Shock in the Pediatric Patient: Shock in the Pediatric Patient: or or Oxygen Don’t Go Oxygen Don’t Go Where the Blood Won’t Flow! Where the Blood Won’t Flow! James D. Fortenberry MD FAAP, FCCM James D. Fortenberry MD FAAP, FCCM Medical Director, PICU Medical Director, PICU Division of Critical Care Medicine Division of Critical Care Medicine Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta
63
Embed
Shock in the Pediatric Patient: or Oxygen Don’t Go Where the Blood Won’t Flow!
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. Objectives. Define shock and its different categories - PowerPoint PPT Presentation
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Shock in the Pediatric Shock in the Pediatric Patient:Patient:
ororOxygen Don’t Go Oxygen Don’t Go
Where the Blood Won’t Where the Blood Won’t Flow!Flow!
James D. Fortenberry MD FAAP, FCCMJames D. Fortenberry MD FAAP, FCCM
Medical Director, PICUMedical Director, PICU
Division of Critical Care MedicineDivision of Critical Care Medicine
Children’s Healthcare of AtlantaChildren’s Healthcare of Atlanta
ObjectivesObjectives Define shock and its different Define shock and its different
categoriescategories Review basic physiologic aspects of Review basic physiologic aspects of
shockshock Describe management of shock Describe management of shock
including:including: oxygen supply and demandoxygen supply and demand fluid resuscitationfluid resuscitation
crystalloid vs. colloid controversycrystalloid vs. colloid controversy vasopressor supportvasopressor support
Definition of ShockDefinition of Shock Uncontrolled blood or fluid lossUncontrolled blood or fluid loss Blood pressure less than 5th Blood pressure less than 5th
percentile for agepercentile for age Altered mental status, low urine Altered mental status, low urine
output, poor capillary refilloutput, poor capillary refill None of the aboveNone of the above
Definition of ShockDefinition of Shock
An acute complex An acute complex pathophysiologic state of pathophysiologic state of circulatory dysfunction which circulatory dysfunction which results in a failure of the results in a failure of the organism to deliver sufficient organism to deliver sufficient amounts of oxygen and other amounts of oxygen and other nutrients to satisfy the nutrients to satisfy the requirements of tissue bedsrequirements of tissue beds
SUPPLY SUPPLY << DEMANDDEMAND
Definition of ShockDefinition of Shock
Inadequate tissue perfusion to Inadequate tissue perfusion to meet tissue demandsmeet tissue demands
Usually result of inadequate blood Usually result of inadequate blood flow and/or oxygen deliveryflow and/or oxygen delivery
Shock is not a blood pressure Shock is not a blood pressure diagnosis!!diagnosis!!
Characteristics of ShockCharacteristics of Shock
End organ dysfunction:End organ dysfunction: reduced urine outputreduced urine output altered mental statusaltered mental status poor peripheral perfusionpoor peripheral perfusion
Gas exchange capability of lungsGas exchange capability of lungs HemoglobinHemoglobin Oxygen contentOxygen content Cardiac outputCardiac output Tissues to utilize substrateTissues to utilize substrate
adequate ventilation and adequate ventilation and oxygenationoxygenation
C: CirculationC: Circulation optimizeoptimize
cardiac functioncardiac function oxygenationoxygenation
Act quickly,Think slowly.
Greek Proverb
Airway Airway ManagementManagement
Patients in shock have:Patients in shock have: OO22 delivery delivery progressive respiratory progressive respiratory
fatigue/failurefatigue/failure energy shunted from vital organsenergy shunted from vital organs afterloadafterload
Airway Airway ManagementManagement
Early intubation provides:Early intubation provides: OO22 delivery and content delivery and content controlled ventilation which:controlled ventilation which:
reduces metabolic demandreduces metabolic demand allows C.O. to vital organsallows C.O. to vital organs
TherapyTherapy
Vagolysis
Chromotropy
V o lum eC V P
P re load
V asodila to rsV asoconstr ic to rs
A fterload
C orrectac idos ishypox ia
hypog lycem ia
Ino trop icagen ts
C on trac tility
S troke V o lum eHeart Rate
Fluid ChoicesFluid Choices
Less FillingLess Filling
Tastes Great !
Tastes Great !
Colloid
Crystalloid
CrystalloidsCrystalloidsHypotonic Fluids (DHypotonic Fluids (D5 5 1/4 1/4 NS)NS) No role in resuscitationNo role in resuscitation Maintenance fluids onlyMaintenance fluids only
Fluids, Fluids, FluidsFluids, Fluids, Fluids
Key to most resuscitative Key to most resuscitative effortsefforts
Give generously and reassessGive generously and reassess
Crystalloids less effective than Crystalloids less effective than equal volume of colloidsequal volume of colloids
Preferred when 1Preferred when 1oo deficit is water deficit is water and/or electrolytes and/or electrolytes
Good in initial resuscitation to Good in initial resuscitation to restore extracellular volumerestore extracellular volume
Hypertonic solutions however, Hypertonic solutions however, may act as plasma volume may act as plasma volume expandersexpanders
Oncotic pressure (tendency to pull unit) CapillaryCapillary
Hydrostatic pressure (tendency to drive unit)
Fluid Fluid TranspoTransportrt
ColloidsColloidsAlbuminAlbumin
Hepatic productionHepatic production MW = 69,000MW = 69,000 80% of COP80% of COP Serum tSerum t1/21/2::
18 hours endogenous18 hours endogenous
16 hours16 hours exogenousexogenous
ColloidsColloidsHydroxyethyl Starch Hydroxyethyl Starch (Hespan)(Hespan) Synthetic Synthetic Derived from corn starchDerived from corn starch AverageAverage MW = 69,000 MW = 69,000 Stable, nonantigenicStable, nonantigenic Used for volume expansionUsed for volume expansion Renal excretionRenal excretion
t t 1/2 1/2 2-67 hours2-67 hours 90% gone in 42 days90% gone in 42 days
Greater in COP than albuminGreater in COP than albumin Longer duration of actionLonger duration of action 0.006% adverse reactions0.006% adverse reactions No effect on blood typingNo effect on blood typing Prolongs PT, PTT and clotting Prolongs PT, PTT and clotting
timestimes DosageDosage
20 ml/Kg/day20 ml/Kg/day max 1500 ml/daymax 1500 ml/day
Based on:Based on: type of deficittype of deficit urgency of repletionurgency of repletion pathophysiology of pathophysiology of
conditioncondition plasma COPplasma COP
Tastes Great !
Tastes Great !
Less FillingLess Filling
Fluid ChoicesFluid Choices
Crystalloids for initial Crystalloids for initial resuscitationresuscitation
PRBC’s to replace blood lossPRBC’s to replace blood loss
Fluid Management in Fluid Management in Pediatric Septic ShockPediatric Septic Shock Emphasis on the golden hourEmphasis on the golden hour Early aggressive use of fluids Early aggressive use of fluids
may improve outcomemay improve outcome Titrate-Reassess!Titrate-Reassess!
Clinical Practice Parameters,Carcillo et al., CCM, 2002
““New” Therapies in New” Therapies in Septic ShockSeptic Shock SteroidsSteroids VasopressinVasopressin Activated Protein C (Xigris) in Activated Protein C (Xigris) in
septic shockseptic shock
Management of Pediatric Septic Management of Pediatric Septic Shock: The Golden HourShock: The Golden Hour
First 15 minutes First 15 minutes Emphasis on response to volumeEmphasis on response to volume
Clinical Practice Parameters, Carcillo et al., CCM, 2002