Fluid resuscitation and vasoactive medication in critically ill children.pptx

Fluid resuscitation and vasoactive medication in critically ill children

1. Dr Mohammad Al Ktifan Pediatric Emergency -AWH Fluid Resuscitation and Guide to Vasoactive Medication in critically ill children  

2. Introduction Fluid resuscitation in children refers to the administration of fluids to restore intravascular volume and improve tissue perfusion in cases of dehydration, shock, or fluid loss due to various conditions such as diarrhea, vomiting, burns, or sepsis. The primary goal is to restore circulatory volume rapidly to prevent collapse. Correcting the intravascular volume loss with fluids improves cardiac output and reduces mortality in children .

3. Inotropes and vasopressors can be used to optimize cardiac output and systemic vascular resistance. Inotropic agents are medications that enhance myocardial contractility, improving cardiac output and tissue perfusion. And indicated with conditions such as septic shock, myocarditis, cardiomyopathy, or after cardiac surgery. The choice and timing of fluid and inotropic therapy should be individualized based on the underlying etiology of shock, hemodynamic parameters, and response to initial interventions.

4. Fluid resuscitation Emergent intravenous fluid administration is required if there is any evidence of inadequate or poor perfusion suggested by: Delayed capillary refill , Tachycardia , Oliguria, Hypotension Commonly used fluids include crystalloids (such as normal saline, lactated Ringer’s solution, and balanced salt solutions) and colloids (such as albumin).

5. Types of fluid resuscitation The type and amount of fluid given to a critically ill child depends on their clinical condition and fluid status , but commonly used fluids include: crystalloid solutions: can be divided into three types: isotoni c , hypertonic and hypotonic and also classified to either non-balanced fluids  such as 0.9% normal saline (NS) or balanced fluids such as lactated Ringer (LR) or Plasmalyte Isotonic : have a similar concentration of electrolytes to that of plasma and include normal saline (0.9% NaCl) and lactated Ringer's solution. They are typically the first-line choice for fluid resuscitation in pediatric patients, especially for conditions like dehydration due to diarrhea or vomiting.

6. Hypertonic Saline (3% NaCl): is used in specific situations such as severe hyponatremia or cerebral edema. Not typically used as the first-line fluid for resuscitation in pediatric patients due to the risk of hypernatremia and volume overload. Hypotonic Saline (0.45% NaCl): Contains lower concentrations of sodium chloride ,Rarely used for fluid resuscitation in pediatric patients due to the risk of hyponatremia and worsening cerebral edema in certain conditions.

7. 2- Colloid solutions : Colloids contain large molecules (e.g., starches, albumin) that remain in the intravascular space longer than crystalloids, thereby increasing intravascular volume. -they are more expensive and may have potential adverse effects. Colloids like albumin or synthetic colloids (e.g., hydroxyethyl starch) may be used in certain cases of severe shock or hypoalbuminemia. 3- Blood products: In cases of severe hemorrhage or shock due to significant blood loss, blood transfusion may be necessary. This can include packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP).

8. Fluid overload F luid overload (FO) in critically ill children has been associated with worse outcomes and higher mortality   F luid bolus therapy should be discontinued as soon as signs of fluid overload develop: - Tachypnea or increased work of breathing with crackles on lung examination - Hypoxemia - periorbital puffiness or edema - Cardiac gallop - Hepatomegaly - Jugular venous distension - Lethargy or coma - Enlarged heart on x-ray (if available)

9. What are vasoactive drugs? In  middle-to-high-income  countries, after 40-60ml/kg of fluid resuscitation, the Surviving Sepsis Campaign International (SSC) Guidelines recommend using vasoactive drugs. with lower fluid volumes and earlier vasoactive use being recommended, particularly  if there are signs of fluid overload . Consider inotropes if children with sepsis remain shocked after 40-60ml/kg of fluid resuscitation. If there is evidence of cardiac dysfunction, consider starting an inotrope earlier

10. What different vasoactive drugs are available? The Surviving Sepsis Campaign International (SSC) Guidelines recommend either  adrenaline  or  noradrenaline  as the first-line inotrope. Adrenaline and noradrenaline both work at α and β receptors. At lower doses, adrenaline can have more of a β effect with increased heart rate and contractility, whilst at higher doses, the α-effects are predominant. Noradrenaline similarly has both α and β, but the α (blood vessel constriction) effects are more predominant .

11. Dobutamine  has a slight vasodilatory effect. This increases contractility without leading to increases in systemic vascular resistance. This makes it a popular choice for children with underlying heart disease (and those with cardiogenic shock). dopamine  is no longer recommended by advanced life support guidelines for septic shock unless adrenaline/noradrenaline are unavailable

12. Vasopressin  can be added as a ‘second line’ agent for children with shock that are not responding to adrenaline and noradrenaline. Vasopressin cause constriction of the renal vessels and secondary increases to the systemic vascular resistance and, therefore, blood pressure. Milrinone  is an inodilator , causing increased cardiac contractility and vasodilation , a nd improves cardiac perfusion and cardiac output .

13. We will discuss uses of fluid resuscitation and vasoactive drug in : 1-hypovolemia (dehydration) and hypovolemia shock 2- septic shock 3- cardiac shock 4- Distributive shock

14. Treatment of hypovolemia (dehydration) EMERGENCY FLUID REPLETION PHASE Rapid volume repletion is required in children with severe hypovolemia. Clinical assessment of hypovolemia is based on physical signs that reflect the status of the effective arterial blood volume and include pulse, blood pressure, and skin.

15. Severe hypovolemia  (Dehydration ) defined as volume depletion ≥10 percent , presents with : decreased peripheral perfusion with a capillary refill >3 seconds , cool and mottled skin , lethargy, and may be hypotension E mergent intravenous (IV) fluid therapy should begin with rapid infusion of 20 mL/kg of isotonic  saline over 5-10 minutes, repeated as needed based on clinical response . In DKA, if patient is in a volume-depleted state, the initial fluid bolus is 10 mL/kg which needs to be given slowly

16. Moderate hypovolemia   For children with marked moderate hypovolemia ( eg , estimated volume depletion >7 percent), especially if they have been unable to take oral fluids, emergent fluid administration may be 10 mL/kg is given over 30 to 60 minutes . In most cases, a bolus of with reassessment to decide on administration of a repeat IV bolus versus transition to oral therapy. 

17. H ypovolemic S hock is characterized by inadequate tissue perfusion from decreased intravascular volume as the result of fluid loss and/or inadequate fluid intake. Sources of volume loss that can lead to hypovolemic shock include the following : - Diarrhea and/or vomiting - Hemorrhage - Osmotic diuresis ( eg , hyperglycemia) - Capillary leak ( eg ,, intraabdominal processes with third space losses [ eg , pancreatitis,, appendicitis], or burn injury) Inadequate fluid intake Insensible losses ( eg , fever or burns)

18. F luid resuscitation in H ypovolemic S hock hypotensive hypovolemic shock - should receive 20 mL/kg per bolus of isotonic crystalloid(, such as normal  saline  or  Lactated Ringer   solution), infused over 5 to 10 minutes and repeated, as needed, up to  three  times in patients without improvement and  no  signs of fluid overload . Additional therapies, such as blood transfusion in patients with hypovolemic shock from hemorrhage, may be required depending upon the response to fluid administration .

19. H ypovolemic S hock compensated hypovolemic shock may receive 20 mL/kg per bolus of isotonic crystalloid, such as normal  saline  or  Lactated Ringer  solution, over 5 to 20 minutes. - Patients should be closely monitored during fluid administration Additional fluid boluses may be indicated depending upon the patient's response.

20. H ypovolemic S hock Refractory shock   In most children with hypovolemic shock, rapid improvement occurs with initial fluid administration. Children who have not improved after receiving a total of 60 mL/kg of isotonic fluid should be evaluated for other causes of shock. - Patients with apparent nonhemorrhagic hypovolemic shock may have associated conditions ( eg , septic shock, heart failure from myocarditis).

21. Further management considerations for children who have not improved after receiving 60 mL/kg of isotonic fluid include : 1 - Patients with hemorrhagic shock should receive blood and require definitive treatment for the cause of hemorrhage. Packed red blood cells should be infused in 10 mL/kg boluses. Delayed fluid resuscitation for traumatic hemorrhagic is not recommended for children.

22. 2- For children with nonhemorrhagic hypovolemic shock, the amount of fluid loss may have been underestimated (as with burn injury) or there may be significant ongoing fluid loss ( eg , from capillary leak with bowel obstruction). 3 -Colloid administration may be an option for patients with decreased arterial volume related to low intravascular oncotic pressure (as in nephrotic syndrome or other causes of hypoalbuminemia).

23. H ypovolemic S hock Vasoactive medications such as epinephrine or norepinephrine have  no  place in the treatment of isolated hypovolemic shock . These interventions do not address the underlying problem of inadequate circulating blood volume and may worsen tissue hypoxia

24. 2- Septic Shock:  fluid resuscitation is the cornerstone in the management of septic shock, various aspects of fluid therapy, viz., type of fluid, optimal volume, and duration of fluid bolus, are still debatable. Ideal fluid:   Crystalloids are the recommended fluids for initial resuscitation in septic shock Recent evidence indicates that use of balanced crystalloids like Ringer lactate or PlasmaLyte during resuscitation is associated with a lower risk of hyperchloremic acidosis, acute kidney injury (AKI), and overall mortality compared to crystalloids with higher chloride concentrations like 0.9% normal saline (NS)

25. Current ( The Surviving Sepsis Campaign ) SSC 2020 guidelines have also recommended the use of balanced salt solution over NS as bolus fluid therapy . However, NS continues to be the most commonly used resuscitation fluid because of issues with cost and availability. Synthetic colloids , as hydroxyethyl starch solutions, have been associated with increased risk of acute kidney injury, coagulopathy, and death in patients with septic shock. Use of albumin is associated with better outcomes and is recommended in conditions with large fluid losses in third spaces, like dengue . The latest guidelines recommend against the use of colloids in the management of sepsis and septic shock

26. Septic Shock: Volume of fluid bolus :   The SSC 2020 guidelines have recommended 40–60 mL/kg of bolus fluid in 1 h (10–20 mL/kg per bolus) can be given in the presence of intensive care facilities, while only 40 mL/kg of bolus fluid in 1 h is recommended if hypotension is present . - N o fluid bolus : if hypotension is not present where these facilities are not available

27. Septic Shock: - Method of fluid administration :  The rapidity with which a fluid bolus can be administered is still unknown, with the recommendations for pushing fluids as fast as possible in the presence of hypotension. In two pediatric RCTs, greater rates of intubation, mechanical ventilation, and hepatomegaly were observed in the group where bolus fluid was administered over 5–10 min compared to when administered over 15–20 min . However, there was no difference in mortality in both groups . The current recommendations advocate a slower rate of fluid bolus administration, particularly in resource-limited settings.

28. Children with complicated heart disease, prior heart failure or risk for cardiomyopathy should begin fluids at 5-10 mL/ kg over not less than 20 minutes , with frequent monitoring for overload signs.

29. Septic Shock: Assessing fluid overload:   While early fluid resuscitation in septic shock improves organ perfusion, it leads to fluid accumulation in later stages, causing fluid overload. Studies have revealed that cumulative fluid overload > 10% is associated with increased mortality Restrictive blood transfusion is recommended not to transfuse packed red blood cells (PRBC) in hemodynamically stable patients with hemoglobin > 7 g%.

30. Septic Shock: - Vasoactive Medications : Patients with septic shock should be started on vasoactive medications in the presence of signs of poor perfusion, even after 40–60 mL/kg of fluid boluses and earlier on development of signs of fluid overload or other concerns for fluid administration. Common agents used in children with septic shock are norepinephrine, epinephrine, dopamine, dobutamine and vasopressin. The evidence to support the use of one specific vasoactive drug over another in children is limited.

31. Vasoactive Medications in septic shock There is no RCT comparing epinephrine and norepinephrine. Epinephrine use has been associated with lower mortality compared to dopamine in 2 RCTs The latest Surviving Sepsis Campaign guidelines in children recommended using either epinephrine or norepinephrine, rather than dopamine in children with septic shock. In patients requiring high-dose catecholamines, vasopressin receptor agonists can be added

32. Adrenaline is indicated for cold shock (0.05 up to 0.3 μg /kg/min) in an attempt to optimize cardiac contractility due to its beta-agonist effect at these dose ranges. - For warm shock, alpha agonists (0.1 μg /kg/min and higher doses) are recommended. Other vasoactive drugs may be used looking for specific hemodynamic effects: inotropes, such as milrinone, to improve contractility, or vasopressors, like vasopressin, in case of vasodilation uncontrolled with noradrenaline

33. 3- Cardiogenic Shock: Cardiogenic shock is a state in which oxygen delivery to the tissues is insufficient relative to body needs, secondary to poor cardiac function. The initial principles of shock resuscitation apply to cardiogenic shock, which include stabilization of airways and breathing, fluid resuscitation, and inotropic support, and supportive management.

34. Cardiogenic Shock: Fluid resuscitation is needed immediately to correct hypovolemia and hypotension situation with precaution of pulmonary edema in cardiogenic shock, fluid bolus volume and rate need to be reduced to 5–10 mL/kg of crystalloid fluid over 20–30 min to prevent the burden on already failing heart with early use of inotropes. The fluid bolus should be altogether avoided in conditions with evidence of increased right ventricular filling pressures, like congestive heart failure

35. Vasoactive medication in cardiogenic shock Dopamine may be the first option to treat mild to moderate cardiogenic shock Dobutamine with noradrenaline are currently recommended as the first choice of inotropes in cardiogenic shock with adrenaline to be used in inotrope resistant shock Milrinone or dobutamine is the first choice to treat acute severe cardiac failure in the absence of hypotension. If cardiogenic shock is complicated by severe hypotension, epinephrine or norepinephrine is preferred depending upon the hemodynamics and myocardial function.

36. fluid-refractory shock in Cardiogenic shock When a child has fluid-refractory shock and presents with signs of poor perfusion and hypotension with vasoconstriction (mottled skin, delayed capillary refill), vasoactive medications should be used to improve blood pressure by increasing myocardial contractility with minimal vasoconstriction. The vasoactive medication of choice for fluid refractory “ cold” shock is epinephrine. The infusion rate should be 0.03-0.2 mcg/kg/min.

37. Distributive Shock Anaphylactic shock requires airway and breathing management, fluid resuscitation, immediate administration of I/M or I/V adrenaline, and removal of the inciting agent. IM Epinephrine  is the first and most important treatment for anaphylaxis, and it should be administered as soon as (0.01 mg/kg (maximum dose of 0.5 mg) per single dose IM  epinephrine  may be repeated at 5- to 15-minute intervals if there is no response or an inadequate response or even sooner if clinically indicated When additional IM doses are required, typically one or rarely two additional doses are needed [second dose was necessary in 12 to 36 % of cases)

38. Anaphylactic shock Intravenous epinephrine continuous infusion and indications   -  Patients who do not respond to several IM injections of  epinephrine   and  aggressive fluid resuscitation may not be adequately perfusing muscle tissues, as most commonly occurs in individuals presenting with profound hypotension or symptoms and signs suggestive of impending shock (dizziness, incontinence of urine and/or stool).

39. Refractory anaphylaxis No improvement in respiratory or cardiovascular symptoms after 2 dose of IM adrenalin Guideline 2021 by resuscitation council of UK : Should be start with fluid resuscitation by IV , start with 10 ml/kg normal saline 0.9% pre bolus over 5-10 minutes and repeated, as needed IM epinephrin should be to give every 5 minutes till IV epinephrin infusion has been started Peripheral low dose of adrenalin infusion ( 1mg ) in 100ml of 0.9% normal slain , start with is 0.5-1 ml/kg/h Monitoring and observation is mandatory - high BP likely indicate adrenalin overdose

40. conclusion The decisions surrounding resuscitation with intravenous fluids vary according to disease states in sick children.  Isotonic saline is still the fluid of choice for resuscitation. There is some evidence supporting balanced salt solutions in resuscitation, but more studies are needed. Fluid overload has been recognized as a risk factor for increased morbidity and mortality , especially in patients with heart disease and impaired renal function.