Shock is defined as circulatory insufficiency resulting in an imbalance between tissue oxygen supply and demand. It occurs when there is a failure to deliver sufficient oxygen and nutrients to tissues to meet metabolic demands. Shock can be caused by decreased oxygen delivery or excessive metabolic demands. There are different classifications of shock including hypovolemic, cardiogenic, and septic shock. Septic shock involves systemic inflammatory response syndrome due to a suspected or proven infection along with cardiovascular and organ dysfunction. Management of septic shock focuses on early recognition, source control, antibiotics, fluid resuscitation, vasopressor support, and monitoring for organ dysfunction.

1. Management of Shock
Moderator:
ASSOT.PROF DR ARUN GIRI
ASST.PROF DR SANDIP KR SINGH
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Presenter:
Dr Subodh Kumar Shah
2ND year Resident
Pediatric

2. Outline :
• Introduction
• Pathophysiology
• Classifications
• Stages of shock
• Septic shock
• Defination
• Management
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3. Introduction
• Shock is defined as circulatory insufficiency that creates an imbalance
between tissue oxygen supply and oxygen demand. The result of
shock is global tissue hypo perfusion and is associated with a
decreased venous oxygen content and metabolic acidosis (lactic
acidosis)
• Shock is a state of acute circulatory dysfunction that results in a
failure to deliver sufficient oxygen and other nutrients to meet the
metabolic demands to the tissues,
Roger’s text book of pediatric intensive care , section: 5
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4. THE PATHOPHYSIOLOGY OF SHOCK
Shock is characterized by a relative imbalance between
the delivery of oxygen and metabolic substrates and the
metabolic demands of the cells and tissues of the body.
While the shock state most commonly occurs in the
setting of decreased oxygen delivery, it is certainly
feasible that excessive metabolic demands could
produce a similar pathologic state.
DO2 = CO x (Hb x 1.34x SaO2) + (0.003x PaO2)
VO2 = CO x (Hb x 1.34 x (SaO2 – SvO2) + 0.003 x(PaO2 PvO2)
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6. PATHOPHYSIOLOGY
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19. SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS)
The presence of two or more of the following criteria, one of which must be
abnormal temperature or leukocyte count:
• Core temperature of >38.5°C or <36°C
• Tachycardia, defined as a mean heart rate >2 SD above normal for age in
the absence of external stimulus, chronic drugs, or painful stimuli;
Or
otherwise unexplained persistent elevation over a 0.5- to 4-hour time period
Or
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20. • for children <1 year old: Bradycardia, defined as a mean heart rate
<10th percentile for age in the absence of external vagal stimulus,
beta-blocker drugs, or congenital heart disease; or otherwise
unexplained persistent depression over a 0.5-hour time period
• Mean respiratory rate >2 SD above normal for age or mechanical
ventilation for an acute process not related to underlying
neuromuscular disease or the receipt of general anesthesia
• Leukocyte count elevated or depressed for age (not secondary to
chemotherapy-induced leukopenia) or >10% immature neutrophils
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21. INFECTION :
• A suspected or proven (by positive culture, tissue stain, or polymerase
chain reaction test) infection caused by any pathogen or a clinical
syndrome associated with a high probability of infection.
• Evidence of infection includes positive findings on clinical exam,
imaging, or laboratory tests (e.g., white blood cells in a normally
sterile body fluid, perforated viscus, chest X-ray consistent with
pneumonia, petechial or purpuric rash, or purpura fulminans
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22. • SEPSIS
SIRS in the presence of or as a result of suspected or proven infection
• SEVERE SEPSIS
Sepsis plus the following: cardiovascular organ dysfunction, acute
respiratory distress syndrome (ARDS), or two or more other organ
dysfunctions
• SEPTIC SHOCK
Sepsis and cardiovascular organ dysfunction
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37. RED FLAG FINDING :

44. Initiations of vasoactive agents

45. MONITORING :

49. FLUID REFRACTORY SHOCK:

53. Reference:
• 1. SURVIVING SEPSIS CAMPAIGN GUIDELINES 2020
• 2. https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Pediatric-Patients
• 3. Nepal Pediatric Society Clinical Guidance for Management of Sepsis and Septic Shock in
the Pediatric Intensive Care Units in Nepal. Journal of Nepal Paediatric Society, 41(1), 110.
https://doi.org/10.3126/jnps.v41i1.35075
• 4. Cleveland Clinic Journal of Medicine January 2020, 87 (1) 53-64; DOI:
https://doi.org/10.3949/ccjm.87a.18143
• 5. SEPSIS - assessment and management, Royal Children's Hospital Clinical Practice
Guidelines,https://www.rch.org.au/climcalguide/guideline_index/SEPSIS_assessment_and_managem
ent/, viewed 114ay 2020.
• From Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference:
definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2–8.
• 6 Nelson Textbook of Pediatrics 21 EDITION
• 7 UPTODATE
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54. Thank you
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