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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

2 Objectives l Define shock and its different categories l Review basic physiologic aspects of shock l Describe management of shock including: – oxygen supply and demand – fluid resuscitation  crystalloid vs. colloid controversy – vasopressor support

3 Definition of Shock l Uncontrolled blood or fluid loss l Blood pressure less than 5th percentile for age l Altered mental status, low urine output, poor capillary refill l None of the above

4 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

5 SUPPLY < DEMAND

6 Definition of Shock l Inadequate tissue perfusion to meet tissue demands l Usually result of inadequate blood flow and/or oxygen delivery l Shock is not a blood pressure diagnosis!!

7 Characteristics of Shock l End organ dysfunction: – reduced urine output – altered mental status – poor peripheral perfusion l Metabolic dysfunction: – acidosis – altered metabolic demands

8 Essentials of Life l Gas exchange capability of lungs l Hemoglobin l Oxygen content l Cardiac output l Tissues to utilize substrate

9 Arterial Oxygen Content Hgb 15 gm/100 mL Hemoglobin SaO 2 97% Oxygen Saturation PaO 2 100 mmHg Partial Pressure O 2 bound to Hgb 100 mm Hg + O 2 in plasma +

10 Oxygen Delivery DO 2 =Cardiac Output x 1.34 (Hgb x SaO 2 ) + Pa0 2 x 0.003 O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2 O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2 Oxygen Express Ca0 2

11 Cardiac Output The volume of blood ejected by the heart in one minute 4 - 8 liters / minute 4 - 8 liters / minute

12 Cardiac Output C.O.=Heart Rate x Stroke Volume l Heart rate l Stroke volume: – Preload- volume of blood in ventricle – Afterload- resistance to contraction – Contractility- force applied

13 Cardiac Output C.O.=Mean arterial pressure (MAP) - CVP/SVR l To improve CO: l MAP l CVP l SVR

14 PreloadAfterloadContractility Resistance Stroke Volume Heart Rate Arterial Blood Pressure O 2 Delivery O 2 Content Cardiac Output x x x

15 Classification of Shock l Hypovolemic – dehydration,burns, hemorrhage l Distributive – septic, anaphylactic, spinal l Cardiogenic – myocarditis,dysrhythmia l Obstructive – tamponade,pneumothorax l Compensated – organ perfusion is maintained l Uncompensated – Circulatory failure with end organ dysfunction l Irreversible – Irreparable loss of essential organs

16 Mechanical Requirements for Adequate Tissue Perfusion l Fluid l Pump l Vessels l Flow

17 Hypovolemic Shock: Inadequate Fluid Volume (decreased preload)

18 Hypovolemic Shock: Causes l Fluid depletion – internal – external l Hemorrhage – internal – external

19 Cardiogenic Shock: Pump Malfunction (decreased contractility)

20 Cardiogenic Shock: Causes Electrical Failure l Mechanical Failure – Cardiomyopathy – metabolic – anatomic – hypoxia/ischemia

21 Distributive Shock Abnormal Vessel Tone (decreased afterload)

22 Distributive Shock Vasodilation Venous Pooling Decreased Preload Maldistribution of regional blood flow

23 Distributive Shock: Causes l Sepsis l Anaphylaxis l Neurogenesis (spinal) l Drug intoxication (TCA, calcium, Channel blocker)

24 Septic Shock Decreased Volume Decreased Pump Function Abnormal Vessel Tone

25 Cardiac Output C.O.=Heart Rate x Stroke Volume l Heart rate l Stroke volume: – Preload- volume of blood in ventricle – Afterload- resistance to contraction – Contractility- force applied

26 Clinical Assessment l Heart rate l Peripheral circulation – capillary refill – pulses – extremity temperature l Pulmonary l End organ perfusion – brain – kidney

27 Improving Stroke Volume: Therapy for Cardiovascular Support PreloadVolume Contractility Inotropes Afterload Vasodilators

28 Septic Shock Early (“Warm”) Decreased peripheral vascular resistance Increased cardiac output Late (“Cold”) Increased peripheral vascular resistance Decreased cardiac output

29 Assessment of Circulation

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

31 Assessment of Circulation

32 OBSTRUCTIVE SHOCK OBSTRUCTED FLOW

33 Obstructive Shock: Causes l Pericardial tamponade l Pulmonary embolism l Pulmonary hypertension

34 Hemodynamic Assessment of Shock

35 Goals of Resuscitation l Overall goal: – increase O 2 delivery – decrease demand Treatment O 2 content Cardiac output Blood pressure Sedation/analgesia

36 Principles of Management l A: Airway – patent upper airway l B: Breathing – adequate ventilation and oxygenation l C: Circulation – optimize  cardiac function  oxygenation

37 Act quickly, Think slowly. Greek Proverb

38 Airway Management l Patients in shock have: – O 2 delivery – progressive respiratory fatigue/failure – energy shunted from vital organs – afterload

39 Airway Management l Early intubation provides: – O 2 delivery and content – controlled ventilation which:  reduces metabolic demand  allows C.O. to vital organs

40 Therapy Vagolysis Chromotropy Heart Rate 

41 Fluid Choices Less Filling Tastes Great ! Colloid Crystalloid

42 Crystalloids Hypotonic Fluids (D 5 1/4 NS) l No role in resuscitation l Maintenance fluids only

43 Fluids, Fluids, Fluids l Key to most resuscitative efforts l Give generously and reassess

44 Crystalloids Isotonic Fluids l Intravascular volume expansion l Hauser: – crystalloids rapidly redistribute l Lethal animal model – NS = good resuscitative fluid – 4x blood volume to restore hemodynamics

45 Crystalloids Isotonic Fluids l 2 trauma studies 4 crystalloids = colloids but:  4x amount  longer time to resuscitation

46 Crystalloids Complications l Under-resuscitation – renal failure l Over-resuscitation – pulmonary edema – peripheral edema

47 Crystalloids Summary l Crystalloids less effective than equal volume of colloids l Preferred when 1 o deficit is water and/or electrolytes l Good in initial resuscitation to restore extracellular volume l Hypertonic solutions however, may act as plasma volume expanders

48 Oncotic pressure (tendency to pull unit) Capillary Hydrostatic pressure (tendency to drive unit) Fluid Transport

49 Colloids Albumin l Hepatic production l MW = 69,000 l 80% of COP l Serum t 1/2 : 18 hours endogenous 16 hours exogenous

50 Colloids Hydroxyethyl Starch (Hespan) l Synthetic l Derived from corn starch l Average MW = 69,000 l Stable, nonantigenic l Used for volume expansion l Renal excretion – t 1/2 2-67 hours – 90% gone in 42 days

51 l Greater in COP than albumin l Longer duration of action l 0.006% adverse reactions l No effect on blood typing l Prolongs PT, PTT and clotting times l Dosage – 20 ml/Kg/day – max 1500 ml/day Colloids Hydroxyethyl Starch (Hespan)

52 Fluid Choices l Based on: – type of deficit – urgency of repletion – pathophysiology of condition – plasma COP Tastes Great ! Less Filling

53 Fluid Choices l Crystalloids for initial resuscitation l PRBC’s to replace blood loss

54 Fluid Management in Pediatric Septic Shock l Emphasis on the golden hour l Early aggressive use of fluids may improve outcome l Titrate-Reassess! Clinical Practice Parameters, Carcillo et al., CCM, 2002

55 Alpha-Beta Meter  ß ß ß ß Dopamine Epinephrine Norepinephrine Dobutamine Neosynephrine

56 Inotropes

57 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)

58 A Rational Approach to Shock in the Pediatric Patient Shock / Hypotension Volume Resuscitation Signs of adequate circulation Adequate MAP NO NO pressors Yes

59 A Rational Approach to Pressor Use in the PICU NO Dopamine Inadequate MAP Dopamine and/or Norepinephrine Signs of adequate circulation Adequate MAP

60 A Rational Approach to Pressor Use in the PICU Dopamine and/or norepinephrine Inadequate MAP low C.O. epinephrine adequate MAP Dobutamine or Milrinone tachycardia phenylephrine?? CO

61 “New” Therapies in Septic Shock l Steroids l Vasopressin l Activated Protein C (Xigris) in septic shock

62 Management of Pediatric Septic Shock: The Golden Hour l First 15 minutes l Emphasis on response to volume Clinical Practice Parameters, Carcillo et al., CCM, 2002

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


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