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Shock in the Pediatric Patient: or Oxygen Don

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Title: Shock in the Pediatric Patient: or Oxygen Doesn t Go Where the Blood Won t Flow! Author: Robert Pettignano Last modified by: IS&T Created Date – PowerPoint PPT presentation

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Title: Shock in the Pediatric Patient: or Oxygen Don


1
Shock in the Pediatric PatientorOxygen Dont
Go Where the Blood Wont Flow!
  • James D. Fortenberry MD FAAP, FCCM
  • Medical Director, PICU
  • Division of Critical Care Medicine
  • Childrens 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 lt 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
SaO2 97 Oxygen Saturation

Hgb 15 gm/100 mL Hemoglobin

O2 in plasma
O2 bound to Hgb
10
Oxygen Delivery
DO2Cardiac Output x 1.34 (Hgb x SaO2) Pa02 x
0.003
O2O2O2O2O2O2
O2O2O2O2O2O2
Oxygen Express
Ca02
11
Cardiac Output
  • The volume of blood ejected by the heart
    in one minute
  • 4 - 8 liters / minute

12
Cardiac OutputC.O.Heart Rate x Stroke Volume
  • Heart rate
  • Stroke volume
  • Preload- volume of blood in ventricle
  • Afterload- resistance to contraction
  • Contractility- force applied

13
Cardiac OutputC.O.Mean arterial pressure
(MAP) - CVP/SVR
  • To improve CO
  • MAP
  • CVP
  • SVR

14
Preload Afterload Contractility
x
Stroke Volume
Heart Rate
Cardiac Output
O2 Content
Resistance
x
x
Arterial Blood Pressure
O2 Delivery
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
Hypovolemic Shock
  • Inadequate Fluid Volume
  • (decreased preload)

18
Hypovolemic ShockCauses
  • Fluid depletion
  • internal
  • external
  • Hemorrhage
  • internal
  • external

19
Cardiogenic Shock
  • Pump Malfunction
  • (decreased contractility)

20
Cardiogenic ShockCauses
  • Electrical Failure
  • 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
  • Sepsis
  • Anaphylaxis
  • Neurogenesis (spinal)
  • Drug intoxication (TCA, calcium, Channel blocker)

24
Septic Shock
Decreased Pump Function
Decreased Volume
Abnormal Vessel Tone
25
Cardiac OutputC.O.Heart Rate x Stroke Volume
  • Heart rate
  • Stroke volume
  • Preload- volume of blood in ventricle
  • Afterload- resistance to contraction
  • Contractility- force applied

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

27
Improving Stroke VolumeTherapy 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 ShockCauses
  • Pericardial tamponade
  • Pulmonary embolism
  • Pulmonary hypertension

34
Hemodynamic Assessment of Shock
35
Goals of Resuscitation
  • Overall goal
  • increase O2 delivery
  • decrease demand

Treatment
Sedation/analgesia
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
Less Filling
Tastes Great !
42
CrystalloidsHypotonic 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
CrystalloidsIsotonic Fluids
  • Intravascular volume expansion
  • Hauser
  • crystalloids rapidly redistribute
  • Lethal animal model
  • NS good resuscitative fluid
  • 4x blood volume to restore hemodynamics

45
CrystalloidsIsotonic Fluids
  • 2 trauma studies
  • crystalloids colloids but
  • 4x amount
  • longer time to resuscitation

46
CrystalloidsComplications
  • Under-resuscitation
  • renal failure
  • Over-resuscitation
  • pulmonary edema
  • peripheral edema

47
CrystalloidsSummary
  • 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
49
ColloidsAlbumin
  • Hepatic production
  • MW 69,000
  • 80 of COP
  • Serum t1/2
  • 18 hours endogenous
  • 16 hours exogenous

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

51
ColloidsHydroxyethyl 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
  • Based on
  • type of deficit
  • urgency of repletion
  • pathophysiology of condition
  • plasma COP

Tastes Great !
Less Filling
53
Fluid Choices
  • Crystalloids for initial resuscitation
  • PRBCs 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
Alpha-Beta Meter
? ß
Dopamine
Epinephrine
Dobutamine
Norepinephrine
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 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
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 dont suddenly deteriorate, healthcare
professionals suddenly notice!
  • Anonymous
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