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Shock in the Pediatric Patient:Shock in the Pediatric Patient:oror
Oxygen Dont GoOxygen Dont GoWhere the Blood Wont Flow!Where the Blood Wont Flow!
James D. Fortenberry MD FAAP, FCCMJames D. Fortenberry MD FAAP, FCCM
Medical Director, PICUMedical Director, PICU
Division of Critical Care MedicineDivision of Critical Care MedicineChildrens Healthcare of AtlantaChildrens Healthcare of Atlanta
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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
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Definition of ShockDefinition of Shock
Uncontrolled blood or fluid lossUncontrolled blood or fluid loss
Blood pressure less than 5th percentileBlood pressure less than 5th percentilefor agefor age
Altered mental status, low urine output,Altered mental status, low urine output,poor capillary refillpoor capillary refill
None of the aboveNone of the above
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Definition of ShockDefinition of Shock
An acute complex pathophysiologicAn acute complex pathophysiologic
state of circulatory dysfunctionstate of circulatory dysfunctionwhich results in a failure of thewhich results in a failure of theorganism to deliver sufficientorganism to deliver sufficientamounts of oxygen and otheramounts of oxygen and other
nutrients to satisfy thenutrients to satisfy therequirements of tissue bedsrequirements of tissue beds
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SUPPLYSUPPLY
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Definition of ShockDefinition of Shock
Inadequate tissue perfusion to meetInadequate tissue perfusion to meettissue demandstissue demands
Usually result of inadequate blood flowUsually result of inadequate blood flowand/or oxygen deliveryand/or oxygen delivery
Shock is not a blood pressure diagnosis!!Shock is not a blood pressure diagnosis!!
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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
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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
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Arterial OxygenContentArterial OxygenContent
Hgb 15 gm/100 mLHgb 15 gm/100 mL
HemoglobinHemoglobin
SaOSaO22 97%97%
Oxygen SaturationOxygen Saturation
PaOPaO22 100 mmHg100 mmHgPartial PressurePartial Pressure
OO22 bound to Hgbbound to Hgb
100 mm Hg100 mm Hg
+
OO22 in plasmain plasma+
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Oxygen DeliveryOxygen DeliveryDO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x 0.003
OO22OO22OO22OO22OO22OO22 OO22OO22OO22OO22OO22OO22Oxygen ExpressOxygen Express
Ca02
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Cardiac OutputCardiac Output
The volume of blood ejected byThe volume of blood ejected bythe heart in one minutethe heart in one minute
44 -- 8 liters / minute8 liters / minute
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Cardiac OutputCardiac Output
C.O.=Heart Rate x Stroke VolumeC.O.=Heart Rate x Stroke Volume
Heart rateHeart rate
Stroke volume:Stroke volume: PreloadPreload-- volume of blood in ventriclevolume of blood in ventricle
AfterloadAfterload-- resistance to contractionresistance to contraction
Contractility
Contractility-- f
orce appliedforce applied
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Cardiac OutputCardiac Output
C.O.=Mean arterial pressure (MAP)C.O.=Mean arterial pressure (MAP) -- CVP/SVRCVP/SVR
To improveCO:To improveCO:
MAPMAP
CVPCVP
SVRSVR
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PreloadPreloadAfterloadAfterloadContractilityContractility
ResistanceResistance
Stroke VolumeStroke Volume Heart RateHeart Rate
Arterial BloodArterial BloodPressurePressure
OO22 DeliveryDelivery
OO22 ContentContent CardiacOutputCardiacOutput
xx
xx xx
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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 CirculatoryfailureCirculatoryfailure
withend organwithend organ
dysfunctiondysfunction IrreversibleIrreversible
Irreparable loss ofIrreparable loss ofessential organsessential organs
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Mechanical RequirementsforMechanical RequirementsforAdequate Tissue PerfusionAdequate Tissue Perfusion
FluidFluid
PumpPump
VesselsVessels
FlowFlow
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Hypovolemic Shock:Hypovolemic Shock:
InadequateInadequateFluidFluid VolumeVolume(decreased preload)(decreased preload)
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Hypovolemic Shock:Hypovolemic Shock:
CausesCauses FluiddepletionFluiddepletion
internalinternal
externalexternal HemorrhageHemorrhage
internalinternal
externalexternal
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Cardiogenic Shock:Cardiogenic Shock:
Pump MalfunctionPump Malfunction(decreased contractility)(decreased contractility)
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Cardiogenic Shock:Cardiogenic Shock:
CausesCausesElectricalFailureElectricalFailure
MechanicalFailureMechanicalFailure CardiomyopathyCardiomyopathy metabolicmetabolic
anatomicanatomic
hypoxia/ischemiahypoxia/ischemia
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Distributive ShockDistributive Shock
Abnormal Vessel ToneAbnormal Vessel Tone(decreasedafterload)(decreasedafterload)
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Distributive ShockDistributive Shock
Vasodilation Venous Pooling
Decreased Preload
Maldistribution of regional blood flow
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Distributive Shock:Distributive Shock:CausesCauses
SepsisSepsis AnaphylaxisAnaphylaxis
Neurogenesis (spinal)Neurogenesis (spinal)
Drug intoxication (TCA,Drug intoxication (TCA,calcium, Channel blocker)calcium, Channel blocker)
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Septic Shock
Decreased
Volume
Decreased
Pump
Function
Abnormal
Vessel
Tone
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Cardiac OutputCardiac Output
C.O.=Heart RatexStroke VolumeC.O.=Heart RatexStroke Volume
Heart rateHeart rate
Stroke volume:Stroke volume: PreloadPreload-- volumeof blood in ventriclevolumeof blood in ventricle
AfterloadAfterload-- resistance to contractionresistance to contraction
Con
tractilityCon
tractility-- fo
rce appliedfo
rce applied
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ClinicalAssessmentClinicalAssessment HeartrateHeartrate
Peripheral circulationPeripheral circulation capillaryrefillcapillaryrefill
pulsespulses extremity temperatureextremity temperature
PulmonaryPulmonary
Endo
rgan perfusionEn
do
rgan perfusion
brainbrain
kidneykidney
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ImprovingStroke Volume:ImprovingStroke Volume:TherapyforCardiovascularSupportTherapyforCardiovascularSupport
Preload Volume
Contractility Inotropes
Afterload Vasodilators
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Septic ShockSeptic ShockEarly (Warm)Early (Warm)
Decreased peripheral vascularresistanceDecreased peripheral vascularresistance
Increased cardiac outputIncreased cardiac output
Late (Cold)Late (Cold)
Increased peripheral vascularresistanceIncreased peripheral vascularresistanceDecreased cardiac outputDecreased cardiac output
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Assessment ofCirculationAssessment ofCirculationarl ate
eart rate ac car ia ac car ia
ra car ia
loo
ressure
ormal ecrea se
eri eralcirculation arm/C
oolecrease /
Increase
ulses
C
oolecrease
ulses
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Heart Rate and Perfusion PressureHeart Rate and Perfusion Pressure(MAP(MAP--CVP) Parameters byAgeCVP) Parameters byAge
Age Heart Rate MAP-CVPerm
ne born
- 8
< - 8 6
< - 6 6
< 7 - 6 6< 9 - 6
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Assessment ofCirculationAssessment ofCirculationarl ate
n or an:kin
ecreaseca refill
er ecreaseca refill
rain Irrita le,
restless
Let ar ic,
unresponsive
Ki nes li uria li uria, anuria
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OBSTRUCTIVE SHOCKOBSTRUCTIVE SHOCK
OBSTRUCTEDFLOWOBSTRUCTEDFLOW
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Obstructive Shock:Obstructive Shock:CausesCauses
Pericardial tamponadePericardial tamponade
Pulmonary embolismPulmonary embolism
Pulmonary hypertensionPulmonary hypertension
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HemodynamicAssessment of ShockHemodynamicAssessment of Shock
Type of Shock Preload Afterload Contractility Cardiac
Output
Cardiogenic
Hypovolemic Septic
Early
Late
Obstructive
Distributive
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Goals of ResuscitationGoals of Resuscitation Overallgoal:Overallgoal:
increaseOincreaseO22 deliverydelivery
decreasedemanddecreasedemand
TreatmentTreatment
OO22 contentcontent CardiacCardiacoutputoutput
BloodBloodpressurepressure
Sedation/analgesiaSedation/analgesia
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Principles ofM
anagementPrinciples ofM
anagement A: AirwayA: Airway
atent upper airwayatent upper airway
B:BreathingB:Breathing adequate ventilation and oxygenationadequate ventilation and oxygenation
C: CirculationC: Circulation
optimizeoptimize cardiacfunctioncardiacfunction
oxygenationoxygenation
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Act quickly,
Thinkslowly.Greek Proverb
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A
irwayM
anagement
A
irwayM
anagement
Patients in shock have:Patients in shock have: OO22 deliverydelivery
progressive respiratory fatigue/failureprogressive respiratory fatigue/failure energy shunted from vitalorgansenergy shunted from vitalorgans
afterloadafterload
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AirwayManagementAirwayManagement
Early intubation provides:Early intubation provides: OO22 delivery andcontentdelivery andcontent
controlled ventilation which:controlled ventilation which: reduces metabolicdemandreduces metabolicdemand
allows C.O. to vitalorgansallows C.O. to vitalorgans
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TherapyTherapy
Vagolysis
Chromotropy
Volume
CVP
Preload
Vasodilators
Vasoconstrictors
Afterload
Correct
acidosishypoxiahypoglycemia
Inotropic
agents
Contractility
Stroke VolumeHeart
Rate U
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FluidChoicesFluidChoices
Colloid Crystalloid
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CrystalloidsCrystalloids
HypotonicFluids (DHypotonicFluids (D55 1/4 NS)1/4 NS)
No role in resuscitationNo role in resuscitation
Maintenanc
e fluids onlyMai
ntenanc
e fluids only
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Fluids, Fluids, FluidsFluids, Fluids, Fluids Key to mostresuscitativeKey to mostresuscitative
effortsefforts GivegenerouslyandreassessGivegenerouslyandreassess
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CrystalloidsCrystalloids
IsotonicFluidsIsotonicFluids Intravascular volumeexpansionIntravascular volumeexpansion
Hauser:Hauser:
crystalloids rapidly redistributecrystalloids rapidly redistribute Lethal animal modelLethal animal model
NS = good resuscitative fluidNS = good resuscitative fluid
4x
blood volume to restore hemodynami
cs4
xblood volume to restore hemody
nami
cs
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CrystalloidsCrystalloids
IsotonicFluidsIsotonicFluids
2 traumastudies2 traumastudies
crystalloids = colloids but:crystalloids = colloids but: 4x amount4x amount
longer time to resuscitationlonger time to resuscitation
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CrystalloidsCrystalloidsComplicationsComplications
UnderUnder--resuscitationresuscitation
renal failurerenal failure
OverOver--resuscitationresuscitation
pulmonaryedemapulmonaryedema
peripheraledemaperipheraledema
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CrystalloidsCrystalloids
SummarySummary Crystalloids lesseffective thanequalCrystalloids lesseffective thanequalvolume of colloidsvolume of colloids
Preferred when
1Preferred when
1oo
deficit is waterdeficit is waterand/orelectrolytesand/orelectrolytes
Good in initial resuscitation to restoreGood in initial resuscitation to restoreextracellular volumeextracellular volume
Hypertonicsolutions however, may actHypertonicsolutions however, may actas plasma volumeexpandersas plasma volumeexpanders
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Oncotic pressure
(tendency to pull unit) CapillaryCapillaryH
ydrostatic pressure(tendency to drive unit)
FluidFluid
Trans ortTrans ort
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ColloidsColloids
AlbuminAlbumin
Hepatic productionHepatic production
MW = ,000MW = ,000
0% of COP80% of COP
Serum tSerum t1/21/2::18 hours endogenous18 hours endogenous
1 hours1 hours exogenousexogenous
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ColloidsColloids
HydroxyethylStarch (Hespan)HydroxyethylStarch (Hespan) SyntheticSynthetic
Derived from cornstarchDerived from cornstarch
Avera
geAvera
ge MW = ,000MW = ,000 Stable, nonantigenicStable, nonantigenic
Used for volumeexpansionUsed for volumeexpansion
RenalexcretionRenalexcretion tt1/21/2 22-- hours67 hours
90% gone in 42 days90% gone in 42 days
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Greater in COP thanalbuminGreater in COP thanalbumin
Longerdurationof actionLongerdurationof action
0.006% adversereactions0.006% adversereactions Noeffecton blood typingNoeffecton blood typing
Prolongs PT, PTTandclotting timesProlongs PT, PTTandclotting times
DosageDosage 20 ml/Kg/day20 ml/Kg/day
max 1500 ml/daymax 1500 ml/day
ColloidsColloids
HydroxyethylStarch (Hespan)HydroxyethylStarch (Hespan)
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FluidChoicesFluidChoices
Based on:Based on:
type of deficittype of deficit urgency of repletionurgency of repletion
pathophysiology of conditionpathophysiology of condition
plasmaCOPplasmaCOP
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FluidChoicesFluidChoices Crystalloids for initialresuscitationCrystalloids for initialresuscitation
PRBCs toreplace blood lossPRBCs toreplace blood loss
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FluidManagement in PediatricFluidManagement in PediatricSeptic ShockSeptic Shock Em hasis on the golden hourEm hasis on the golden hour
Early aggressive use of fluids mayEarly aggressive use of fluids mayim rove outcomeim rove outcome
TitrateTitrate--Reassess!Reassess!
Clinical Practice Parameters,
Carcillo et al., CCM, 2002
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A
lphaA
lpha--BetaM
eterBetaM
eterEE DopamineDopamineEpinephrineEpinephrine
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DopamineActivityDopamineActivity
0.50.5--5.0 mcg/kg/min5.0 mcg/kg/min -- dopaminergicreceptorsdopaminergicreceptors
2.02.0--10 mcg/kg/min10 mcg/kg/min -- betareceptors (inotrope)betareceptors (inotrope)1010--20 mcg/kg/min20 mcg/kg/min -- al ha and betareceptorsal ha and betareceptors
Over 20 mcg/kg/minOver 20 mcg/kg/min -- al hareceptors (pressors)al hareceptors (pressors)
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A Rational Approach to Shock in the PediatricA Rational Approach to Shock in the Pediatric
PatientPatient
Shock / HypotensionShock / Hypotension
Volume ResuscitationVolume Resuscitation
Signs of adequate circulationSigns of adequate circulation
Adequate MAPAdequate MAP
NONO
NONO
pressorspressorsYesYes
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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
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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
MAPMAPDobutamineDobutamine
or Milrinoneor Milrinone
tachycardiatachycardia
phenylephrine??phenylephrine??
COCO
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New Therapies in SepticNew Therapies in Septic
ShockShock SteroidsSteroids
VasopressinVasopressin
ActivatedProtein C (Xigris) insepticActivatedProtein C (Xigris) insepticshockshock
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Management of Pediatric SepticManagement of Pediatric Septic
Shock: The GoldenHourShock: The GoldenHour
First 15 minutesFirst 15 minutes
Em hasis on response to volumeEm hasis on response to volume
Clinical Practice Parameters,
Carcillo et al., CCM, 2002
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Patients dontsuddenlyPatients dontsuddenlydeteriorate, healthcaredeteriorate, healthcare
professionalssuddenlyprofessionalssuddenlynotice!notice!
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