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James D. Fortenberry MD FAAP, FCCM Medical Director, PICU

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Presentation on theme: "James D. Fortenberry MD FAAP, FCCM Medical Director, PICU"— 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 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

3 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

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


6 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!!

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

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

9 Arterial Oxygen Content
100 mm Hg PaO2 100 mmHg Partial Pressure Hgb 15 gm/100 mL Hemoglobin SaO2 97% Oxygen Saturation + + O2 bound to Hgb O2 in plasma

10 DO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x 0.003
Oxygen Delivery DO2=Cardiac Output x 1.34 (Hgb x SaO2) + Pa02 x 0.003 O2O2O2O2O2O2 Oxygen Express O2O2O2O2O2O2 Ca02

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

12 Cardiac Output C.O.=Heart Rate x 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
To improve CO: MAP CVP SVR

14 Cardiac Output x x Preload Afterload Contractility x Stroke Volume
Heart Rate Cardiac Output O2 Content Resistance x x O2 Delivery Arterial Blood Pressure

15 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

16 Mechanical Requirements for Adequate Tissue Perfusion
Fluid Pump Vessels Flow

17 Inadequate Fluid Volume (decreased preload)
Hypovolemic Shock: Inadequate Fluid Volume (decreased preload)

18 Hypovolemic Shock: Causes
Fluid depletion internal external Hemorrhage

19 Pump Malfunction (decreased contractility)
Cardiogenic Shock: Pump Malfunction (decreased contractility)

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

21 Abnormal Vessel Tone (decreased afterload)
Distributive Shock Abnormal Vessel Tone (decreased afterload)

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

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

24 Decreased Pump Function
Septic Shock Decreased Pump Function Decreased Volume Abnormal Vessel Tone

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

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

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

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


33 Obstructive Shock: Causes
Pericardial tamponade Pulmonary embolism Pulmonary hypertension

34 Hemodynamic Assessment of Shock

35 Goals of Resuscitation
Overall goal: increase O2 delivery decrease demand O2 content Cardiac output Treatment Sedation/analgesia Blood pressure

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

37 Act quickly, Think slowly.
Greek Proverb

38 Airway Management Patients in shock have: O2 delivery
progressive respiratory fatigue/failure energy shunted from vital organs afterload

39 Airway Management Early intubation provides: O2 delivery and content
controlled ventilation which: reduces metabolic demand allows C.O. to vital organs

40 Therapy Vagolysis Heart Rate Chromotropy

41 Fluid Choices Colloid Crystalloid Tastes Great ! Less Filling

42 Crystalloids Hypotonic Fluids (D5 1/4 NS)
No role in resuscitation Maintenance fluids only

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

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

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

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

47 Crystalloids Summary 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

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

49 Colloids Albumin Hepatic production MW = 69,000 80% of COP Serum t1/2:
18 hours endogenous 16 hours exogenous

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

51 Colloids Hydroxyethyl 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

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

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

54 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

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

56 Inotropes

57 Dopamine Activity 0.5-5.0 mcg/kg/min - dopaminergic receptors
mcg/kg/min - beta receptors (inotrope) 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 pressors Yes NO

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

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

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

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

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

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