Shock in the Pediatric Shock in the Pediatric Patient:Patient:

ororOxygen Don’t Go Oxygen Don’t Go

Where the Blood Won’t Where the Blood Won’t Flow!Flow!

Dr. Virendra Kumar GuptaDr. Virendra Kumar GuptaMD PediatricsMD Pediatrics

Fellowship In pediatric Gastroentero-Hepatology & Fellowship In pediatric Gastroentero-Hepatology & Liver TransplantationLiver Transplantation

Assistant Professor Assistant Professor Institute of Paediatric GastroenterologyInstitute of Paediatric Gastroenterology

Nims University Jaipur Nims University Jaipur 

ObjectivesObjectives Define shock and its different Define shock and its different

categoriescategories Review basic physiologic aspects of Review basic physiologic aspects of

shockshock Describe management of shock Describe management of shock

including:including: oxygen supply and demandoxygen supply and demand fluid resuscitationfluid resuscitation

crystalloid vs. colloid controversycrystalloid vs. colloid controversy vasopressor supportvasopressor support

IntroductionIntroduction Shock is a syndrome that results from Shock is a syndrome that results from

inadequate oxygen delivery to meet inadequate 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 metabolic Untreated this leads to metabolic acidosis, organ dysfunction and deathacidosis, organ dysfunction and death

Oxygen DeliveryOxygen Delivery Oxygen delivery = Cardiac Output x Oxygen delivery = Cardiac Output x

Arterial Oxygen Content Arterial Oxygen Content (DO(DO22 = CO x CaO = CO x CaO22))

Cardiac Output = Heart Rate x Stroke Cardiac Output = Heart Rate x Stroke Volume Volume ((CO = HR x SV)CO = HR x SV)

– SV determined by preload, afterload and SV determined by preload, afterload and contractility contractility

Art Oxygen Content = Oxygen content of Art Oxygen Content = Oxygen content of the RBC + the oxygen dissolved in plasma the RBC + the oxygen dissolved in plasma

(CaO(CaO22 = Hb X SaO = Hb X SaO22 X 1.34 + (.003 X PaO X 1.34 + (.003 X PaO22))

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

SUPPLY SUPPLY << DEMANDDEMAND

Definition of ShockDefinition of Shock

Inadequate tissue perfusion to Inadequate tissue perfusion to meet tissue demandsmeet tissue demands

Usually result of inadequate blood Usually result of inadequate blood flow and/or oxygen deliveryflow and/or oxygen delivery

Shock is not a blood pressure Shock is not a blood pressure diagnosis!!diagnosis!!

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

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

PreloadPreloadAfterloadAfterloadContractilitContractilityy

ResistanResistancece

Stroke Stroke VolumeVolume Heart RateHeart Rate

Arterial Blood Arterial Blood PressurePressureOO22 Delivery Delivery

OO22 Content Content Cardiac Cardiac OutputOutput

xx

xx xx

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 is organ perfusion is

maintainedmaintained UncompensatedUncompensated

Circulatory failure Circulatory failure with end organ with end organ dysfunctiondysfunction

IrreversibleIrreversible Irreparable loss of Irreparable loss of

essential organsessential organs

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

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

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.

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

Cardiogenic ShockCardiogenic Shock Cardiogenic shock is commonly Cardiogenic shock is commonly

described as “pump failure” described as “pump failure” (decreased contractility)(decreased contractility)

The common causes areThe common causes are myocarditis, dysrhythmias,and myocarditis, dysrhythmias,and

drugs with a myocardial depressant drugs with a myocardial depressant action, acidosis, congenital heart action, acidosis, congenital heart lesions and sepsis. lesions and sepsis.

SIRS/Sepsis/Septic shock

Mediator release:exogenous & endogenous

Decreased blood flow

Cardiacdysfunction

Imbalance of oxygen

supply and demand

Alterations inmetabolism

SEPTIC SHOCKSEPTIC SHOCK

Decreased Volume / Decreased Pump Function/Abnormal Vessel Tone

Mechanical Requirements Mechanical Requirements for Adequate Tissue for Adequate Tissue PerfusionPerfusion

FluidFluid PumpPump VesselsVessels FlowFlow

Clinical AssessmentClinical Assessment Heart rateHeart rate Peripheral circulationPeripheral circulation

capillary refillcapillary refill pulsespulses extremity temperatureextremity temperature

PulmonaryPulmonary End organ perfusionEnd organ perfusion

brainbrain kidneykidney

Improving Stroke Volume:Improving Stroke Volume:Therapy for Cardiovascular Therapy for Cardiovascular SupportSupport

Preload Volume

Contractility Inotropes

Afterload Vasodilators

Septic ShockSeptic ShockEarly (“Warm”)Early (“Warm”)

Decreased peripheral vascular Decreased peripheral vascular resistanceresistance

Increased cardiac outputIncreased cardiac output

Late (“Cold”)Late (“Cold”)Increased peripheral vascular Increased peripheral vascular

resistanceresistanceDecreased cardiac outputDecreased cardiac output

Assessment of CirculationAssessment of CirculationEarly Late

Heart rate Tachycardia Tachycardia/Bradycardia

Bloodpressure

Normal Decreased

Peripheralcirculation

Warm/CoolDecreased/Increasedpulses

CoolDecreasedpulses

Assessment of CirculationAssessment of CirculationEarly Late

End- organ:Skin

Decreasedcap refill

Very decreasedcap refill

Brain I rritable,restless

Lethargic,unresponsive

Kidneys Oliguria Oliguria, anuria

Heart Rate and Perfusion Pressure Heart Rate and Perfusion Pressure (MAP-CVP) Parameters by Age(MAP-CVP) Parameters by Age

Age Heart Rate MAP- CVPTerm

newborn120- 180 55

< 1 120- 180 60< 2 120- 160 65< 7 120- 160 65< 15 90- 140 65

Hemodynamic Assessment of Hemodynamic Assessment of ShockShock

Type of Shock Preload Afterload Contractility CardiacOutput

Cardiogenic

Hypovolemic Septic

Early

Late

Obstructive

Distributive

Goals of ResuscitationGoals of Resuscitation Overall goal:Overall goal:

increase Oincrease O22 delivery delivery decrease demanddecrease demand

TreatmentTreatmentOO22 contentcontent

CardiaCardiac c outpuoutputt

Blood Blood pressurpressuree

Sedation/Sedation/analgesiaanalgesia

Principles of ManagementPrinciples of Management A: AirwayA: Airway

patent upper airwaypatent upper airway B: BreathingB: Breathing

adequate ventilation and oxygenationadequate ventilation and oxygenation C: CirculationC: Circulation

optimizeoptimize cardiac functioncardiac function oxygenationoxygenation

Act quickly,Think slowly.

Greek Proverb

Airway Airway ManagementManagement

Patients in shock have:Patients in shock have: OO22 delivery delivery progressive respiratory progressive respiratory

fatigue/failurefatigue/failure energy shunted from vital organsenergy shunted from vital organs afterloadafterload

Airway Airway ManagementManagement

Early intubation provides:Early intubation provides: OO22 delivery and content delivery and content controlled ventilation which:controlled ventilation which:

reduces metabolic demandreduces metabolic demand allows C.O. to vital organsallows C.O. to vital organs

TherapyTherapy

Vagolysis

Chromotropy

V o lu m eC V P

P re load

V asodila to rsV asoconstr ic to rs

A fterload

C orre ctac id os ishypox ia

hypog lycem ia

Ino trop icagen ts

C on tra c tility

S troke V o lu m eHeart Rate

Fluid ChoicesFluid Choices

Less FillingLess Filling

Tastes Great !

Tastes Great !

Colloid

Crystalloid

CrystalloidsCrystalloidsHypotonic Fluids (DHypotonic Fluids (D5 5 1/4 1/4 NS)NS) No role in resuscitationNo role in resuscitation Maintenance fluids onlyMaintenance fluids only

Fluids, Fluids, FluidsFluids, Fluids, Fluids

Key to most resuscitative Key to most resuscitative effortsefforts

Give generously and reassessGive generously and reassess

CrystalloidsCrystalloidsIsotonic 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 4x blood volume to restore

hemodynamicshemodynamics

CrystalloidsCrystalloidsIsotonic FluidsIsotonic Fluids

2 trauma studies2 trauma studies crystalloids = colloids but:crystalloids = colloids but:

4x amount4x amount longer time to resuscitationlonger time to resuscitation

CrystalloidsCrystalloidsComplicationsComplications Under-resuscitationUnder-resuscitation

renal failurerenal failure Over-resuscitationOver-resuscitation

pulmonary edemapulmonary edema peripheral edemaperipheral edema

CrystalloidsCrystalloidsSummarySummary

Crystalloids less effective than Crystalloids less effective than equal volume of colloidsequal volume of colloids

Preferred when 1Preferred when 1oo deficit is water deficit is water and/or electrolytes and/or electrolytes

Good in initial resuscitation to Good in initial resuscitation to restore extracellular volumerestore extracellular volume

Hypertonic solutions however, may Hypertonic solutions however, may act as plasma volume expandersact as plasma volume expanders

Oncotic pressure (tendency to pull unit) CapillaryCapillary

Hydrostatic pressure (tendency to drive unit)

Fluid Fluid TranspoTransportrt

ColloidsColloidsAlbuminAlbumin Hepatic productionHepatic production MW = 69,000MW = 69,000 80% of COP80% of COP Serum tSerum t1/21/2::

18 hours endogenous18 hours endogenous16 hours16 hours exogenousexogenous

ColloidsColloidsHydroxyethyl Starch Hydroxyethyl Starch (Hespan)(Hespan) Synthetic Synthetic Derived from corn starchDerived from corn starch AverageAverage MW = 69,000 MW = 69,000 Stable, nonantigenicStable, nonantigenic Used for volume expansionUsed for volume expansion Renal excretionRenal excretion

t t 1/2 1/2 2-67 hours2-67 hours 90% gone in 42 days90% gone in 42 days

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

ColloidsColloidsHydroxyethyl Starch Hydroxyethyl Starch (Hespan)(Hespan)

Fluid ChoicesFluid Choices

Based on:Based on: type of deficittype of deficit urgency of repletionurgency of repletion pathophysiology of pathophysiology of

conditioncondition plasma COPplasma COP

Tastes Great !

Tastes Great !

Less FillingLess Filling

Fluid ChoicesFluid Choices Crystalloids for initial Crystalloids for initial

resuscitationresuscitation PRBC’s to replace blood lossPRBC’s to replace blood loss

Fluid Management in Fluid Management in Pediatric Septic ShockPediatric Septic Shock Emphasis on the golden hourEmphasis on the golden hour Early aggressive use of fluids Early aggressive use of fluids

may improve outcomemay improve outcome Titrate-Reassess!Titrate-Reassess!

Clinical Practice Parameters,Carcillo et al., CCM, 2002

Alpha-Beta Alpha-Beta MeterMeter

ßßDopamineDopamine

EpinephrineEpinephrineNorepinephrine

Norepinephrine Dobutamine

DobutamineNeosynephrine

Neosynephrine

InotropesInotropesAgent Site of action Dose

(g/kg/min)Eff ects

Dopamine Dopaminergic

1- 35- 10

11- 20

Renal vasodilatorInotropeVasoconstrictionIncrease PVR

Dobutamine and 1- 20 InotropeVasodilation

Epinephrine 0.05- 1.0 InotropeTachycardia

Norepinephrine 0.05- 1.0 ProfoundvasoconstrictionInotrope

Nitroprusside VasodilatorArterial >venous

0.5- 1.0 Vasodilation

Milrinone PDE inhibitor 0.5- 0.75 InotropeVasodilator

Dopamine ActivityDopamine Activity

0.5-5.0 mcg/kg/min - dopaminergic 0.5-5.0 mcg/kg/min - dopaminergic receptorsreceptors2.0-10 mcg/kg/min - beta receptors 2.0-10 mcg/kg/min - beta receptors (inotrope)(inotrope)10-20 mcg/kg/min - alpha and beta 10-20 mcg/kg/min - alpha and beta receptorsreceptorsOver 20 mcg/kg/min - alpha receptors Over 20 mcg/kg/min - alpha receptors (pressors)(pressors)

A Rational Approach to Shock in the A 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

NO NO pressorspressorsYesYes

A Rational Approach to Pressor A Rational Approach to Pressor Use in the PICUUse in the PICU

NONO

DopamineDopamine

Inadequate MAPInadequate MAP

Dopamine and/or Dopamine and/or NorepinephrineNorepinephrine

Signs of adequate circulationSigns of adequate circulation

Adequate MAPAdequate MAP

A Rational Approach to Pressor A Rational Approach to Pressor Use in the PICUUse in the PICU

Dopamine and/or Dopamine and/or norepinephrinenorepinephrine

Inadequate MAPInadequate MAP

low C.O.low C.O.

epinephrineepinephrine

adequate adequate MAPMAP

Dobutamine Dobutamine or or

MilrinoneMilrinone

tachycardiatachycardia

phenylephrine??phenylephrine??

COCO

““New” Therapies in New” Therapies in Septic ShockSeptic Shock SteroidsSteroids VasopressinVasopressin Activated Protein C (Xigris) in Activated Protein C (Xigris) in

septic shockseptic shock

Management of Pediatric Septic Management of Pediatric Septic Shock: The Golden HourShock: The Golden Hour First 15 minutes First 15 minutes Emphasis on response to volumeEmphasis on response to volume

Clinical Practice Parameters, Carcillo et al., CCM, 2002

Early Goal directed therapy in treatment of sepsis and septic shock- Rivers et al., NEJM, Nov 2001

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

Patients don’t Patients don’t suddenly deteriorate, suddenly deteriorate, healthcare healthcare professionals suddenly professionals suddenly notice!notice!

THANK YOUTHANK YOU