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The Mystery of The Shocked BabyThe Mystery of The Shocked Baby
History
A 10-day-old female infant born at 39 weeks of gestation. She was born by normal spontaneous vaginal delivery and was discharged home.
The mother has a history of primary infertility 3 years.
The mother’s pregnancy, labor were unremarkable.
History This infant was feeding and voiding appropriately
in first days of life.
But parental account that their infant became progressively “fussy”. She breathed faster and required a longer time for each bottle-feeding.
On the day of presentation she fed no more than 30ml of formula and hadn’t voided since the night before.
Vital signs
Temperature 36.8 C Heart rate 190 b/min
CRT = 5 Sec
RR = 69 b/min Blood pressure from the right arm 78/50 mmHg
Sao2 from the right hand is 96% Weight is 3.3 kg
Examination
CNS: conscious but confused with decreased spontaneous movements and weak crying.
CVS: precordium is hyperdynamic, pulmonary component S2 is loud, no murmurs and Lower extremity pulses are difficult to palpate.
Chest: RD Grade ІІ, Equal breath sounds bilaterally with fine rales at both lung bases.
Examination
The liver is palpable 4 cm below the right costal margin.
Her feet are cool to touch.
Baby was pale.
There are no skin lesions.
What is the problem with this baby ?
Shock:Shock:
Shock is the inadequate perfusion Shock is the inadequate perfusion of the body’s vital organsof the body’s vital organs
Indices of tissue perfusion
Pallor & skin mottling Capillary refill time (>3 sec) Heart rate ( > 170 B\min ) Toe-core temperature difference (>2ºC) Urine output (<1 mL/kg/hr) Blood lactate (>2.5 mmol/L)
Which one is shocked ?
Causes of neonatal shock
O2
Pump
Pipes
Circulation
Tank
Non Vital
Vital organs
Remember !!
Once shock is suspected start supportive measures as soon as possible:
airway and assuring its patency. providing oxygen or positive pressure
ventilation. achieving intravascular ( peripheral or
central )or intraosseous access.
Algorithm for management of shock:
Algorithm for management of shock:
Fluid Boluse
Excessive volume expansion may be potentially harmful in Cardiogenic Shock.
Preterm babies can not deal with
Excessive volume expansion which increase likelihood of PDA & NEC.
Why not more than 20ml/kg ?
Clinical signs of hypovolemic shock depend on the degree of intravascular volume depletion:
25% in compensated shock 25-40% in uncompensated shock ( But with myocardial depression)
more than 40% in irreversible shock.
Dopamine Doses
New school Effect Old school
0.5 to 2 μg/kg/min Renal and mesenteric vasodilatation
2.5 to 5 μg/kg/min
2 to 8 μg/kg/min Increased myocardial contractility and heart rate
5 to 10 μg/kg/min
> 8 μg/kg/minSignificant peripheral VC & increase in PVR and blood
pressure10 to 20 μg/kg/min
Dobutamine
Mech: produces vasodilation and increases Cardiac muscle contration.
1st line in: Preterm < 48 hrs PPHN Heart failure
Adrenalin (The most potent inotrope)
Adrenalin results in significant increases in:
Myocardial contractility Cardiac output Peripheral vascular resistance Blood pressure
Milrinone = Primacor
Mech: Improve contractility Improve diastolic function Systemic and pulmonary vasodilation= Decrease
after load & Decrease Pulmonary BP
Indication: Shock post Cardiac Surgery Septic Shock Severe PPHN
When to response ??
Reassess within 10 min of fluid bolus
Reassess every 15–20 min of new dose of Inotropes
Caution !!
Inotropic agents: contraindicated in hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is common in IDMs
Caution !!
Catecholamines : Never administer intra-arterially
Dopamine shown to suppress TSH secretion
Remember !!
Correction of negative inotropic factors:
as hypoxia, hypoglycemia, hypocalcemia, acidosisand electrolytes imbalance,
if present.
Digoxin is used in non-critically ill infants.
What about NaHco3 ?
Indications: To correct normal anion gap metabolic acidosis caused
by Renal (RTA) or GI Losses (Diarrhea, Surgery for NEC,ileostomy).
Treatment of life-threatening hyperkalemia.
In significant metabolic acidosis (pH<7.20 or BD > 10), it may be useful to give NaHco3.
(very controversial)
Textbook of Neonatal Resuscitation, 7th Edition
NaHco3 Dose
Dose (in mEq) based on Base Deficit = 0.3 X Base deficit (mEq/L) X weight (kg).
Give ½ dose then assess need for remainder
Dose is given over 30 minutes at least. Sodium Bicarbonate 8.4 % contains 1 mEq NaHCO3 / mL
Incompatible with dobutamine, dopamine, epinephrine, midazolam.
NaHco3 side effects
IVH (with rapid infusion)
Increase PCO2 so decrease pH (if given during inadequate ventilation)
Local tissue necrosis Hypocalcemia Hypernatremia and hypokalemia
Caution !!
Do not treat metabolic acidosis with hyperventilation.
NaHCO3 is not a recommended therapy in NRP
It is best to correct the underlying cause of the metabolic acidosis.
Corticosteroid therapy
Mech: up-regulate adrenergic receptor & as replacement in adrenal insufficiency.
When: in extremely PT with hypotension refractory to volume & vasopressors (high dose dopamine or epinephrine).
Hydrocortisone: 1 mg/kg every 8-12 hrs for 2-3 days.
Dexamethasone: 0.1 mg/kg followed by 0.05 mg/kg IV every 12 H for 5 doses.
Back to our case
Baby was placed on O2 and received one fluid bolus plus Dopamine 10 μg/kg/min + Dobutamine 10 μg/kg/min without any improvement in perfusion.
This bad news was told to the parents in an appropriate way.
Investigations
Serum glucose Blood gases Hematocrit (Hct) Electrolyte CBC, CRP, and cultures Chest x-ray Echocardiography & ECG Renal functions & Liver function tests
Investigations
CBC: Hct 41%, WBC 15 × 103, platelet count 23 × 103.
PH 7.18, CO2 30, NaHCO3 10 mEq/L, BE -16. Na 145 mEq/L, K 5 mEq/L, Ca 9 mg/dl.
RBS = 69 mg/dl. CRP -Ve Urea 40 mg/dl, Creatinine 1.0 mg/dl.
Chest X-ray: Cardiomegaly, increased pulmonary vascularity.
Case progression
Dopamine increased to 20 μg/kg/min + Dobutamine 20 μg/kg/min without any improvement in perfusion.
After senior consultant PGE1 infusion was started and Echocardiogram was being arranged.
Duct dependent systemic circulation
Neonates who present with shock within the first 3 weeks of life are likely to have CHD with duct dependent systemic flow.
It is appropriate to begin PGE-1, even if before A diagnosis made by echocardiography.
PGE1 infusion:
Dose: 0.05-0.1μg/kg/min, start with 0.05μg/kg/min, if no improvement increase to 0.1 μg/kg/min.
Adverse effects: Hypotension, flushing, tachycardia, apnea, fever, and Hypokalemia.
When Baby respond to PGE-1 ?
Maximum effect seen within 30 min in cyanotic lesions,
may take several hours in acyanotic lesions
Echocardiogram: HLHS
Left-sided obstructive heart disease (Duct-dependent systemic circulation)
These diseases include:
Hypoplastic left heart syndrome (HLHS)(most common and severe)
Critical aortic stenosis (AS) Co-arctation of the aorta (COA) Interrupted aortic arch (IAA)
Approaches to HLHS
What about Entral feeding ?
Infants in shock should not be fed.
Intestines will require 2 days or more for recovery before small feedings can be attempted.
Initiate total parenteral nutrition as soon as possible.
Shock & Assisted Ventilation
NCPAP is Contraindicated in Severe cardiovascular instability.
Ventilation is an excellent inotrope
Shock & Ventilatory setting
Refractory Shock
Hypopituitarism Hypoadrenalism (Congenital adrenal hyperplasia, Addison disease)
Large PDA Central line leakage GIT problems (e.g. NEC, perforation)
Drugs ( e.g. muscle relaxants ) Poor myocardial contractility (e.g. cardiomyopathy)
Inborn errors of metabolism (e.g. Organic acidemia )
Refractory Shock:
Hidden Hemorrhage
Subgaleal HemorrhageAdrenal hemorrhage
Refractory Shock:
Hidden Hemorrhage
Fractured Humerus Fractured femur
Refractory Shock:
Periventricular hemorrhage / intraventricular hemorrhage
Refractory Shock:
Pneumothorax
Refractory Shock:
Pneumopericardium
Refractory Shock:
Pneumothorax & Pneumopericardium
Recent Approach :Recent Approach :
Functional Echocardiography and Doppler Flow Velocimetry:
Assessment of global heart contractility
Assessment of superior vena cava flow
Take Home Massage
Once shock is suspected start supportive measures as soon as possible.
Thereafter, treatment is directed by
the underlying pathology.
Take Home Massage
In Shock: Obtain vascular access including arterial line, better through
umbilical vessels.
BP is maintained until very late Hypotension is a pre-terminal sign
Take Home Massage
PGE1 is considered before diagnosis is confirmed if duct-dependent systemic
blood flow is suspected.
NaHCO3 is not a recommended therapy in NRP.
Thank youThank you