mangement of shock in children

1. MANAGEMENT OF SHOCK
DR ANKIT KUMAR
PG JR 1
SOURCES-
1- OP GHAI
2- NELSON
3- IAP
4- PICU PROTOCOL
5- SSCG 2021

2. Shock
• Characterised by inadequate tissue perfusion resulting in imbalance
between oxygen delivery and oxygen consumption.
• Leads to anaerobic metabolism and tissue acidosis leading to
irrevocable cell damage thus early recognition is important.

3. Classification of shock
• 1. Hypovolemic Shock (reduced intravascular volume)
• 2. Cardiogenic Shock (inadequate pump action of heart)
• 3. Obstructive Shock (blood flow obstruction from left or right heart)
• 4. Distributive Shock - septic, anaphylactic, neurogenic

5. • 1. Compensated Shock - homeostasis maintains perfusion of
essential organs
• 2. Decompensated Shock- homeostasis no longer able to maintain
perfusion to essential organs

7. Diagnosis of Shock
• Early signs -
Tachycardia, cool extremities, prolonged capillary refill time, poor
peripheral pulses and narrow pulse pressure.
• Late signs -
Hypotension, cyanosis

8. Predictor of mortality in shock
• Shock index – HR/Systolic blood pressure
• Modified shock index – HR/mean arterial pressure
(MAP ={[DBPx2]+SBP}/3)

9. Hypovolemic shock Cardiogenic Shock Neurogenic Shock Septic Shock
HR ↑↑↑ ↑↑ Bradycardia ↑↑
RR ↑ ↑ Bradypnoea ↑
Extremities Cool Cool Warm Warm/Cool
Mix Venous O2 Sat. Low(<50) Low(<50) High(>70) High (>70)

10. Hypovolemic Shock
Grades 1 2 3 4
% loss <15 15-30 30-40 >40
ml loss <750 750-1500 1500-2000 >2000
HR <100 >100 >120 >140
MAP Normal ↓ ↓↓ ↓↓

11. Fluid bolus
• Which fluid – isotonic crystalloid (Normal Saline). Balanced solution
(Iso-P, RL)
• How much – 20-60ml/kg (over 15-20min) if ICU facility present,
if not present then 20-40ml/kg (over 15-20min)

12. SAM with dehydration with shock
• Fluid of choice – RL with D5 > N/2 D5 >> RL
• Volume – 15ml/kg over 1st hour → if doesn’t improve
↓ ↓
If improved – SAM with shock Septic Shock
↓
15ml/kg over next hour
↓
Resomol -5-10ml/kg/hr

13. Septic Shock 2020 IAP guidelines
Steps 2020 recommendations 2021 surviving sepsis guidelines
Screening Diagnosis and
management
Suggested for systemic screening
for timely detection
Recommended – Obtaining blood
culture before initiation of
antimicrobial therapy
No need of blood lactate values
for categorising children.
qSOFA no longer screening tool,
Lactate levels are better (but not
single)
Suspected adults, measure blood
Lactate
treatment And resuscitation
begin immediately
Antimicrobial therapy In children with septic shock give
antibiotic within 1st hour → preferably
broad spectrum → taper down
subsequently as per culture.
Daily assessment of timely de-
escalation of antimicrobials, duration
as per site, aetiology and control of
source.
Sepsis without shock - antimicrobial
within 3 hrs
Possible septic shock or high likelyhood of
sepsis Administer antibiotic immediately
ideally within 1st hour of recognition

14. Steps 2020 recommendations 2021 surviving sepsis guidelines
Fluid therapy 40-60ml/kg of fluid in 1st hr with
clinical assessment
Crystalloid>colloids
Use of balanced solution rather
than 0.9% saline
No use of starch, gelatin
Suggested for 30ml/kg in first 3 hrs.
Use of balanced salt solutions
No use oof starch
Hemodynamic Monitoring A- Advanced hemodynamic
variables
1- modified shock index
2-mixed venous o2 saturation
3-systemic vascular resistance
B- Use of serial trends of lactate
rather than single value
C- Suggested against isolated use of
clinical signs in categorising, warm
and cold shock
D- No recommendation for or
agianst mean arterial pressure
Initial target mean arterial pressure
of 65mmHg over higher MAP
targets

15. Steps 2020 recommendations 2021 surviving sepsis
Vasoactive medications Either Epi or NorEpi in 1st place
rather than DOPA (Dopamine may
be used as first line where the
other 2 are not available)
Add vasopressin if required to
achieve target
No recommendations
A- specific 1st line vasoactive agents
or adding inodilator in children
with cardio dysfunction already on
vasopressors.
B-vasopressors in peripheral line
Use nonorepinephrine as 1st line
agent over other casopressors.
Add vasopressin instead of
increasing doseof norepi
Ventilation A trial of NIV over invasive
ventilation with PARDS
Suggested against –
A- Routine use of iNO
B- Use of etomidate
No recommendation for or against
A- intubation in fluid refractory
vasopressor resistant shock
B- HFO
C- recruitment manoeuvre
Suggested use of HFNC instead of
non invasive ventilation
Recommend prone ventilation for
at least 12 hrs

16. Steps 2020 recommendations 2021 surviving sepsis
Steroid IV Hydrocortisone used for treating
children with septic shock who are
not stabilised by adequate fluid and
vasopressor therapy.
Use of iv corticosteroid suggested
Endocrine and metabolic Recommendation against –
Routine insulin therapy to maintain
sugar <140mg/dl
No recommendation-
A- Range of blood sugar levels as
target, but suggested to target
180mg/dl
B- whether to target normal calcium
levels (but maintain normal ionised
calcium)
Suggested against – routine use of
levothyroxine
Suggested using sodium
bicarbonate therapy

17. Steps 2020 recommendations 2021 surviving sepsis
Nutrition Enteral nutrition as preferred to
parentral nutrition and withholding
parenteral nutrition till 7 days of
PICU admission
Suggested againt –
A- supplementing with specialised
lipid emulsion
B- routine assessment of gastric
residual volume and routine
prokinetic agents
Suggested early initiation of enteral
nutrition (72 hrs)
Blood products Suggested against
A- Transfusion of PRBC with Hb
>7gm/dl for stabilised children
B- prophylactic platelet and plasma
transfusion in non bleeding cases
But during resuscitation phase of
shock maintain Hb >10gm/dl
No recommendation for Hb
transfusion threshold for unstable
patient
Recommend Restrictive transfusion
therapy

18. Steps 2020 recommendations 2021 surviving sepsis
Extracorporeal therapy Suggested for –
Early RRT for children with fluid
overload and VVECMO
In PARDS and refractory hypoxemia
NOTE – No role of ROUTINE IVIG
AND ROUTINE STRESS ULCER AND
DEEP VEIN PROPHLAXIS

19. Neonatal Sepsis

20. Neonatal Shock
• Hypotension in 1st 24hrs is defined as
1-mean BP <30mmHg
2-Mean BP <gestational age in weeks
Neonatal shock is defined as CFT >3-4secs, poor peripheral pulse,
oliguria, base deficit >5, arterial lactate >2 mmol/l along with or
without hypotension and superior vena cava flow <40ml/kg/min.

22. Case scenario
1- A 8 month old boy was brought to ER with h/o excessive crying irritability
decreased urine output and refusal to feed for the 1st 12 hrs.
h/o mild fever cough cold for 2 days. Well immunised child, no significant past
history
O/E Afebrile lethargic HR-196/min, RR-70/min, BP-60/40 mmHg, periphery cool,
CFT prolonged, tachycardia, central pulse weak, SpO2 on RA – 70%
Systemic Exam –
RS- basal crepts with subcoastal in drawing
CVS – muffled heart sound with gallop rhythm, per abdomen soft, liver 4cm below
costal margin
CNS – AF normal

23. What is the physiological status of this child
• Hypotensive shock/ cardiogenic shock with respiratory distress.

24. Management
• ABC
• 100% O
• Fluid bolus -10ml/kg
• Lab investigation including septic workup
↓
Status after 1st bolus
HR-180, BP- 70/40, periphery still cold and pulse feeble, no urine output, liver size
still same
Investigations – Hb - 11.5gm/dl, WBC -6500, RBS-120mg/dl, ionised calcium – 0.7,
lactate - 3, ABG – pH-7.1, PCO2, 23%, PO2 – 65, Bicarb -9.3, base excess- 14.5
Further plan – minimal signs of improvement after 1st bolus and started on
Epinephrine and intubation

25. Benefits of intubation in this scenario – overtake increased work of breathing, reduce oxygen demand by respiratory
muscles, PEEP opens alveoli an reduces the left ventricular afterload.
Vitals after 1hr –
HR-168, BP-same, central pulses good, peripheral cool with weak pulse
↓
No more fluid boluses and increase dose of inotrope to 0.3mics/kg/min
↓
HR-150 with mean arterial pressure 56 but still periphery cold with weak pulse
Do lactate, ABG – ph=7.2, pCO2 – 30, pAO2 – 80, bicarb 12, base excess -8, lactate 3.1 and child has passed some urine
↓
Add dobutamine
↓
HR- 130, mean blood pressure -67, Cp-good, PP- good, urine output -1ml/kg/hr . Lactate 2.2, pH -7.34, pCO2 -32, bicarb
– 18

26. Case scenario
2- 8 yr female with fever for 4 days, cough for 4 days, respiratory
distress.
O/E - airway open and stable with RR-34 / min with increased
breathing efforts with B/L crackles with SpO2 85%, HR-162/min, CFT-
1sec, BP-68/30, CP- pulse, PP- good, skin temp- warm, GCS -15/15,
pupil 2mm not reactive to light, activity – normal and symmetrical
blood sugar 59 with multiple pustules on leg

27. What is the physiological status of this child
• Respiratory distress with warm shock

28. Initial management
• Facemask oxygen @6lit/min
• Fluid bolus - 20ml/kg NS
• Dextrose bolus
HR - 154/min
CFT -2 sec
BP - 72/42 mmHg
Central pulse - good
peripheral Pulses- poor
Skin temp - warm
EECG - normal
Fluid bolus -
20ml/kg NS
HR - 148/min
CFT -2 sec
BP - 72/42 mmHg
Central pulse - good
peripheral Pulses- good
Skin temp - warm
EECG - normal
IVC - full
Hepatomegaly
NorEpi - 0.1 mic/kg/min

29. Investigation sent
• Complete hemogram
• KFT
• LFT
• ABG
• Lactate levels
• Blood culture

30. AFTER 45 MINS
• HR - 145/min
• CFT - 2 sec
• BP - 76/34 mmHg
• Central pulse- good
• Peripheral pulses- good
• Skin temp - warm
• ECG - normal

31. • Patient still not improved
• Why?

32. Refractory septic shock
• Pericardial effusion
• Tensions pneumothorax
• Hypothyroidism
• Ongoing fluid loss
• Inappropriate sources control
• Immunocompromised host

33. Case scenario
3– 5 yr old child with acute febrile illness.
O/E – redness of conjunctiva, extremity edema, abdominal complaints,
sterile pyuria, neutrophil leucocytosis, lymphopenia, elevated CRP, ESR
Elevated liver enzymes, acute kidney injury and shock with COVID + 1
month back with HR-130/min, BP -66/32 mmHg, SpO2 – 90%

34. What is the physiological status of this child
• Hypotensive shock, cardiogenic/vasoplegic + respiratory distress

35. • Shock - inotropic support with Adr 0.1-0.3 mic/ kg/min
• Respiratory support - high flow nasal canula, 2l/min 40% FiO2
• Sepsis - ceftriaxone started after sending blood culture
• Iv immunoglobulin 2g/kg over 18hrs
• Inj methylprednisolone pulse 30mg/kg OD

36. Management Of Shock in covid 19
• Consider crystalloid fluid bolus 10-20 ml/kg cautiously over 30-
60 minutes with early vasoactive support (epinephrine)
• Start antimicrobials within the first hour, after taking blood
cultures, according to hospital antibiogram or treatment
guidelines
• Consider inotropes (milrinone or dobutamine) if poor
perfusion and myocardial dysfunction persists despite fluid
boluses, vasoactive drugs and achievement of target mean
arterial pressure
• Hydrocortisone may be added if there is fluid refractory
catecholamine resistant shock (avoid if already on
dexamethasone or methylprednisolone)
• Once stabilized, restrict IV fluids to avoid fluid overload
• Initiate enteral nutrition – sooner the better

37. Multisystem Inflammatory
Syndrome (MIS-C) management
guide
• Multi System Inflammatory Syndrome in Children (MIS-C) is a new
syndrome in children characterized by unremitting fever >38°C and
epidemiological linkage with SARS-CoV-2. It usually occurs after 2–4
weeks of recovery from acute COVID-19

39. Alternative diagnoses that must be excluded before making a diagnosis of MIS-C
(i) Tropical fevers (malaria, dengue, scrub typhus, enteric fever)
(ii) Toxic shock syndrome (staphylococcal or streptococcal)
(iii) Bacterial sepsis
MIS-C with Kawasaki Disease (KD) phenotype is characterised by fever, conjunctival redness, oropharyngeal findings
(red and/or cracked lips, strawberry tongue), rash, swollen and/or erythematous hands and feet and cervical
lymphadenopathy

40. Tier 1 tests (may be done at Covid Care Centre, Dedicated Covid Health Centre): CBC, complete metabolic
profile (LFT/KFT/blood gas/glucose), CRP and/or ESR, SARS-CoV-2 serology and/or RT-PCR, blood culture
Positive Tier 1 screen (both of these should be present):
1. CRP >5 mg/L and/or ESR >40 mm/hour;
2. At least one of these: AEC <1000/μL, platelet count <150,000/μL, Na <135 mEq/L, neutrophilia,
hypoalbuminemia

41. Tier 2 tests (may be done at Dedicated Covid Hospital): Cardiac (ECG,
echocardiogram, BNP, troponin T); inflammatory markers (procalcitonin, ferritin,
PT, PTT, D-Dimer, fibrinogen, LDH, triglyceride, cytokine panel);
blood smear; SARS-CoV-2 serology
* Common tropical infections include malaria, dengue, enteric fever, rickettsial
illness (scrub typhus), etc.

43. Appropriate supportive care is needed preferably in ICU for treatment of
cardiac dysfunction, coronary involvement, shock or multi-organ
dysfunction syndrome (MODS)
IVIG to be given slower (over up to 48 hours) in children with cardiac
failure/ fluid overload
Taper steroids over 2-3 weeks with clinical and CRP monitoring
Aspirin 3-5 mg/kg/day, maximum 75 mg/day in all children for 4-6 weeks
(with platelet count >80,000/μL) for at least 4-6 weeks or longer for those
with coronary aneurysms
Low molecular weight heparin (Enoxaparin) 1 mg/kg/dose twice daily s/c
in >2 months (0.75mg/kg/dose in <2 months) if patient has thrombosis or
giant aneurysm with absolute coronary diameter ≥8 mm or Z score ≥10 or
LVEF <30%

44.  For children with cardiac involvement,
repeat ECG 48 hourly & repeat ECHO
at 7–14days and between 4 to 6 weeks
(and after 1 year if initial ECHO was
abnormal

45. Anaphylactic shock
• Acute clinical syndrome characterized by severe life threatening gene
generalized type 1, hypersensitivity reaction, usually caused by
exposure to foreign substance
• Leads to mast cell degranulation.
• Clinical diagnosis, lab parameters not so important

46. Clinical features
• Acute onset - within minutes to hours
• Skin and mucosa involvement
• Respiratory compromise - dyspnea, wheeze, stridor, hypoxemia
• Circulatory compromise- low BP or associated symptoms
• GI symptoms- cramps abdominal pain, vomiting

47. Management
• Initial management (1st minute)
Keep supine (sitting if Respiratory distress)
Assess airway, breathing, circulation, heart rate, BP, SpO2
Provide O2
Identify and remove allergic trigger
1st dose of i.m. epinephrine @ 0.01mg/kg/dose (1mg/ml of
1:1000) at anterolateral aspect of left thigh

48. • 1 to 5 mins
sitting posposition
O2 by HFNC
If stridor - neb with epinephrine @0.5ml/kg
If wheeze - neb with salbutamol @ 0.15mg/kg
Hypotension
Supine position
iv access
Bolus of NS @20ml/kg by iv/io rapid push

49. • 5 to 10mins
If no improvement give 2nd dose of im epinephrine
2nd nebulised epinephrine
2nd nebulised salbutamol
2nd bolus of NS @20ml/kg

50. • 10 to 20 mins
3rd nebulised epinephrine
3rd nenebulised salbutamol
Proceed for intubation
Hypotension
Iv epinephrine @ 0.05mcg/kg/min with titrate by
0.02 mcg/kg/min

51. • If still no improvement
Suspect refractory anaphylaxis
Start iv norepinephrine infusion @ 0.05mcg/kg/min with titrate
by 0.02mcg/kg/ min ( max upto 2mcg/kg/min)
Iv glucagon bolus @ 20-30 mcg/kg/dose over 5 mins followed by
5-15mcg/min titrated till achievement of clinical effects

52. Thank you!