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Shock
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!
Dr. Virendra Kumar GuptaDr. Virendra Kumar Gupta
MD PediatricsMD Pediatrics
Fellowship In pediatric Gastroentero-Hepatology & LiverFellowship In pediatric Gastroentero-Hepatology & Liver
TransplantationTransplantation
Assistant ProfessorAssistant Professor
Institute of Paediatric GastroenterologyInstitute of Paediatric Gastroenterology
Nims University Jaipur Nims University Jaipur
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. IntroductionIntroduction
Shock is a syndrome that results fromShock is a syndrome that results from
inadequate oxygen delivery to meetinadequate oxygen delivery to meet
metabolic demandsmetabolic demands
Oxygen delivery (DOOxygen delivery (DO22 ) is less than) is less than
Oxygen Consumption (< VOOxygen Consumption (< VO22))
Untreated this leads to metabolicUntreated this leads to metabolic
acidosis, organ dysfunction and deathacidosis, organ dysfunction and death
4. Oxygen DeliveryOxygen Delivery
Oxygen delivery = Cardiac Output x ArterialOxygen delivery = Cardiac Output x Arterial
Oxygen ContentOxygen Content
(DO(DO22 = CO x CaO= CO x CaO22))
Cardiac Output = Heart Rate x Stroke VolumeCardiac Output = Heart Rate x Stroke Volume
((CO = HR x SV)CO = HR x SV)
– SV determined by preload, afterload andSV determined by preload, afterload and
contractilitycontractility
Art Oxygen Content = Oxygen content of theArt Oxygen Content = Oxygen content of the
RBC + the oxygen dissolved in plasmaRBC + the oxygen dissolved in plasma
(CaO(CaO22 = Hb X SaO= Hb X SaO22 X 1.34 + (.003 X PaOX 1.34 + (.003 X PaO22))
5. Figure 1. FACTORS AFFECTING OXYGEN DELIVERY
DO2
CaO2
CO
SV
HR
Oxygenation
Hgb
A-a gradient
DPG
Acid-Base Balance
Blockers
Competitors
Temperature
Drugs
Conduction System
Ventricular
Compliance
EDV
ESV Contractility
CVP
Venous Volume
Venous Tone
Afterload Blockers
Temperature Competitors
Drugs Autonomic Tone
Metabolic Milieu
Ions
Acid Base
Temperature
Drugs
Toxins
Influenced By
Influenced By
Influenced By
Influenced By
7. 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!!
8. 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
9. 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
11. 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
12. Hypovolemic Shock
Most common form of shock world-wide
Results in decreased circulating blood
volume, decrease in preload, decreased
stroke volume and resultant decrease in
cardiac output.
Etiology: Hemorrhage, renal and/or GI
fluid losses, capillary leak syndromes
13. Distributive Shock
Due to an abnormality in vascular tone leading
to peripheral pooling of blood with a relative
hypovolemia.
Etiology
– Anaphylaxis
– Drug toxicity
– Neurologic injury
– Early sepsis
Management
– Fluid
– Treat underlying cause
14. Obstructive Shock
Mechanical obstruction to ventricular
outflow
Etiology: Congenital heart disease, massive
pulmonary embolism, tension pneumothorax,
cardiac tamponade
Inadequate C.O. in the face of adequate
preload and contractility
Treat underlying cause.
15. Dissociative Shock
Inability of Hemoglobin molecule to give up
the oxygen to tissues
Etiology: Carbon Monoxide poisoning,
methemoglobinemia, dyshemoglobinemias
Tissue perfusion is adequate, but oxygen
release to tissue is abnormal
Early recognition and treatment of the cause
is main therapy
16. Cardiogenic ShockCardiogenic Shock
Cardiogenic shock is commonly describedCardiogenic shock is commonly described
as “pump failure” (decreased contractility)as “pump failure” (decreased contractility)
The common causes areThe common causes are
myocarditis, dysrhythmias,and drugsmyocarditis, dysrhythmias,and drugs
with a myocardial depressant action,with a myocardial depressant action,
acidosis, congenital heart lesions andacidosis, congenital heart lesions and
sepsis.sepsis.
17. SIRS/Sepsis/Septic shock
Mediator release:
exogenous & endogenous
Decreased blood
flow
Cardiac
dysfunction
Imbalance of
oxygen
supply and
demand
Alterations in
metabolism
SEPTIC SHOCKSEPTIC SHOCK
Decreased Volume / Decreased Pump Function/Abnormal Vessel
Tone
23. 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
24. 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
25. 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
26. Hemodynamic Assessment of ShockHemodynamic Assessment of Shock
Type of Shock Preload Afterload Contractility Cardiac
Output
Cardiogenic ⇑ ⇑ ⇓ ⇓
Hypovolemic ⇓ ⇑ ⇔ ⇓
Septic
Early
Late
⇓
⇑
⇓
⇑
⇔
⇓
⇑
⇓
Obstructive ⇓ ⇑ ⇓ ⇓
Distributive ⇓ ⇓ ⇑ ⇔
30. 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
31. 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
32. 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
35. Fluids, Fluids, FluidsFluids, Fluids, Fluids
Key to most resuscitativeKey to most resuscitative
effortsefforts
Give generously and reassessGive generously and reassess
36. 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
39. 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
40. Oncotic pressure
(tendency to pull unit)
CapillaryCapillary
Hydrostatic pressure
(tendency to drive unit)
FluidFluid
TransportTransport
42. 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
43. 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)
44. 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
45. Fluid ChoicesFluid Choices
Crystalloids for initial resuscitationCrystalloids for initial resuscitation
PRBC’s to replace blood lossPRBC’s to replace blood loss
46. 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
50. 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
51. 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
52. 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
53. ““New” Therapies in SepticNew” Therapies in Septic
ShockShock
SteroidsSteroids
VasopressinVasopressin
Activated Protein C (Xigris) in septicActivated Protein C (Xigris) in septic
shockshock
54. 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
55.
56. Early Goal directed therapy in treatment of sepsis and septic shock- Rivers et al., NEJM, Nov 2001
57. Community-Acquired SepsisCommunity-Acquired Sepsis
Pneumonia-Quinolone PLUS B-lactamPneumonia-Quinolone PLUS B-lactam
Abdominal-Carbapenem OR Pip-TazoAbdominal-Carbapenem OR Pip-Tazo
Skin/Soft Tissue-Vanco PLUS Carbapenem or Pip-TazoSkin/Soft Tissue-Vanco PLUS Carbapenem or Pip-Tazo
Urinary Tract-Quinolone PLUS Amp/VancoUrinary Tract-Quinolone PLUS Amp/Vanco
Unknown-Vanco PLUS B-lactamUnknown-Vanco PLUS B-lactam
Health-Care Associated SepsisHealth-Care Associated Sepsis
Lung-B-lactam PLUS VancoLung-B-lactam PLUS Vanco
BloodstreamBloodstream -B-lactam PLUS Vanco +/- Antifungal-B-lactam PLUS Vanco +/- Antifungal
Surgical SiteSurgical Site -B-lactam PLUS Vanco +/- Anaerobic coverage-B-lactam PLUS Vanco +/- Anaerobic coverage
Suspected Candida-CaspofunginSuspected Candida-Caspofungin
Unknown-B-lactam PLUS VancoUnknown-B-lactam PLUS Vanco
Antibiotic Guidelines in Sepsis by Suspected SiteAntibiotic Guidelines in Sepsis by Suspected Site