This document describes the case of a 10-day-old infant presenting with signs of shock including tachycardia, poor perfusion, and decreased urine output. Examinations revealed hepatomegaly and other signs suggestive of shock. Investigations showed metabolic acidosis and low blood sugar. The infant did not respond to initial fluid resuscitation and inotropic support. Echocardiogram revealed hypoplastic left heart syndrome. Prostaglandin E1 was started and the infant responded, confirming duct-dependent systemic circulation. The case highlights the importance of early recognition and management of neonatal shock.

1. The Mystery of The Shocked BabyThe Mystery of The Shocked Baby

2. History
 A 10-day-old female infant born at 39 weeks of
gestation. She was born by normal spontaneous
vaginal delivery and was discharged home.
 The mother has a history of primary infertility
3 years.
 The mother’s pregnancy, labor were
unremarkable.

3. History
 This infant was feeding and voiding appropriately
in first days of life.
 But parental account that their infant became
progressively “fussy”. She breathed faster and
required a longer time for each bottle-feeding.
 On the day of presentation she fed no more than
30ml of formula and hadn’t voided since the night
before.

4. Vital signs
 Temperature 36.8 C
 Heart rate 190 b/min
 CRT = 5 Sec
 RR = 69 b/min
 Blood pressure from the right arm 78/50 mmHg
 Sao2 from the right hand is 96%
 Weight is 3.3 kg

5. Examination
 CNS: conscious but confused with decreased
spontaneous movements and weak crying.
 CVS: precordium is hyperdynamic, pulmonary
component S2 is loud, no murmurs and Lower
extremity pulses are difficult to palpate.
 Chest: RD Grade ІІ, Equal breath sounds bilaterally
with fine rales at both lung bases.

6. Examination
 The liver is palpable 4 cm below the right costal
margin.
 Her feet are cool to touch.
 Baby was pale.
 There are no skin lesions.

7. What is the problem with
this baby ?

8. Shock:Shock:
Shock is the inadequate perfusionShock is the inadequate perfusion
of the body’s vital organsof the body’s vital organs

9. Indices of tissue perfusion
 Pallor & skin mottling
 Capillary refill time (>3 sec)
 Heart rate ( > 170 Bmin )
 Toe-core temperature difference (>2ºC)
 Urine output (<1 mL/kg/hr)
 Blood lactate (>2.5 mmol/L)

10. Which one is shocked ?

11. Causes of neonatal shock
O2
Pump
Pipes
Circulation
Tank
Non
Vital
Vital
organs

12. Remember !!
Once shock is suspected start supportive
measures as soon as possible:
 airway and assuring its patency.
 providing oxygen or positive pressure
ventilation.
 achieving intravascular ( peripheral or central )
or intraosseous access.

13. Algorithm for management of shock:

14. Algorithm for management of shock:

15. Fluid Boluse
 Excessive volume expansion may be
potentially harmful in Cardiogenic Shock.
 Preterm babies can not deal with
Excessive volume expansion which
increase likelihood of PDA & NEC.

16. Why not more than 20ml/kg ?
Clinical signs of hypovolemic shock depend on the
degree of intravascular volume depletion:
 25% in compensated shock
 25-40% in uncompensated shock
( But with myocardial depression)
 more than 40% in irreversible shock.

17. Dopamine Doses
New school Effect Old school
0.5 to 2 μg/kg/min
Renal and mesenteric
vasodilatation
2.5 to 5 μg/kg/min
2 to 8 μg/kg/min
Increased myocardial
contractility and heart rate
5 to 10 μg/kg/min
> 8 μg/kg/min
Significant peripheral VC &
increase in PVR and blood
pressure
10 to 20 μg/kg/min

18. Dobutamine
Mech: produces vasodilation and increases
Cardiac muscle contration.
1st line in:
 Preterm < 48 hrs
 PPHN
 Heart failure

19. Adrenalin (The most potent inotrope)
Adrenalin results in significant
increases in:
 Myocardial contractility
 Cardiac output
 Peripheral vascular resistance
 Blood pressure

20. Milrinone = Primacor
Mech:
 Improve contractility
 Improve diastolic function
 Systemic and pulmonary vasodilation= Decrease
after load & Decrease Pulmonary BP
Indication:
 Shock post Cardiac Surgery
 Septic Shock
 Severe PPHN

21. When to response ??
Reassess within 10 min
of fluid bolus
Reassess every 15–20 min of new dose
of Inotropes

22. Caution !!
Inotropic agents: contraindicated in
hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is
common in IDMs

23. Caution !!
Catecholamines : Never administer intra-
arterially
Dopamine shown to suppress TSH
secretion

24. Remember !!
Correction of negative inotropic
factors:
as hypoxia, hypoglycemia, hypocalcemia, acidosis
and electrolytes imbalance,
if present.
Digoxin is used in non-critically ill infants.

25. What about NaHco3 ?
Indications:
 To correct normal anion gap metabolic acidosis caused
by Renal (RTA) or GI Losses (Diarrhea, Surgery for NEC,ileostomy).
 Treatment of life-threatening hyperkalemia.
 In significant metabolic acidosis (pH<7.20 or BD >
10), it may be useful to give NaHco3.
(very controversial)

26. Textbook of Neonatal
Resuscitation, 7th Edition

27. NaHco3 Dose
 Dose (in mEq) based on Base Deficit = 0.3 X Base deficit
(mEq/L) X weight (kg).
 Give ½ dose then assess need for remainder
 Dose is given over 30 minutes at least.
 Sodium Bicarbonate 8.4 % contains 1 mEq NaHCO3 / mL
 Incompatible with dobutamine, dopamine,
epinephrine, midazolam.

28. NaHco3 side effects
 IVH (with rapid infusion)
 Increase PCO2 so decrease pH
(if given during inadequate ventilation)
 Local tissue necrosis
 Hypocalcemia
 Hypernatremia and hypokalemia

29. Caution !!
Do not treat metabolic acidosis with
hyperventilation.
NaHCO3 is not a recommended therapy in
NRP
It is best to correct the underlying cause of the
metabolic acidosis.

30. Corticosteroid therapy
Mech: up-regulate adrenergic receptor & as replacement
in adrenal insufficiency.
When: in extremely PT with hypotension refractory to
volume & vasopressors (high dose dopamine or
epinephrine).
Hydrocortisone: 1 mg/kg every 8-12 hrs for
2-3 days.
Dexamethasone: 0.1 mg/kg followed by 0.05 mg/kg
IV every 12 H for 5 doses.

31. Back to our case
Baby was placed on O2 and
received one fluid bolus plus
Dopamine 10 μg/kg/min +
Dobutamine 10 μg/kg/min
without any improvement in
perfusion.
This bad news was told to the parents in an
appropriate way.

32. Investigations
 Serum glucose
 Blood gases
 Hematocrit (Hct)
 Electrolyte
 CBC, CRP, and cultures
 Chest x-ray
 Echocardiography & ECG
 Renal functions & Liver function tests

33. Investigations
 CBC: Hct 41%, WBC 15 × 103,
platelet count 23 × 103.
 PH 7.18, CO2 30, NaHCO3 10 mEq/L, BE -16.
 Na 145 mEq/L, K 5 mEq/L, Ca 9 mg/dl.
 RBS = 69 mg/dl.
 CRP -Ve
 Urea 40 mg/dl, Creatinine 1.0 mg/dl.

34. Chest X-ray: Cardiomegaly, increased
pulmonary vascularity.

35. Case progression
 Dopamine increased to 20 μg/kg/min +
Dobutamine 20 μg/kg/min without any
improvement in perfusion.
 After senior consultant PGE1 infusion was
started and Echocardiogram was being
arranged.

36. Duct dependent systemic circulation
 Neonates who present with shock within
the first 3 weeks of life are likely to
have CHD with duct dependent systemic
flow.
 It is appropriate to begin PGE-1, even if
before A diagnosis made by
echocardiography.

37. PGE1 infusion:
 Dose: 0.05-0.1μg/kg/min, start with
0.05μg/kg/min, if no improvement increase to
0.1 μg/kg/min.
 Adverse effects: Hypotension, flushing,
tachycardia, apnea, fever, and Hypokalemia.

38. When Baby respond to PGE-1 ?
Maximum effect seen within 30 min
in cyanotic lesions,
may take several hours in acyanotic
lesions

39. Echocardiogram: HLHS

40. Left-sided obstructive heart disease
(Duct-dependent systemic circulation)
These diseases include:
 Hypoplastic left heart syndrome (HLHS)
(most common and severe)
 Critical aortic stenosis (AS)
 Co-arctation of the aorta (COA)
 Interrupted aortic arch (IAA)

41. Approaches to HLHS

42. What about Entral feeding ?
 Infants in shock should not be fed.
 Intestines will require 2 days or more for
recovery before small feedings can be
attempted.
 Initiate total parenteral nutrition as soon
as possible.

43. Shock & Assisted Ventilation
NCPAP is Contraindicated in Severe
cardiovascular instability.
Ventilation is an excellent inotrope

44. Shock & Ventilatory setting

45. Refractory Shock
 Hypopituitarism
 Hypoadrenalism (Congenital adrenal hyperplasia, Addison disease)
 Large PDA
 Central line leakage
 GIT problems (e.g. NEC, perforation)
 Drugs ( e.g. muscle relaxants )
 Poor myocardial contractility (e.g. cardiomyopathy)
 Inborn errors of metabolism (e.g. Organic acidemia )

46. Refractory Shock:
Hidden Hemorrhage
Subgaleal HemorrhageAdrenal hemorrhage

47. Refractory Shock:
Hidden Hemorrhage
Fractured Humerus Fractured femur

48. Refractory Shock:
Periventricular hemorrhage / intraventricular hemorrhage

49. Refractory Shock:
Pneumothorax

50. Refractory Shock:
Pneumopericardium

51. Refractory Shock:
Pneumothorax & Pneumopericardium

52. Recent Approach :Recent Approach :
Functional Echocardiography and
Doppler Flow Velocimetry:
 Assessment of global heart contractility
 Assessment of superior vena cava flow

53. Take Home Massage
Once shock is suspected start
supportive measures as soon as
possible.
Thereafter, treatment is directed by
the underlying pathology.

54. Take Home Massage
In Shock: Obtain vascular access
including arterial line, better through
umbilical vessels.
BP is maintained until very late
Hypotension is a pre-terminal sign

55. Take Home Massage
PGE1 is considered before diagnosis is
confirmed if duct-dependent systemic
blood flow is suspected.
NaHCO3 is not a recommended
therapy in NRP.

56. Thank youThank you