This document provides information on pediatric shock, including its definition, categories, regulatory systems, predisposing factors, etiology, stages, management principles, therapeutic endpoints, fluid resuscitation, vasoactive drugs, blood products, monitoring, and extracorporeal membrane oxygenation. It details the stepwise management of hemodynamic support in neonates with shock. The document aims to guide the recognition and treatment of shock in children.

1. Dr. BALBIR SINGH
DNB PEDIATRICS
J.L.N. HOSPITAL & RESEARCH CENTRE
BHILAI

2. DEFINITION
• Shock is an acute syndrome that occurs because
of cardio vascular dysfunction and inability of
circulatory system to provide adequate oxygen and
nutrients to meet the metabolic demand of vital
organ.
Or
Acute circulatory failure with inadequate tissue
perfusion resulting in generalized cellular hypoxia.
If untreated leads to metabolic acidosis, organ
dysfunction and death.

3. CATEGORISATION OF SHOCK
1. On the basis of type
 Hypovolemic
 Cardiogenic
 Distributive
 Obstructive
 Dissociative
2. On the basis of Severity
 Compensated
 Decompensated
 Irreversible

4. REGULATORY SYSTEM
• Baroreceptors / Chemoreceptors in carotid body .
Aortic Arch.
• Volume receptors – In rt Atrium and pulmonary bed.
• Adrenal medulla through catecholamine.
• Renin Angiotensin Aldosterone System .
• Hypothalemic pituitary response through ACTH and
Vasopressin

5. PRE-DISPOSING FACTOR
- Asphyxia
- Prematurity
- Sepsis
- Blood loss
- Metabolic Derrangement
(i) Hypoglycemia (ii) Hypocalcemia

6. ETIOLOGY OF SHOCK
HYPOVOLEMIC
Blood Loss
- Fetomaternal
- Twin to twin transfusion
- Birth Trauma
- DIC
Fluid Loss
- Excessive insensible loss in preterm
- Poor fluid intake
- Vommiting
- Diarrhea
CARDIOGENIC
- CHD
- Congenital myocarditis
- Cardiomyopathy
- Arrhythmias
- Hypoglycemia
- Acidosis and sepsis

7. DISTRIBUTIVE
- Septicemia
- Adrenal Insufficiency
- Neurogenic
- HIE
- Administration of vasodilators
OBSTRUCTIVE
- Congenital Diaphragmatic Hernia
- Tension Pneumothorax
- Interstitial Emphysema
- Cardiac Tamponade
DISSOCIATIVE
- Severe anaemia
- Methaemoglobinemia

8. COMPENSATED
Blood Pressure Normal
Decreased tissue perfusion
- Cold, pale,Ashen grey skin
-Tachycardia
- Normal / Mild Tachypnoea
-CFT- prolonged
-U/O- Adequate
-BP- Normal
- Normal /Wide pulse pressure
- Bounding Peripheral pulses
- Vomiting and Ileus
- Irritable
- Peripheral to core temperature diff. >2 F.

9. DECOMPENSATED STAGE
• Anaerobic metabolism sets decreased tissue perfusion-
lactic acidosis-depresses myocardium.
• Characterized by hypotension and exxag signs of
decreased tissue perfusion
• Marked tachycardia
• Tachypnoea / acidotic breathing
• Marked decreased in CFT
• Mottling
• Hypotension
• Oliguria
• Lethargic
• Temperature difference b/n p/c > 5° F.

10. IRREVERSIBLE STAGE
• Characterised by severe damage to vitals organs-
Death occurs inspite of restoration of circulation
• Bradycardia
• Acidotic breathing and apnea
• Cold and Cyanotic periphery
• Anuria
• Gross hypotension
• Coma

11. PRINCIPLES OF MANAGEMENT
1) Rapid recognition and resuscitation
2) Correction of secondary consequences
of Shock
3) Maintain vital organ function
4) Identification and correction of aggravating
factors
5) VIP approach should be used.
V= Ventilation
I= Infusion
P= Pumping or Cardiovascular stability

12. THERAPEUTIC ENDPOINTS
• Normal pulses(no differential b/w peripheral
& central)
• CRT< 2sec
• Warm extremities
• Normal mental status
• Normal BP
• Urine output > 1ml/kg/hr
• ↓Serum Lactate
• ↓ Base deficit
• Svo2 >70%

13. Positioning & O₂ Administration
• Place a hypotensive child in the Trendlenburg
position as long as breathing is not compromised
• Allow a stable child to remain in most comfortable
position
• High flow O₂ in all children with shock
• Ventillatory support may be needed

14. Vascular Access
• For fluid resuscitation & administration of
medication
• Compensated Shock- Peripheral access is
preffered
• Hypotensive Shock- Intraosseous or Central

15. FLUID RESUSCITATION
• Give isotonic crystalloid in a 20 ml/kg bolus over
5-20 min.
• Repeat 20 ml/kg boluses to restore blood pressure
and tissue perfusion.
• Repeat fluid bolus based on clinical signs like
HR,CRT,level of consciousness & urine output.
• Suspected cardiogenic shock-large fluid boluses
not recommended.
• Monitor for pulmonary oedema or worsening
tissue perfusion during infusion.
• FLUID REFRACTORY SHOCK – not responding
to >60ml/kg fluid.

16. • Fluid resuscitation may consist of natural or
artificial colloids or crystalloids.
• Crystalloids are less expensive.
• Fluid resuscitation initially target a CVP of
>8mmHg.
• More rapid & greater amount may be needed
in pt. with sepsis induced tissue hypoperfusion

17. TYPE OF SHOCK:
FLUID BOLUSES / RATE OF DELIVERY
Type of shock Volume of Rate of delivery
fluid
Hypovolemic shock (non- 20 ml/kg bolus (repeat Deliver rapidly
DKA) PRN) (over 5-10 min)
Distribute shock
Obstructive shock
Cardiogenic shock 5-10 ml/kg bolus Deliver more slowly
(Non poisonings) (repeat PRN) (over 10-20 min)

18. MONITORING
To assess effectiveness of fluid resuscitation &
pharmacological support
• Spo₂
• Heart rate
• Blood pressure & pulse pressure
• Mental status
• Temprature
• Urine output

19. FREQUENT ASSESSMENT
Frequently reassess child’s
respiratory,cardiovascular & neurologic status to
• Evaluate trends in child’s condition
• Determine response to therapy
• Plan the next treatment interventions
At any point child’s condition could
deteriorate,requiring life saving interventions such
as Endotracheal intubation or Needle thoracotomy.

20. Indication for Blood Products
• Hypovolemic neonate due to blood loss with
inadequate perfusion despite 2-3 boluses of 20 ml/kg
of isotonic crystalloid
• Packed RBCs 10 ml/kg
• Warm blood should be used
• Complications- hypothermia,myocardial
dysfunction,hypocalcemia

21. PHARMACOLOGIC SUPPORT
• Vasoactive agents used because they affect
-Myocardial contractility
-Heart rate
-Vascular smooth muscle tone
• Choice of agent depend on child’s physiologic state
• Indicated when shock persist after adequate volume
resuscitation to optimize preload

22. (1) Ionotropes -Dopamine,Dobutamine,Epinephrine
• ↑ Cardiac contractility,↑ HR
• Variable effect on SVR
(2) Phosphodiesterase inhibitors -Milrinone,amrilinone
• ↓ Afterload
• Improve coronary artery blood flow & contractility
(3)Vasodilators – Nitroglycerine,Nitroprusside
• ↓ Afterload,↓ Venous return
(4)Vasopressors(Vasoconstrictors) –
Epinephrine,NE,Dopamine,Vasopressin
• ↑ SVR
• NE has ionotropic effects whereas Vasopressin is a pure vasoconstrictor

23. CHOICE OF VASOACTIVE AGENT DEPENDS ON UNDERLYING
PATHOPHYSIOLOGY
Normal BP Low BP
First line Second line First line Second line
Cardiogenic shock Dobutamine Milrinone Adrenaline Low dose
(myocardial dysfunction milrinone
+increase SVR)
Warm septic shock(decrease NA(preferred) or dopamine NA + Vasopressin
SVR+ - myocardial with aggressive fluid dobutamine/ (never alone,
dysfunction) rususcitation. Add dopamine add to NA)
dobutamibe if shock not
reversed
Cold septic shock (myocardial Dobutamine milrinone Adrenaline/D Add NA if
dysfunction SVR increase) opamine MAP remains
low.

24. Dopamine Dobutamine Norepinephrine Epinephrine
Low dose ↑ C.O. ↑ TPR ↑ cardiac contraction
2-5 µg/kg/min ↑ stroke volume ↑ SBP ↑DBP ↑ H.R.
vasodilatation ↑ renal without marked ↑
perfusion in H.R.
Moderate dose No/ minor effect C.O. unchanged BP rise → dose on
5-10 µg/kg/min on BP and PVR Especially useful in rapid I.V. inj.
↑ myocardial contraction children with low BP SBP> DBP
↑ C.O.
High dose > 15 µg/kg/min Dose 3-20 µg/kg Dose 0.1- 1 µg/kg/min Vasodilataion at small
Vasoconstriction /min dose
↑ SBP Vasoconstriction at
↑ pulse pressure higher dose
Dose 0.01-2µg/kg/min
Drip calculation – Drip calculation – Drip calculation – Drip calculation –
6 x b.w.(kg) =mg in 6 x b.w.(kg) =mg 0.6 x b.w.(kg) =mg in 0.6 x b.w.(kg) =mg in
100ml;1 ml / hr = 1 mcg/ in 100ml;1 ml / hr 100ml;1 ml / hr = 0.1 100ml;1 ml / hr = 0.1
kg / min = 1 mcg/ kg / min mcg/ kg / min mcg/ kg / min

25. ASSESSMENT OF RESPONSE TO IONOTROPES
1. Improvement in blood pressures
2. Improvement in thermoregulation
3. Increased urine output
4. Increased oxygenation
5. Decreased base deficit and lactate
6. Shift of mixed venous concentration towards normal
7. The core- peripheral temperature gradient narrows
8. Cardiac output returns to normal
9. Patient looks better.

26. STEROID THERAPY
• Hydrocortisone therapy be reserved for use in
children
–with catecholamine resistance
- suspected or proven Adrenal insufficiency
• Patient at risk for Adrenal insufficiency
- children with severe septic shock & purpura
- with pituitary or adrenal abnormalities
• Children who have clear risk factor should be
treated with stress dose steroid (Hydrocortisone
50mg/m²/24hrs)

27. Extracorporeal Membrane
Oxygenation(ECMO)
• Use of ECMO be limited to refractory
pediatric septic shock and/or respiratory
failure that can’t be supported by
conventional therapies

28. Stepwise management of hemodynamic support in
neonates
Recognize decrease mental status and perfusion, maintain airway
and establish access according to PALS guidelines
Push 20 cc/kg isotonic saline or colloid boluses up & over 60 cc/kg
Correct hypoglycemia & hypocalcemia
Administer antibiotics
Fluid responsive
Fluid refractory shock
Observe in PICU
Establish Central Venous access, begin dopamine or
dobutamine therapy and establish arterial monitoring
Fluid refractory - dopamine / dobutamine resistant shock

29. FLUID REFRACTORY - DOPAMINE / DOBUTAMINE
RESISTANT SHOCK
Titrate epinephrine for cold shock, norepinephrine for warm shock to normal
clinical endpoints & ScvO2 saturation > 70%
Catcholamine - resistant shock
Begin Hydrocortisone if at risk of absolute adrenal insufficiency
Normal BP Low BP Low BP
Cold shock Cold shock Warm shock
ScvO2 < 70% ScvO2 < 70% ScvO2 > 70%
Add vasodilator
Titrate volume
or type III Titrate volume
& norepinephrine
Phosphodiesterase inhibitor & epinephrine
with volume loading
Persistent Catcholamine - resistant shock

30. Persistent Catcholamine - resistant shock
Start cardiac output measurement & direct fluid, inotrop, vasopressor,
vasodilator and hormonal therapy to attain CI > 3.3 and < 6.0 L/min/M2
Refractory shock Consider ECMO
Persistent Catcholamine - resistant shock

31. REFERENCES
• PALS Provider Manual – 2010, American Academy of
Pediatrics,American Heart Association,Indian Academy of
Pediatrics.
• Surviving Sepsis Campaign (SSC): International
Guidelines for Management of Severe Sepsis and
Septic Shock : 2008- Critical Care Medicine 2008 Vol.
36,No.1.
• Analysis of the evidence for the lower limit of systolic
& mean arterial pressure in children: Krarn U. Haque,
MD, FAAP; Arno L Zaritsky, MD, FAAP, FCCM:Pediatr
Crit Care Med 2007 Vol. 8, No. 2.
• Behrman R E, Kleigman RM,Jenson HB, Nelson Text
Book of Pediatrics, 18th edition,2007.
• Ionotropic Therapy:The Intensivist:Newsletter of
Pediatric Intensive Care Chapter:IAP- Jan.2007;3-13