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SHOCK

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SHOCK

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SHOCK

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

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