-resuscitation  renal failurerenal failure Over-resuscitationOver-resuscitation  pulmonary edemapulmonary edema  peripheral edemaperipheral edema
  47. 47. CrystalloidsCrystalloids SummarySummary Crystalloids less effective than equalCrystalloids less effective than equal volume of colloidsvolume of colloids Preferred when 1Preferred when 1oo deficit is waterdeficit is water and/or electrolytesand/or electrolytes Good in initial resuscitation to restoreGood in initial resuscitation to restore extracellular volumeextracellular volume Hypertonic solutions however, may actHypertonic solutions however, may act as plasma volume expandersas plasma volume expanders
  48. 48. Oncotic pressure (tendency to pull unit) CapillaryCapillary Hydrostatic pressure (tendency to drive unit) FluidFluid TransportTransport
  49. 49. ColloidsColloids AlbuminAlbumin 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
  50. 50. ColloidsColloids Hydroxyethyl Starch (Hespan)Hydroxyethyl Starch (Hespan) SyntheticSynthetic Derived from corn starchDerived from corn starch AverageAverage MW = 69,000MW = 69,000 Stable, nonantigenicStable, nonantigenic Used for volume expansionUsed for volume expansion Renal excretionRenal excretion  tt 1/21/2 2-67 hours2-67 hours  90% gone in 42 days90% gone in 42 days
  51. 51. 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 timesProlongs PT, PTT and clotting times DosageDosage  20 ml/Kg/day20 ml/Kg/day  max 1500 ml/daymax 1500 ml/day ColloidsColloids Hydroxyethyl Starch (Hespan)Hydroxyethyl Starch (Hespan)
  52. 52. Fluid ChoicesFluid Choices Based on:Based on:  type of deficittype of deficit  urgency of repletionurgency of repletion  pathophysiology of conditionpathophysiology of condition  plasma COPplasma COP Tastes Great ! Tastes Great ! Less Filling Less Filling
  53. 53. Fluid ChoicesFluid Choices Crystalloids for initial resuscitationCrystalloids for initial resuscitation PRBC’s to replace blood lossPRBC’s to replace blood loss
  54. 54. Fluid Management in PediatricFluid Management in Pediatric Septic ShockSeptic Shock Emphasis on the golden hourEmphasis on the golden hour Early aggressive use of fluids mayEarly aggressive use of fluids may improve outcomeimprove outcome Titrate-Reassess!Titrate-Reassess! Clinical Practice Parameters, Carcillo et al., CCM, 2002
  55. 55. Alpha-Beta MeterAlpha-Beta Meter ααßßDopamineDopamine EpinephrineEpinephrine Norepinephrine Norepinephrine Dobutam ine Dobutam ine Neosynephrine Neosynephrine
  56. 56. InotropesInotropes Agent Site of action Dose (µg/kg/min) Effects Dopamine Dopaminergic β α > β 1-3 5-10 11-20 Renal vasodilator Inotrope Vasoconstriction Increase PVR Dobutamine β1 and β2 1-20 Inotrope Vasodilation Epinephrine β > α 0.05-1.0 Inotrope Tachycardia Norepinephrine α > β 0.05-1.0 Profound vasoconstriction Inotrope Nitroprusside Vasodilator Arterial > venous 0.5-1.0 Vasodilation Milrinone PDE inhibitor 0.5-0.75 Inotrope Vasodilator
  57. 57. Dopamine ActivityDopamine Activity 0.5-5.0 mcg/kg/min - dopaminergic receptors0.5-5.0 mcg/kg/min - dopaminergic receptors 2.0-10 mcg/kg/min - beta receptors (inotrope)2.0-10 mcg/kg/min - beta receptors (inotrope) 10-20 mcg/kg/min - alpha and beta receptors10-20 mcg/kg/min - alpha and beta receptors Over 20 mcg/kg/min - alpha receptors (pressors)Over 20 mcg/kg/min - alpha receptors (pressors)
  58. 58. A Rational Approach to Shock in theA 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 NONO pressorspressors YesYes
  59. 59. 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
  60. 60. 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 MAPMAP DobutamineDobutamine oror MilrinoneMilrinone tachycardiatachycardia phenylephrine??phenylephrine?? COCO
  61. 61. ““New” Therapies in SepticNew” Therapies in Septic ShockShock SteroidsSteroids VasopressinVasopressin Activated Protein C (Xigris) in septicActivated Protein C (Xigris) in septic shockshock
  62. 62. Management of Pediatric SepticManagement of Pediatric Septic Shock: The Golden HourShock: The Golden Hour First 15 minutesFirst 15 minutes Emphasis on response to volumeEmphasis on response to volume Clinical Practice Parameters, Carcillo et al., CCM, 2002
  63. 63. Patients don’t suddenlyPatients don’t suddenly deteriorate, healthcaredeteriorate, healthcare professionals suddenlyprofessionals suddenly notice!notice! AnonymousAnonymous