Multisystem Inflammatory Syndrome with COVID-19 in pediatrics:- this topic will make u to get knowledge in MISC condition in children and management of covid child with MISC along with Nursing care

3. Child with covid-19 infection will develop a
significant systemic inflammatory Responses.
This responses are “Multisystem Inflammatory
Syndrome”(MISC). In this condition All children
have been diagnosed and managed appropriately
along standard referral pathways.

4. A child presenting with persistent fever,
inflammation (neutrophilia, elevated CRP and
lymphopenia) and evidence of single or multi-organ
dysfunction (shock, cardiac, respiratory, renal,
gastrointestinal or neurological disorder) with
additional features.

5. 1. Mucocutaneous inflammation
2. Myocardial malfunction
3. Shock/ hypotension
4. Coagulopathy
5. GIT involvement

6. Symptoms of MIS-C may vary in children, but can include:
•Fever
•Abdominal pain
•Vomiting
•Diarrhea
•Neck pain
•Rash
•Bloodshot eyes
•Feeling extra tired

7. Diagnostic criteria (WHO)
• Children and adolescents 0–18 years of age with fever ≥3 days
• And any two of the following:
 Rash or bilateral non-purulent conjunctivitis or muco-cutaneous
inflammation signs (oral, hands or feet)
 Hypotension or shock
 Features of myocardial dysfunction, pericarditis, valvulitis, or coronary
abnormalities (including ECHO findings or elevated Troponin/NT-
proBNP)
 Evidence of coagulopathy (PT, PTT, elevated D-Dimer)
 Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal
pain)
• And elevated markers of inflammation such as ESR, C-reactive protein,
or procalcitonin
• And no other obvious microbial cause of inflammation, including
bacterial sepsis, staphylococcal or streptococcal shock syndromes
• And evidence of recent COVID-19 infection (RT-PCR, antigen test or
serology positive), or likely contact with patients with COVID-19

14. INTRODUCTION
Shock is the state of insufficient blood flow to the
tissues of the body as a result of problems with the
circulatory system. If prolonged and left untreated
can leads to multiple organ failure and eventually.
An acute, complex state of circulatory
dysfunction that results in failure to deliver
sufficient amount of oxygen and nutrients to
meet tissue metabolic demands.
DEFINITION

15. Phases of shock
 COMPENSATED SHOCK :-
Intrinsic regulatory mechanisms
Vital organ is maintained
• CONFUSION
• TACHYCARDIA
• NORMAL OR MILD
TACHYPNOEA
• >>CFT
• U/O ADEQUATE
• BP NORMAL

16. Phases of shock
UN COMPENSATED SHOCK :-
Compromise of microvascular perfusion
Deterioration of organ function
Hypotension develops
• DROWSINESS
• MARKED
TACHYCARDIA
• TACHYPNOEAAND
ACIDOSIS
• VERY SLOW CFT
• OLIGURIA/ANURIA
• HYPOTENSION

17. Phases of shock
IRREVERSIBLE SHOCK
Damage to key organ • CHILD UNRESPONSIVE
• BRADYCARDIA
• APNOEA
• COLD CYANOTIC SKIN
• ANURIA
• UNRECORDABLE BP

19. • Early signs
Tachycardia
Mildly delayed capillary
refill
Fussy child
Signs of shock

20. • Late signs
Persisting tachycardia or
bradycardia
Hypotension
Poor capillary refill
Altered mental status
Irregular breathing pattern
Poor muscle tone
Lower limit of sbp= 70
Signs of shock

21. CLASSIFICATION
• HYPOVOLEMIC SHOCK
• SEPTIC SHOCK
• CARDIOGENIC SHOCK
• OBSTRUCTIVE SHOCK
• DISTRIBUTIVE SHOCK

23. 1. HYPOVOLEMIC SHOCK
 Most common form of shock world-wide results in
decreased circulating boold volume, decrease in preload,
decreased stroke volume and resultant decrease in
cardiac output.
 Decrease in the intravascular blood volume to such an
extent that effective tissue perfusion cannot be
maintained.

24. CHARACTERSTICS
CHARACTERIZED BY FLUID LOSS
INTERNAL/EXTERNAL
DECREASED PRELOAD
WATER/ELECTROLYTE LOSS
PLASMA LOSS
BLOOD LOSS

25. ETIOLOGY
HEMORRHAGE
RENAL AND GI FLUID LOSSES
CAPILLARY LEAK SYNDROMES

26. SIGNS AND SYMPTOMS
• Nausea/diarrhoea
• Trauma/blood loss
• Dehydration
• Dry mucous membranes
• Absent tears
• Decreased skin turgor
• Hypotension
• Tachycardia
• Site of blood loss

28. Laboratory studies:
– ABG
– Blood sugar
– Electrolytes
– CBC
– PT/PTT
– Type and cross
– Cultures

29. Establishment of adequate oxygenation and oxygenation
and ventilation
O2- always the first drug administered
adequate IV
Early correction of hypovolemia
Crystalloids
first bolus 20cc/kg
continuous monitoring of CVP maintain >10mmhg
Identify causes of ongoing losses
blood available if haemorrhagic shock
MANAGEMENT

34. • Optimize preload
• Normal saline (NS) or lactated ringer’s (RL)
• Except for myocardial failure use 10-20ml/kg
every 2-10 minutes. Reassess after every bolus.
• At 60ml/kg consider: ongoing losses, adrenal
insufficiency, intestinal ischemia, obstructive
shock. Get CXR. May need inotropes.

35. 1. septic SHOCK

36. Definition
• Sepsis is defined as a condition meeting the SIRS
definition in the presence of suspected or proven
infection.
• Septic shock is Sepsis with cardiovascular
dysfunction (hypotension, poor perfusion, elevated
lactate)

41. or

52. NURSINGMANAGEMENT
•Assessment of the child in shock across-the-room assessment
•ABC
• Important historical information and physical
exam findings must be included when considering
the clinical manifestations and differential
diagnosis of shock

53. •Historical information asked must include
•1) age
•2) pre-existing conditions/illness,
•3) fever,
•4) vomiting/diarrhoea,
•5) poor feeding,
•6) urine output,
•7) lethargy,
•8) trauma,
•9) toxic ingestion.

54. •The physical exam must include1) general
appearance/alertness/eye
contact/activity,
•2) Heart rate,
•3) Tachypnea
•4) Fever
•5) Blood pressure
•6) Skin perfusion,
a) capillary refill,
b) colour,
c) skin temperature, ,
•7) oliguria (if an observation period is
permitted),
•8) altered mental status

55. •Plan and interventions goal is recognition of shock
and restoring perfusion to normal
•ABCS
•keep child warm

56. Treatment
1) oxygenation,
2) vascular access,
3) fluid administration, and
4) drug therapy.

57. •Oxygenation providing 100 oxygen
•assuring adequate hemoglobin, stopping
hemorrhage, and replacing blood if the hematocrit
is less than 30.
•Consider endotracheal intubation, but be aware of
the cardiovascular effects that intubation and
positive ventilation can cause

58. •Vascular access insertion of a (preferably two) large
intravenous catheters, and obtaining necessary lab tests
(CBC, blood culture, electrolytes, BUN,
creatinine, glucose, calcium, coagulation profile
and blood gas). If vascular access is difficult
to obtain, use an intraosseous (IO) device

59. Fluids are categories related to a shock
•Crystalloids
•Colloids
•Blood products Crystalloids
Lactated ringer’s,
normal saline,
dextrose
Colloids
dextran,
haesteril,
gelafundin
Blood products
Replacement of blood loss.
Fluid replacement therapy-10
to 15ml/kg

61. •Rate of fluids Be liberal and aggressive with fluid
resuscitation, giving 20 ml/kg initially and
repeating as needed. For septic shock, more than
40ml/kg in the first hour has been shown to
improve outcome.
•When approaching 80 ml/kg,
consider the use of an inotropic agent such as
dopamine or epinephrine. Central venous pressure
monitoring will help fluid management in critical
patients

62. Fluid bouls administration
General guidelines
Administer 20ml/kg of isotonic crystalloid solution very rapidly
(over 5 to 20 minutes)
If the child has severe myocardial dysfunction, smaller fluid boluses (5
to 10ml/kg) is delivered more slowly (over 10 to 20 minutes).
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.

63. DRUG THERAPY