Shock is a clinical state characterized by inadequate tissue perfusion resulting from insufficient oxygen and substrate delivery to meet metabolic demands. There are several types of shock defined by etiology (hypovolemic, cardiogenic, distributive) and effects on blood pressure (compensated, decompensated). Signs of shock include tachycardia, altered mental status, and decreased urine output. Treatment involves rapid fluid resuscitation and vasoactive drugs like dopamine, epinephrine, and norepinephrine to support cardiac output as needed.

1. SHOCK by: CRISBERT I. CUALTEROS, MD

2. Shock A clinical state characterized by inadequate tissue perfusion resulting in oxygen and substrate delivery that is insufficient to meet tissue metabolic demands.

3. Types of Shock According to Etiology: Hypovolemic shock Cardiogenic shock Distributive shock

4. Hypovolemic Shock Inadequate intravascular volume relative to vascular space. Causes: diarrhea vomiting trauma

5. Cardiogenic Shock Adequate intravascular volume but cardiac dysfunction limits cardiac output. Ex: myocarditis

6. Distributive Shock Inappropriate distribution of blood volume. Causes: Sepsis Anaphylaxis Neurogenic shock

7. Types of Shock According to Its Effect on Blood Pressure: Compensated shock Decompensated shock

8. Signs of Shock: Tachycardia Mottled or pale color Cool skin Diminished peripheral pulses Change in mental status Oliguria Delayed CRT

9. Types of Shock According to Its Effect on Blood Pressure: Compensated shock Decompensated shock

10. P5 Systolic Blood Pressure for Age Age Systolic BP (p5) 0-1 month 60 mmHg > 1 month to 1 yr 70 mmHg >1 yr - 10 yo (age in yrs x 2) + 70 > 10 yo 90 mmHg

11. Septic Shock Inflammatory triad Fever Tachycardia Vasodilation Change in mental status Inconsolable irritability Lack of interaction with parents Inability to be aroused

12. Clinical Diagnosis of Septic Shock Suspected infection Decreased perfusion Decreased mental status Decreased urine output Prolonged CRT or flash CR Diminished or bounding peripheral pulses Mottled cool extremities

13. Objectives of Fluid Resuscitation: Rapidly restore effective circulating volume in hypovolemic & distributive shock. Restore oxygen-carrying capacity in hemorrhagic shock states. Correct metabolic imbalances secondary to volume depletion.

14. Types of Fluids: Crystalloids Colloids Blood Products

15. Crystalloids Ex.: Lactated Ringer’s, normal saline Advantages: Readily available Inexpensive No allergic reactions Disadvantage: Remain in intravascular compartment for few minutes.

16. Crystalloids Dextrose-Containing Solution: Osmotic diuresis Hypokalemia Ischemic brain injury

17. Colloids Ex.: Dextran, Haesteril, Gelafundin Advantage: Remain in intravascular compartment longer Disadvantage: Cause sensitivity reactions

18. Blood Products Indications: Replacement of blood loss Correction of coagulopathies Complications: Blood-borne infections Hypothermia

19. Blood Products Recommended for fluid replacement of volume loss in pediatric trauma victims with inadequate perfusion despite 2 to 3 boluses of crystalloid solution. Administer: 10 to 15 ml/kg PRBC 20 ml/kg WB

20. Fluid Bolus Administration General guideline: Administer 20 ml/kg of isotonic crystalloid solution very rapidly (over 5 to 20 minutes).

21. Fluid Bolus Administration 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).

22. Fluid Bolus Administration 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.

23. Fluid Bolus Administration 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).

24. Drugs That Support Cardiac Output Inotropes Vasopressors Vasodilators Inodilators

25. Inotropes : increase cardiac contractility and heart rate. Vasopressors : increase vascular resistance and blood pressure Drugs That Support Cardiac Output

26. Vasodilators : decrease vascular resistance and cardiac afterload and promote peripheral perfusion Inodilators : increase cardiac contractility and reduce afterload Drugs That Support Cardiac Output

27. Dopamine Dobutamine Epinephrine Norepinephrine Sodium nitroprusside Milrinone Drugs That Support Cardiac Output

28. Dopamine Indications: Inadequate cardiac output Hypotension Need for enhanced splanchnic blood flow and urine output

29. Dose: 2 to 20 μg/kg/minute Infusion: 6 x body weight = mg to add to diluent to create a total volume of 100 ml. 1 ml/hr delivers 1 μg/kg/min Dopamine

30. Premixed solution: Infusion rate (ml/hr): = weight (kg) x desired dose ( μg/kg/min) x 60 min/hr concentration (ug/ml) 200 mg/ 250 ml: conc 800 μg/ml 400 mg/ 250 ml: conc 1600 μg/ml Dopamine

31. Dobutamine Indications: Myocardial dysfunction Inadequate cardiac output (elevated systemic or pulmonary vascular resistance)

32. Dobutamine Dose: 2 to 20 μg/kg/minute Infusion: 6 x body weight = mg to add to diluent to create a total volume of 100 ml. 1 ml/hr delivers 1 μg/kg/min

33. Premixed solution: Infusion rate (ml/hr): = weight (kg) x desired dose ( μg/kg/min) x 60 min/hr concentration (ug/ml) 250 mg/ 250 ml: conc 1000 μg/ml 500 mg/ 250 ml: conc 2000 μg/ml Dobutamine

34. Epinephrine Indications: Inadequate cardiac output Hypotension Symptomatic bradycardia Pulseless cardiac arrest Septic shock

35. Dose: 0.1 to 1 μg/kg/minute Infusion: 0.6 x body weight = mg to be added to sufficient diluent to create a total volume of 100 ml. 1 ml/hr delivers 0.1 μg/kg/min Epinephrine

36. Norepinephrine Indications: Hypotension (especially due to vasodilation) Inadequate cardiac output Spinal shock α-adrenergic blockade

37. Norepinephrine Dose: 0.1 to 2 μg/kg/minute Infusion: 0.6 x body weight = mg to be added to sufficient diluent to create a total volume of 100 ml. 1 ml/hr delivers 0.1 μg/kg/min

38. Sodium Nitroprusside Indications: Hypertensive emergencies Inadequate cardiac output with high systemic or pulmonary vascular resistance Cardiogenic shock

39. Dose: 1 to 8 μg/kg/minute Infusion: 6 x body weight = mg to add to diluent to create a total volume of 100 ml. 1 ml/hr delivers 1 μg/kg/min Sodium Nitroprusside

40. Milrinone Indications: Inadequate cardiac output with high systemic or pulmonary vascular resistance Cardiogenic shock Septic shock

41. Loading dose: 50 to 75 μg/kg Infusion: 0.5 to 0.75 μg/kg/min 0.6 x body weight = mg to be added to sufficient diluent to create a total volume of 100 ml. 1 ml/hr delivers 0.1 μg/kg/min Milrinone

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? Consider further fluid boluses Epinephrine (0.1 to 1 μg/kg/min) or Dopamine at higher doses (up to 20 μg/kg/min) Norepinephrine (0.1 to 2 μg/kg/min) Consider further fluid boluses Dobutamine (2 to 20 μg/kg/min) or Dopamine (2 to 20 μg/kg/min) or Low-dose epinephrine (0.05 to 0.3 μg/kg/min) Inamrinone: load with 0.75 to 1 mg/kg over 5 mins, may repeat up to 3 mg/kg. Infusion: 5 to 10 μg/kg/min Milrinone: load with 50 to 75 μg/kg. Infusion: 0.5 to 0.75 μg/kg/min. Approach to Selection of Vasoactive Medications for Postresuscitation Hemodynamic Stabilization

43. First 5 minutes Recognize altered mental status and perfusion Maintain airway and establish access according to PALS guidelines 5 to 15 minutes Push 20 cc/kg of isotonic crystalloid or colloid boluses up to and over 60 cc/kg Correct hypoglycemia and hypocalcemia Fluid responsive ? Observe in PICU Fluid refractory shock Establish central venous access, begin dopamine or dobutamine therapy and establish arterial monitoring Proposed Algorithm for Treatment of Septic Shock Yes No Fluid refractory-dopamine/dobutamine resistant shock Titrate epinephrine for cold shock. Norepinephrine for warm shock. 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. Give hydrocortisone Normal blood pressure, cold shock, SVC O 2 sat <70% Proposed Algorithm for Treatment of Septic Shock Yes No Add vasodilator or Type III phosphodiesterase inhibitor with volume loading Catecholamine-resistant shock Is patient at risk for adrenal insufficiency? Do not give hydrocortisone Observe in PICU Patient is stable Patient is unstable Patient is unstable Low blood pressure, cold shock, SVC O 2 sat <70% Low blood pressure, warm shock Titrate volume and epinephrine Titrate volume and norepinephrine Low dose vasopressin or angiotensin? 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. Persistent catecholamine-resistant shock Place pulmonary artery catheter and direct fluid, inotrope, vasopressor, vasodilator, and hormonal therapies to attain normal MAP-CVP and CI >3.3 and <6L/min/m 2 Proposed Algorithm for Treatment of Septic Shock Add vasodilator or Type III phosphodiesterase inhibitor with volume loading Observe in PICU Refractory shock Consider ECMO Titrate volume and epinephrine Titrate volume and norepinephrine Low dose vasopressin or angiotensin? 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

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