2013 pediatric subspecialty boot camp_shock
TRANSCRIPT
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PEDIATRIC SHOCKAyse Akcan Arikan
Texas Children’s Hospital
Pediatric Critical Care Section
Fellows Bootcamp 2013
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Objectives
• By the end of this workshop, the learner will be able to:• Differentiate between septic and cardiogenic shock states according to clinical assessment and evaluation
• Generate a therapeutic/diagnostic plan according to institutional and SCCM guidelines where applicable
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What is shock?
a. BP less than 5th percentile of age normal
b. Uncontrolled fluid loss/blood loss
c. Tachycardia and hypotension
d. Acidosis and increased lactate
e. Signs of organ dysfunction with decreased UOP, altered mental status, etc.
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Pediatric Shock• Definition – what it is and what it is not• Pathophysiology• Recognition – early is key!• Management- guidelines• Case scenarios• Ask for references, and you shall receive
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PumpFluidPipesSite of exchange
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Pediatric shock• Cellular pathology• Has nothing to do with blood pressure (until very late),
cardiac output, heart rate• Inability to meet the metabolic demands (=oxygen) of the
tissue – or inability of the cell to use oxygen• Supply-demand imbalance
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What is shock?
• A hemodynamic abnormality that leads to inability to meet tissue metabolic demands.
• Dynamic, progressive.
• A systemic reduction in tissue perfusion decreased tissue O2 delivery. • A shift to anaerobic metabolism• Less efficient – 20-fold less ATP generated• Leads to lactic acidosis
• Over time, progresses to,• Cell membrane ion pump dysfunction• Cellular edema, leakage of cells’ contents• Inadequate regulation of intracellular pH• Cell death, organ failure, cardiac arrest, and death.
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Pediatric shock• Dynamic process
• Progressive• Changing physiology*
• Requires bedside management• Oxygen debt• Energy uncoupling
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Vocabulary• CO –cardiac output• CI cardiac index – CO indexed to BSA• SVR, SVRI - systemic vascular resistance• PVR,PVRI – pulmonary vascular resistance• MAP – mean arterial pressure• CVP – central venous pressure• SV – stroke volume• PAP – pulmonary artery pressure• DO2 – oxygen delivery• VO2 – oxygen consumption
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Vocabulary - II• CO – cardiac output: volume of blood ejected by the heart
in one minute 4-8 L/min• Heart rate• Stroke volume
• Contractility• Afterload• Preload
• SVR = MAP – CVP / CO
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Oxygen Delivery – DO2• Oxygen delivery= CO X CaO2 (Arterial oxygen content)• CO=Heart rate X Stroke volume• Stroke volume depends on preload, afterload and
contractility
•Arterial Oxygen content (CaO2) = Hb x Sa02 x 1.34 +(0.003 x Pa02)
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Oxygen Consumption – VO2• VO2 = CO x (CaO2 – CvO2)• Under normal conditions DO2 >> VO2 (physiological
reserve) – this is why you can exercise and don’t die
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Oxygen delivery – consumption imbalance in shock
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Shock pathophysiology
• Oxygen delivery DO2 < oxygen demand VO2
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OXYGEN DELIVERY
CARDIAC OUTPUT X ARTERIAL OXYGEN CONTENT
Cardiac Output
Arterial oxygen content
Heart rate Stroke Volume
PreloadAfterloadContractility
HemoglobinOxygen SaturationPartial pressure of oxygen dissolved in plasma
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Oxygen extraction ratio= (SaO2-SmvO2)/SaO2SmvO2 = mixed venous oxygen saturations (PA)ScvO2 = upper extremity line
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Shock – signs and symptoms• Evidence of end organ hypoperfusion
• Decreased urine output• Altered mental status• Poor peripheral perfusion
• Metabolic dysfunction• Lactic acidosis• Altered metabolic demands
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Shock: Feel the feet, look at the neck• Tachycardia? - Non-specific, but early• Skin changes? - Prolonged cap refill (vasoconstriction) with
compensated shock. Flash refill with early distributive shock and with irreversible shock.
• Pallor? – If Hb is fine, is your patient acidotic
• Impaired mental status? – Fussy, irritable? Sleepy?
• Oliguria? – When was the last diaper?
• Hypotension? – You have missed the ball • Widened pulse pressure (>40 mmHg)? - distributive shock, aortic insufficiency,
AVMs?
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Compensatory Mechanisms• Baroreceptors-In aortic arch and carotid sinus, low MAP
cause vasoconstriction, increases BP, CO and HR• Chemoreceptors- Respond to cellular acidosis, results in
vasoconstriction and respiratory stimulation
• Renin Angiotensin Aldosterone - Decreased renal perfusion leads to angiotensin causing vasoconstriction and aldosterone causing salt and water retentions
• Humoral Responses-Catecholamines• Autotransfusion-Reorientation of extravascular fluid
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Stages of Shock
• Compensated Shock: • Cardiac output (HR x SV) and systemic vascular resistance (peripheral
vasoconstriction) work to keep BP within normal limits. • Tachycardia; decreased pulses & cool extremities in cold shock; flushing
and bounding pulses in warm shock; oliguria; may have mild lactic acidosis
• Uncompensated Shock: • Compensatory mechanisms are overwhelmed.• Hypotension, altered mental status; increased lactic acidosis• Generally quick progression to cardiac arrest.
• Irreversible Shock: • Irreversible organ damage, cardiac arrest, death.
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• Compensated
• Uncompensated
• Irreversible
Act quicklyThink slowly
DEATH
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Types of shock
•Hypovolemic•Hemorrhagic
•Cardiogenic•Distributive
•Septic*•Obstructive
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Classifications of Shock
• Hypovolemic Shock• Decreased preload due to
internal or external losses.
• Distributive Shock• Decrease in SVR, with
abnormal distribution of blood flow functional hypovolemia, decreased preload.
• Typically, NL or CO.
• Cardiogenic Shock• “Pump failure.” CO,
systolic function.
• Obstructive Shock• Outflow from left or
right side of heart physically obstructed.
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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
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Table 2.
Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine *.Brierley, Joe; Carcillo, Joseph; Choong, Karen; Cornell, Tim; DeCaen, Allan; Deymann, Andreas; Doctor, Allan; Davis, Alan; Duff, John; Dugas, Marc-Andre; Duncan, Alan; Evans, Barry; Feldman, Jonathan; Felmet, Kathryn; Fisher, Gene; Frankel, Lorry; Jeffries, Howard; Greenwald, Bruce; Gutierrez, Juan; Hall, Mark; Han, Yong; Hanson, James; Hazelzet, Jan; Hernan, Lynn; Kiff, Jane; Kissoon, Niranjan; Kon, Alexander; Irazusta, Jose; Lin, John; Lorts, Angie; Mariscalco, Michelle; Mehta, Renuka; Nadel, Simon; Nguyen, Trung; Nicholson, Carol; Peters, Mark; Okhuysen-Cawley, Regina; Poulton, Tom; Relves, Monica; Rodriguez, Agustin; Rozenfeld, Ranna; Schnitzler, Eduardo; Shanley, Tom; Skache, Sara; Skippen, Peter; Torres, Adalberto; von Dessauer, Bettina; Weingarten, Jacki; Yeh, Timothy; Zaritsky, Arno; Stojadinovic, Bonnie; Zimmerman, Jerry; Zuckerberg, Aaron
Critical Care Medicine. 37(2):666-688, February 2009.DOI: 10.1097/CCM.0b013e31819323c6
Table 2. American College of Critical Care Medicine hemodynamic definitions of shock
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Type of shock Mechanism of circulatory failure
Signs and symptoms
Interventions
Hypovolemic Volume depletion absolute or relative, CO ↓, SVR ↑
Tachycardia, diminished pulses, sunken eyes and fontanels, oliguria, prolonged cap refill time
Crystalloid bolus 20 ml/kg until hemodynamics improve, reassess after each bolus, blood products in hemorrhagic shock
Cardiogenic CO ↓, SVR ↑ Tachycardia, diminished pulses, hepatomegaly, JVD
Inotropic agents dopamine, dobutamine, epinephrine, milrinoneSmall volume boluses 5-10 ml/kg might be administered carefully while monitoring responseGet echo earlyConsider PGE
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Type of shock Mechanism of circulatory failure
Signs and symptoms
Interventions
DistributiveAnaphylacticNeurogenic
CO ↑, then ↓, SVR ↓↓
Angioedema, respiratory distress, stridor, wheezing, early hypotension
Start adrenergic support while giving fluids, obtain vascular access early, supratherapeutic doses of inotropes might be required
CO normal, SVR ↓ Hypotension in the absence of tachycardia
Support SVR with vasopressors, phenylephrine might be required, give fluids as necessary
Obstructive Preload ↓, CO ↓, SVR normal to ↑
Tachycardia, hypotension, JVD, tracheal deviation if pneumothorax, equalization of pressures with elevated CVP if invasive monitoring in place
Rapidly fatal if underlying process not recognized and reversed, fluid boluses should be given while preparation is made for emergent drainage
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Type of shock Mechanism of circulatory failure
Signs and symptoms Interventions
Septic “Warm shock” CO ↑, SVR↓
Tachycardia, bounding pulses, warm extremities with hypotension, hyperpnoea, altered mentation
Crystalloid boluses of 20 ml/kg repeat until hemodynamics stable, first choice agents vasopressors (dopamine or norepinephrine)
“Cold shock” CO ↓, SVR ↑(60% of pediatric cases)
Tachycardia, poor peripheral perfusion, diminished pulses, hyperpnoea, altered mentation
Crystalloid boluses of 20 ml/kg, repeat until hemodynamics stable, early inotropic support with dopamine or epinephrine might be required, echocardiography might be useful to guide therapy
CO ↓, SVR ↓ Tachycardia, diminished pulses, with hypotension, hyperpnoea, altered mentation
Crystalloid boluses of 20 ml/kg repeat until hemodynamics stable, early inotropic support with dopamine or epinephrine might be required, echocardiography might be useful to guide therapy
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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
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Table 3.
Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine *.Brierley, Joe; Carcillo, Joseph; Choong, Karen; Cornell, Tim; DeCaen, Allan; Deymann, Andreas; Doctor, Allan; Davis, Alan; Duff, John; Dugas, Marc-Andre; Duncan, Alan; Evans, Barry; Feldman, Jonathan; Felmet, Kathryn; Fisher, Gene; Frankel, Lorry; Jeffries, Howard; Greenwald, Bruce; Gutierrez, Juan; Hall, Mark; Han, Yong; Hanson, James; Hazelzet, Jan; Hernan, Lynn; Kiff, Jane; Kissoon, Niranjan; Kon, Alexander; Irazusta, Jose; Lin, John; Lorts, Angie; Mariscalco, Michelle; Mehta, Renuka; Nadel, Simon; Nguyen, Trung; Nicholson, Carol; Peters, Mark; Okhuysen-Cawley, Regina; Poulton, Tom; Relves, Monica; Rodriguez, Agustin; Rozenfeld, Ranna; Schnitzler, Eduardo; Shanley, Tom; Skache, Sara; Skippen, Peter; Torres, Adalberto; von Dessauer, Bettina; Weingarten, Jacki; Yeh, Timothy; Zaritsky, Arno; Stojadinovic, Bonnie; Zimmerman, Jerry; Zuckerberg, Aaron
Critical Care Medicine. 37(2):666-688, February 2009.DOI: 10.1097/CCM.0b013e31819323c6
Table 3. Threshold heart rates and perfusion pressure mean arterial pressure-central venous pressure or mean arterial pressure-intra-abdominal pressure for age
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What is the goal of shock treatment ?
•Optimizing oxygen content of the blood
• Improving volume and distribution of cardiac output
•Reducing oxygen demand•Correcting metabolic derangements
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Treatment• Overall goal: Normalization of tissue perfusion and
homeostasis• A - airway
• Secure, patent• Oxygen administration – 100% FiO2 (except in some cases of
cardiogenic shock)
• B - breathing• Decrease WOB, intubation-mechanical ventilation may be
necessary (decrease oxygen consumption)
• C - circulation• Improve cardiac output• Ensure adequate preload – FLUIDS!!!
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Treatment - II• Have I mentioned fluids?• Give lots of fluids – fast!• Then – give some more –up to 200 ml/kg may be required• REASSESS! (After every step/intervention)• Pay attention to hepatomegaly, JVD, rales, worsening
respiratory distress – if your patient is not responding to the fluids, reconsider your diagnosis
• Once you reach 60 ml/kg, consider starting vasoactive infusions –more on this later
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Treatment - III• D – “derangements”
• Correct metabolic abnormalities – hypoglycemia, hypocalcemia, etc
• Etiology specific treatment
•DO NOT DELAY ANTIBIOTICS FOR ANY REASON IF YOU SUSPECT SEPTIC SHOCK !• Source control
• Consider transfusion of PRBCs
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Assessing efficacy of treatment
• Blood pressure: Normal *• Quality of central and peripheral pulses: Strong, distal
pulses equal to central pulses.• Skin perfusion: Warm, with capillary refill 1-2 seconds.• Mental status: Normal. Urine output: >1 mL/kg per hour, once effective
circulating volume is restored.
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Sepsis• High mortality despite improvements
• KID database : 4.2% in all-comers, 2.3% in previously healthy, 7.8% in chronically ill
• Guidelines are not effective unless protocol driven• Early intervention is critical – no delay is acceptable. • Every hour spent without reversing shock increases OR of
mortality
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SIRS SEPSIS SEVERESEPSIS
SEPTIC SHOCK
T > 38.5 or < 36
Tachycardia
Tachypnea
WBC
SIRS +
Infection
(suspected or proven)
SEPSIS +
CV dysfunction or
ARDS or
≥ 2 organ failures
SEPSIS +
CV dysfunctiondespite >40 ml/kg in 1 hr
2 of the above 4
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Early Goal-directed Therapy
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Pediatrics 2003; 112:793
Early Resuscitation
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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
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Figure 1.
Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine *.Brierley, Joe; Carcillo, Joseph; Choong, Karen; Cornell, Tim; DeCaen, Allan; Deymann, Andreas; Doctor, Allan; Davis, Alan; Duff, John; Dugas, Marc-Andre; Duncan, Alan; Evans, Barry; Feldman, Jonathan; Felmet, Kathryn; Fisher, Gene; Frankel, Lorry; Jeffries, Howard; Greenwald, Bruce; Gutierrez, Juan; Hall, Mark; Han, Yong; Hanson, James; Hazelzet, Jan; Hernan, Lynn; Kiff, Jane; Kissoon, Niranjan; Kon, Alexander; Irazusta, Jose; Lin, John; Lorts, Angie; Mariscalco, Michelle; Mehta, Renuka; Nadel, Simon; Nguyen, Trung; Nicholson, Carol; Peters, Mark; Okhuysen-Cawley, Regina; Poulton, Tom; Relves, Monica; Rodriguez, Agustin; Rozenfeld, Ranna; Schnitzler, Eduardo; Shanley, Tom; Skache, Sara; Skippen, Peter; Torres, Adalberto; von Dessauer, Bettina; Weingarten, Jacki; Yeh, Timothy; Zaritsky, Arno; Stojadinovic, Bonnie; Zimmerman, Jerry; Zuckerberg, Aaron
Critical Care Medicine. 37(2):666-688, February 2009.DOI: 10.1097/CCM.0b013e31819323c6
Figure 1. Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children. Proceed to next step if shock persists. 1) First hour goals-Restore and maintain heart rate thresholds, capillary refill MAP]-central venous pressure [CVP]) for age, central venous O2 saturation >70%, and CI >3.3, 2 in pediatric intensive care unit (PICU). Hgb, hemoglobin; PICCO, pulse contour cardiac output; FATD, femoral arterial thermodilution; ECMO, extracorporeal membrane oxygenation; CI, cardiac index; CRRT, continuous renal replacement therapy; IV, intravenous; IO, interosseous; IM, intramuscular.
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TCH Shock Protocol
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Definitions• Pressor-increases SVR, and therefore BP• Inotrope-Increases contractility, SV• Chronotrope- increases HR• Lusitrope- improves diastolic relaxation, SV• Vasodilator- decreases SVR, afterload• “Inodilator”
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TCH BOOTCAMPShock II – Cardiogenic shock
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PumpFluidPipesSite of exchange
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• Tachycardia• Tachypnea• Hx of sweating/tiring with feeds• Vomiting, feeding intolerance• Fussiness• Gallop• Hepatomegaly• Rales• Decreased UOP• Cardiomegaly• Altered mentation• “Septic” newborn !• Cyanosis
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VENTRICULAR FUNCTION CURVESNORMAL AND FAILING LV
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Cardiogenic shock• Electrical failure• Mechanical failure
• Myocarditis• Cardiomyopathy• Anatomic
• Obstructive• Congestive
• Ischemic• Trauma
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Cardiogenic shock• Anatomic
• Left sided obstructive = ductal dependent systemic flow IAA, critical AS, HLHS, etc HCM*
• Congestive • large L R shunts• Acute valvular regurgitation
• Ductal dependent pulmonary blood flow• Parallel circulation – TGA-IVS• Obstructed pulmonary flow – TAPVR, obstructed
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Ischemic Heart Disease in Children
• ALCAPA• Anomalous Left Coronary Artery arising from the Pulmonary
Artery
• Kawasaki Disease• Aneurysms
• Other vasculitis
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Treatment• Support the failing pump• Decrease oxygen consumption/metabolic demand
• Intubation*, mechanical ventilation• Sedation, NMB• Prevention of fever, stress
• Consider bolus 5-10 ml/kg• Consider PGE• Echo early
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Treatment - II• Optimize contractility
• Correct metabolic derangements• Inotropic support
• Afterload reduction• Decongestion• Address the underlying cause – surgery?• Mechanical support
• ECMO• Implantable devices, VAD, EXCOR, etc
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Type of shock Mechanism of circulatory failure
Signs and symptoms
Interventions
Hypovolemic Volume depletion absolute or relative, CO ↓, SVR ↑
Tachycardia, diminished pulses, sunken eyes and fontanels, oliguria, prolonged cap refill time
Crystalloid bolus 20 ml/kg until hemodynamics improve, reassess after each bolus, blood products in hemorrhagic shock
Cardiogenic CO ↓, SVR ↑ Tachycardia, diminished pulses, hepatomegaly, JVD
Inotropic agents dopamine, dobutamine, epinephrine, milrinoneSmall volume boluses 5-10 ml/kg might be administered carefully while monitoring responseGet echo earlyConsider PGE
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Question• 13 month old patient with DCM, HR 180 (sinus), CVP 25
mm Hg, BP 55/24, lactate 4->8, SvO2 50%, cap refill of 5 seconds, best choice of action is:
a. Epinephrine gtt
b. Milrinone gtt
c. Phenylephrine gtt
d. NS bolus 20 ml/kg
e. Esmolol (B-blocker) for HR control
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Question • 12 year old female presents with fever, tachycardia, right
flank pain, WBC count is elevated. Vital signs are HR 155, RR 35, BP 124/73, T 102. She is somnolent. Working diagnosis is sepsis secondary to pyelonephritis. What is the next most appropriate intervention?
A. Renal US
B. Normal saline bolus
C. Antibiotics
D. Vasopressor infusion
E. Urinalysis
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Question • 12 year old female presents with fever, tachycardia, right
flank pain, WBC count is elevated. Vital signs are HR 110, RR 25, BP 124/83, T 102. She is AAO x 3 and is . Working diagnosis is sepsis secondary to pyelonephritis. What is the next most appropriate intervention?
A. Renal US
B. Normal saline bolus
C. Antibiotics
D. Vasopressor infusion
E. Urinalysis
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Case 1
• 15-year-old male is just transferred to 11 WT from PICU, POD #3 from partial small bowel resection after multiple gunshot wounds to the abdomen. The nurse calls an RRT because his HR has increased in the last hour from 90 to 130, despite pain score of 1/10 on morphine drip. On exam, he is afebrile, HR is 140, BP 80/50. Cap refill is >3 seconds in his cool extremities and pulses are 1+.
• What is your assessment?• What is the stage of shock?• What is the classification of shock?• What is your initial management?
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Case 2
• 6-year-old previously healthy girl is transferred from West Campus ER with fever, bloody diarrhea x 1 day. She’s had no urine x 24 hrs and is becoming harder to awaken. On exam, her HR is 152, BP 72/32, temp 103. She’s sleepy but arousable.
She’s flushed with capillary refill <1 second.
• What is your assessment?• What is the stage of shock?• What is the classification of shock?• What is your differential for the etiology?• What is your initial management? If a higher level of care is needed,
how would you obtain it?
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Case 3
• 4-month-old boy former premie, presents to ED with decreased po x 2 days with 2 times daily emesis, following what sounds like viral URI. Urine output has been 3 wet diapers daily. He is afebrile with HR 180; BP has not been obtained. He has a weak cry, is mottled with 3-second capillary refill, pulses 1+ in all extremities. Liver is palpable 4 cm below RCM. S4 is present without murmur.
• What is your assessment?• What is the stage of shock?• What is the classification of shock? • What is your differential for the etiology?• What is your initial management?
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What is the end goal for resuscitation ?
• Mixed venous sats• Lactate clearance• Traditional clinical variables –UOP, perfusion, pulses, CVP• Combination of all three with common sense
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Minimize variationEarly Resuscitation
Intensive Care Med 2008; 34:1065
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Intensive Care Med 2008; 34:1065
Minimize variationEarly Resuscitation
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• crashingpatient.com• ccmtutorials.com• cvphysiology.com• learnhemodynamics.com*• library.med.utah.edu