Shock is decreased end organ perfusion Shock presents before hypotension Hypotension represents uncompensated shock Hypotension is >2SD below normal for age 1000-1250g SBP49-61 1251-1500g SBP 46-61 1501-1750 SBP 46-58 1751-2000 SBP-48-61 For infants <30 weeks gestation mean BP should be at least the gestational age i.e. 29 week GA=MAP 29 Make sure cuff size correct (2/3 of upper arm) Cuff too small= BP Cuff too large= BP Blood Pressure *But……. Do you have a BP cuff?
What are the signs of shock in a neonate?? Tachycardia Poor perfusion Cold extremities with a normal core temperature Lethargy Apnea & Bradycardia Tachypnea Metabolic acidosis Weak pulses
Urine Output What is normal? Normal ~1- 2cc/kg/hour What can make urine output normal or even high even when an infant is in shock???
Is there a history of Birth Asphyxia? Birth asphyxia may be associated with hypotension
At delivery was there: Maternal bleeding –Abrupto placenta –Placenta previa Excessively delayed cord clamping
Name the Types of Shock in Neonates A B C D E F G
Types of Shock in a Neonate A. Hypovolemic B. Septic Shock C. Cardiogenic Shock D. Neurogenic E. Drug-induced F. Endocrine G. Extreme prematurity
3 kg infant presents from outside with extreme pallor, bleeding from umbilical cord and is cold with a HR of 200 What type of shock Work-up?? Treatment??
Hypovolemic Antepartum blood loss (often associated w/asphyxia) –Abruptio placentae –Placenta previa –Twin-twin transfusion –Fetomaternal hemorrhage Postpartum blood loss –Coagulation disorders –Vitamin K deficiency –Iatrogenic causes (loss of catheter –Birth trauma (liver injury, adrenal hemorrhage, ICH, intraperitoneal hemorrhage
1 week old 4 kg infant born to a mother with diabetes. Difficulty with IV therefore UVC placed Doing better til this morning when noted to have a systolic BP of 40, HR of 170, temperature of 34°C Type of shock Work-up Treatment
Septic Shock Endotoxemia with release of vasodilator substances Gram-negative often cause but can occur with gram-positive
Infant required bag-mask ventilation at birth presents to nursery noted to be cyanotic, in respiratory distress, cold, clammy without breath sounds of the right Type of shock Work-up Treatment
Cardiogenic Shock 1. Birth asphyxia 2. Metabolic problems (eg hypoglycemia, hyponatremia, hypocalcemia, acidemia) can decrease cardiac output 3. Congenital heart disease (such as hypoplastic left heart or aortic stenosis) 4. Arrythmias 5. Any obstruction of venous return (tension pneumothorax)
Term baby with Apgars of 3 at 3 minutes and 5 at5 minutes noted to have poor perfusion on arrival to nursery Type of shock Work-up Treatment
2.5 kg infant with status epilepticus and has been loaded with 20mg/kg of phentobarbital initially then given an additional 5mg/kg q 5 minutes X5 for persistent seizures because no other drugs available to control seizures. After 5 th dose noted to be very poorly perfused Type of shock Work-up Treatment
Drug-Induced Sedatives Magnesium Digitalis Barbituates especially if high dose
Term infant with ambiguous genitalia present at 3 weeks of age with hypotension Type of shock Work-up (initial) Treatment
Endocrine Disorders Complete 21-hydroxylase deficiency Adrenal hemorrhage (What electrolyte abnormalities do you expect in adrenogenital syndrome?? –A. Low sodium, high potassium –B. Hi sodium, high potassium –C. Low sodium, low potassium
27 week infant noted to have a mean arterial blood pressure of 24 on the new automatic BP machine Type of shock Work-up Treatment
Extreme Prematurity Hypotension is very common –40% in 27-29 weeks –60-100% in 24-26 weeks –Most likely due to adrenocortical insufficiency, poor vascular tone, immature catecholamine responses –Hypotension in ELBW infants is associated w/IVH and needs to be corrected
Work UP Look for signs of blood loss, sepsis and clinical signs of shock Complete Blood Count –Decreased hematocrit can occur with bleeding however remember in acute blood loss maybe normal –Increased or decreased WBC or increase in immature cells may point to sepsis
Work-up continued Coagulation studies (if disseminated intravascular coagulation suspected) Serum glucose, electrolytes, and calcium levels Cultures, CRP Kleihauer-Betke to rule out fetomaternal transfusion is suspected Arterial blood gases to look for hypoxia and acidosis
Treatment-Determine cause if possible to guide treatment 1. Volume expansion 2. Blood replacement 3. Empiric antibiotics 4. Inotropes 5. Steroids 6. Blood 7. Chest aspiration a.Hypovolemic b.Septic c.Cardiogenic d.Neurogenic e.Drug-induced f.Endocrine g.ELBW Match the treatments with the causes