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

5. SUPPLY < DEMAND

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

32. OBSTRUCTIVE SHOCK
OBSTRUCTED FLOW

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!
Anonymous