Shock in the pediatric patient or oxygen don t go where the blood won t flow
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Shock in the Pediatric Patient: or Oxygen Don’t Go Where the Blood Won’t Flow!. James D. Fortenberry MD FAAP, FCCM Medical Director, PICU Division of Critical Care Medicine Children’s Healthcare of Atlanta. Objectives. Define shock and its different categories

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Shock in the Pediatric Patient: or Oxygen Don’t Go Where the Blood Won’t Flow!

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Shock in the pediatric patient or oxygen don t go where the blood won t flow

Shock in the Pediatric Patient:orOxygen Don’t Go Where the Blood Won’t Flow!

James D. Fortenberry MD FAAP, FCCM

Medical Director, PICU

Division of Critical Care Medicine

Children’s Healthcare of Atlanta


Objectives

Objectives

  • Define shock and its different categories

  • Review basic physiologic aspects of shock

  • Describe management of shock including:

    • oxygen supply and demand

    • fluid resuscitation

      • crystalloid vs. colloid controversy

    • vasopressor support


Definition of shock

Definition of Shock

  • Uncontrolled blood or fluid loss

  • Blood pressure less than 5th percentile for age

  • Altered mental status, low urine output, poor capillary refill

  • None of the above


Definition of shock1

Definition of Shock

An acute complex pathophysiologic state of circulatory dysfunction which results in a failure of the organism to deliver sufficient amounts of oxygen and other nutrients to satisfy the requirements of tissue beds


Supply demand

SUPPLY < DEMAND


Definition of shock2

Definition of Shock

  • Inadequate tissue perfusion to meet tissue demands

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

  • Shock is not a blood pressure diagnosis!!


Characteristics of shock

Characteristics of Shock

  • End organ dysfunction:

    • reduced urine output

    • altered mental status

    • poor peripheral perfusion

  • Metabolic dysfunction:

    • acidosis

    • altered metabolic demands


Essentials of life

Essentials of Life

  • Gas exchange capability of lungs

  • Hemoglobin

  • Oxygen content

  • Cardiac output

  • Tissues to utilize substrate


Arterial oxygen content

Arterial Oxygen Content

100 mm Hg

PaO2 100 mmHg

Partial Pressure

SaO2 97%

Oxygen Saturation

+

Hgb 15 gm/100 mL

Hemoglobin

+

O2 in plasma

O2 bound to Hgb


Oxygen delivery

Oxygen Delivery

DO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x 0.003

O2O2O2O2O2O2

Oxygen Express

O2O2O2O2O2O2

Ca02


Cardiac output

Cardiac Output

The volume of blood ejected by the heart in one minute

4 - 8 liters / minute


Cardiac output c o heart rate x stroke volume

Cardiac OutputC.O.=Heart Rate x Stroke Volume

  • Heart rate

  • Stroke volume:

    • Preload- volume of blood in ventricle

    • Afterload- resistance to contraction

    • Contractility- force applied


Cardiac output c o mean arterial pressure map cvp svr

Cardiac OutputC.O.=Mean arterial pressure (MAP) - CVP/SVR

  • To improve CO:

  • MAP

  • CVP

  • SVR


Shock in the pediatric patient or oxygen don t go where the blood won t flow

Preload

Afterload

Contractility

x

Heart Rate

Stroke Volume

Cardiac Output

O2 Content

Resistance

x

x

O2 Delivery

Arterial Blood Pressure


Classification of shock

Hypovolemic

dehydration,burns, hemorrhage

Distributive

septic, anaphylactic, spinal

Cardiogenic

myocarditis,dysrhythmia

Obstructive

tamponade,pneumothorax

Compensated

organ perfusion is maintained

Uncompensated

Circulatory failure with end organ dysfunction

Irreversible

Irreparable loss of essential organs

Classification of Shock


Mechanical requirements for adequate tissue perfusion

Mechanical Requirements for Adequate Tissue Perfusion

  • Fluid

  • Pump

  • Vessels

  • Flow


Hypovolemic shock

Hypovolemic Shock:

Inadequate Fluid Volume

(decreased preload)


Hypovolemic shock causes

Hypovolemic Shock:Causes

  • Fluid depletion

    • internal

    • external

  • Hemorrhage

    • internal

    • external


Cardiogenic shock

Cardiogenic Shock:

Pump Malfunction

(decreased contractility)


Cardiogenic shock causes

Cardiogenic Shock:Causes

Electrical Failure

  • Mechanical Failure

    • Cardiomyopathy

    • metabolic

    • anatomic

    • hypoxia/ischemia


Distributive shock

Distributive Shock

Abnormal Vessel Tone

(decreased afterload)


Distributive shock1

Distributive Shock

Vasodilation

Venous Pooling

Decreased Preload

Maldistribution of regional blood flow


Distributive shock2

Distributive Shock:

Causes

  • Sepsis

  • Anaphylaxis

  • Neurogenesis (spinal)

  • Drug intoxication (TCA, calcium, Channel blocker)


Shock in the pediatric patient or oxygen don t go where the blood won t flow

Septic Shock

Decreased Pump Function

Decreased Volume

Abnormal Vessel Tone


Shock in the pediatric patient or oxygen don t go where the blood won t flow

Cardiac OutputC.O.=Heart Rate x Stroke Volume

  • Heart rate

  • Stroke volume:

    • Preload- volume of blood in ventricle

    • Afterload- resistance to contraction

    • Contractility- force applied


Clinical assessment

Clinical Assessment

  • Heart rate

  • Peripheral circulation

    • capillary refill

    • pulses

    • extremity temperature

  • Pulmonary

  • End organ perfusion

    • brain

    • kidney


Improving stroke volume therapy for cardiovascular support

Improving Stroke Volume:Therapy for Cardiovascular Support

Preload

Volume

Inotropes

Contractility

Vasodilators

Afterload


Septic shock

Septic Shock

Early (“Warm”)

Decreased peripheral vascular resistance

Increased cardiac output

Late (“Cold”)

Increased peripheral vascular resistance

Decreased cardiac output


Assessment of circulation

Assessment of Circulation


Heart rate and perfusion pressure map cvp parameters by age

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


Assessment of circulation1

Assessment of Circulation


Obstructive shock

OBSTRUCTIVE SHOCK

OBSTRUCTED FLOW


Obstructive shock causes

Obstructive Shock:Causes

  • Pericardial tamponade

  • Pulmonary embolism

  • Pulmonary hypertension


Hemodynamic assessment of shock

Hemodynamic Assessment of Shock


Goals of resuscitation

O2 content

Cardiac output

Blood pressure

Goals of Resuscitation

  • Overall goal:

    • increase O2 delivery

    • decrease demand

Treatment

Sedation/analgesia


Principles of management

Principles of Management

  • A: Airway

    • patent upper airway

  • B: Breathing

    • adequate ventilation and oxygenation

  • C: Circulation

    • optimize

      • cardiac function

      • oxygenation


Act quickly think slowly

Act quickly,Think slowly.

Greek Proverb


Airway management

Airway Management

  • Patients in shock have:

    • O2 delivery

    • progressive respiratory fatigue/failure

    • energy shunted from vital organs

    • afterload


Airway management1

Airway Management

  • Early intubation provides:

    • O2 delivery and content

    • controlled ventilation which:

      • reduces metabolic demand

      • allows C.O. to vital organs


Therapy

Therapy

Vagolysis

Heart Rate

Chromotropy


Fluid choices

Fluid Choices

Colloid

Crystalloid

Less Filling

Tastes Great !


Crystalloids hypotonic fluids d 5 1 4 ns

CrystalloidsHypotonic Fluids (D5 1/4 NS)

  • No role in resuscitation

  • Maintenance fluids only


Fluids fluids fluids

Fluids, Fluids, Fluids

  • Key to most resuscitative efforts

  • Give generously and reassess


Crystalloids isotonic fluids

CrystalloidsIsotonic Fluids

  • Intravascular volume expansion

  • Hauser:

    • crystalloids rapidly redistribute

  • Lethal animal model

    • NS = good resuscitative fluid

    • 4x blood volume to restore hemodynamics


Crystalloids isotonic fluids1

CrystalloidsIsotonic Fluids

  • 2 trauma studies

    • crystalloids = colloids but:

      • 4x amount

      • longer time to resuscitation


Crystalloids complications

CrystalloidsComplications

  • Under-resuscitation

    • renal failure

  • Over-resuscitation

    • pulmonary edema

    • peripheral edema


Crystalloids summary

CrystalloidsSummary

  • Crystalloids less effective than equal volume of colloids

  • Preferred when 1o deficit is water and/or electrolytes

  • Good in initial resuscitation to restore extracellular volume

  • Hypertonic solutions however, may act as plasma volume expanders


Shock in the pediatric patient or oxygen don t go where the blood won t flow

Oncotic pressure (tendency to pull unit)

Hydrostatic pressure (tendency to drive unit)

Fluid Transport

Capillary


Colloids albumin

ColloidsAlbumin

  • Hepatic production

  • MW = 69,000

  • 80% of COP

  • Serum t1/2:

    18 hours endogenous

    16 hoursexogenous


Colloids hydroxyethyl starch hespan

ColloidsHydroxyethyl Starch (Hespan)

  • Synthetic

  • Derived from corn starch

  • Average MW = 69,000

  • Stable, nonantigenic

  • Used for volume expansion

  • Renal excretion

    • t 1/2 2-67 hours

    • 90% gone in 42 days


Colloids hydroxyethyl starch hespan1

ColloidsHydroxyethyl Starch (Hespan)

  • Greater in COP than albumin

  • Longer duration of action

  • 0.006% adverse reactions

  • No effect on blood typing

  • Prolongs PT, PTT and clotting times

  • Dosage

    • 20 ml/Kg/day

    • max 1500 ml/day


Fluid choices1

Fluid Choices

  • Based on:

    • type of deficit

    • urgency of repletion

    • pathophysiology of condition

    • plasma COP

Tastes Great !

Less Filling


Fluid choices2

Fluid Choices

  • Crystalloids for initial resuscitation

  • PRBC’s to replace blood loss


Fluid management in pediatric septic shock

Fluid Management in Pediatric Septic Shock

  • Emphasis on the golden hour

  • Early aggressive use of fluids may improve outcome

  • Titrate-Reassess!

Clinical Practice Parameters,

Carcillo et al., CCM, 2002


Alpha beta meter

Alpha-Beta Meter

ß

Dopamine

Epinephrine

Dobutamine

Norepinephrine

Neosynephrine


Inotropes

Inotropes


Dopamine activity

Dopamine Activity

0.5-5.0 mcg/kg/min - dopaminergic receptors

2.0-10 mcg/kg/min - beta receptors (inotrope)

10-20 mcg/kg/min - alpha and beta receptors

Over 20 mcg/kg/min - alpha receptors (pressors)


Shock in the pediatric patient or oxygen don t go where the blood won t flow

A Rational Approach to Shock in the Pediatric Patient

Shock / Hypotension

Volume Resuscitation

Signs of adequate circulation

Adequate MAP

NO pressors

Yes

NO


Shock in the pediatric patient or oxygen don t go where the blood won t flow

A Rational Approach to Pressor Use in the PICU

Signs of adequate circulation

Adequate MAP

NO

Dopamine

Inadequate MAP

Dopamine and/or Norepinephrine


Shock in the pediatric patient or oxygen don t go where the blood won t flow

A Rational Approach to Pressor Use in the PICU

Dopamine and/or norepinephrine

adequate MAP

Dobutamine or Milrinone

CO

Inadequate MAP

low C.O.

tachycardia

epinephrine

phenylephrine??


New therapies in septic shock

“New” Therapies in Septic Shock

  • Steroids

  • Vasopressin

  • Activated Protein C (Xigris) in septic shock


Management of pediatric septic shock the golden hour

Management of Pediatric Septic Shock: The Golden Hour

  • First 15 minutes

  • Emphasis on response to volume

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


Patients don t suddenly deteriorate healthcare professionals suddenly notice

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

Anonymous


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