management of shock.pptx including anaphylactic shock, suviving sepsis guidelines

The presentation is made by me with data references from nelson, piyush gupta and some recent articles.

1. MANAGEMENT OF SHOCK Under the guidance of- Dr. Prachi Chaudhary Dr. Dharmanshu chaube Presented by- Dr. Sanchi

2. Objectives of presentation To briefly understand different types of shock and its pathophysiology To understand the clinical signs of shock. To manage according to different types of shock.

3. SHOCK is an acute process characterized by the body’s inability to deliver adequate oxygen to meet the metabolic demand of vital organs and tissues. It is important to recognise shock and initiate therapy before it causes irreversible damage to vital organs.

4. Quick History A quick history to be taken to get an idea to categorize the type of shock the patient has presented with History of: 1. Excessive fluid loss because of diarrhea /vomiting /blood loss due to trauma 2. Environmental exposure/allergies / potential drug ingestion 3. Previous medical problems , known case of congenital/acquired heart disease 4. History of fall /trauma leading to spinal cord injury /severe brainstem injury 5.Fever , features suggestive of infection and circulatory collapse

5. Types of shock SHOCK HYPOVOLEMIC SHOCK DISTRIBUTIVE SHOCK CARDIOGENIC SHOCK OBSTRUCTIVE SHOCK SEPTIC SHOCK ANAPHYLACTIC SHOCK NEUROGENIC SHOCK

6. Pathophysiology of different types of shock Hypovolemic Cardiogenic Distributive Septic Obstructive Decreased preload secondary to internal or external losses Cardiac pump failure secondary to poor myocardial function Abnormalities of vasomotor tone from loss of venous and arterial capacitance Encompasses multiple forms of shock Hypovolemic : third spacing of fluids into the extracellular ,interstitial space Distributive : early shock with decreased afterload Cardiogenic: depression of myocardial function by endotoxins Decreased cardiac output secondary to direct impediment to right or left heart outflow or restriction of all cardiac chambers

7. Potential etiologies of different types of shock Hypovolemic Cardiogenic Distributive Septic Obstructive Blood loss :hemorrhage Plasma loss:burns , nephrotic syndrome ; Water /electrolyte loss : Vomiting ,diarrhea Congenital heart disease Cardiomyopathies infectious or acquired, dilated or restrictive Ischemia Arrhythmias Anaphylaxis Neurologic ;loss of sympathetic vascular tone secondary to spinal cord or brainstem injury Drugs Bacterial Viral Fungal (immunocompromised patients are at increased risk ) Tension pneumothorax Pericardial tamponade Pulmonary embolism Anterior mediastinal masses Critical coarctation of aorta

8. Management of Shock

9. SIGNS OF SHOCK Poor Peripheral pulse Narrow pulse pressure Cold extremity Prolong CRT Tachycardia Tachypnea Decreased level of consciousness Hypotension (late finding) Decrease urine output

10. LABORATORY STUDY IN SHOCK Helps to: To assess severity of shock Evaluate for organ dysfunction Identify metabolic derangements Evaluate response to therapy

11. INVESTIGATIONS CBC BLOOD GLUCOSE SERUM ELECTROLYTES BLOOD UREA/CREATININE SERUM LACTATE LEVELS ABG COAGULATION PROFILE X-RAY CHEST APPROPRIATE MICROBIOLOGICAL STUDIES

12. LABORATORY FINDINGS Lab findings often include hematological abnormalities and electrolyte disturbances. Hematological abnormalities – can have anemia , thrombocytopenia, elevated neutrophil counts and increased immature forms, toxic granulations. Glucose dysregulation ( hypoglycemia / hyperglycemia ) Metabolic acidosis Hypocalcemia Hypoalbuminemia Hyperkalemia

13. PRINCIPLES IN MANAGEMENT OF SHOCK Increase blood oxygen content Improve cardiac output Reducing Oxygen Demand Correcting Metabolic Derangements Identify and reverse the underlying cause of shock

14. GOAL DIRECTED STEPWISE MANAGEMENT OF HEMODYNAMIC SUPPORT IN INFANTS AND CHILDREN WITH SHOCK

15. Recommendation: Initial resuscitation and Hemodynamic Support Initial Resuscitation- Goals during 1 st six hours of resuscitation: Central venous pressure= 8-12mmHg Mean arterial pressure= >65mmHg Urine output= >0.5ml/Kg/hr Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65% respectively.

16. MANAGEMENT OF HYPOVOLEMIC SHOCK Positioning Airway and Breathing Vascular access Fluid Resuscitation Monitoring Laboratory Studies Medication

17. 1 .POSITIONING 2.AIRWAY AND BREATHING : oxygen support Ventilatory support should be given if required (invasive/non invasive) 3.VASCULAR ACCESS: Peripheral vein cannulation Intraosseous route (if iv line cannulation is not possible) Central venous line placement for large volume resuscitation.

18. 4.FLUID RESUSCITATION: TYPES OF FLUID- ISOTONIC CRYSTALLOID SOLUTION : -Fluid of choice (NS or RL) studies have shown that crystalloids containing high chloride concentration (e.g. 0.9%NS) is associated with hyperchloremic acidosis, systemic inflammation , AKI, coagulopathy, mortality when compared to more balanced crystalloids (e.g. ringer’s lactate) COLLOID SOLUTION :- -FFP, 5%albumin or Dextran 40 dextran 60 May cause Hypersensitivity Reaction.

19. Can consider colloid administration if after administration of multiple bolus of crystalloid condition does not improve. May be used in condition related to DECREASED plasma oncotic pressure: Malnutrition Hypoprotenemia Nephrotic syndrome

20. B. RATE AND VOLUME: FLUID RESUSTITATION TYPES OF SHOCK VOLUME OF FLUID RATE OF DELIVERY HYPOVOLEMIC SHOCK AND DISTRIBUTIVE SHOCK 20 ml/kg reassess (Repeat as required) Over 5 to 10 mins CARDIOGENIC SHOCK OBSTRUCTIVE SHOCK 5-10 ml/kg reassess Over 20-30 mins

21. FLUID RESUSTITATION Give bolus 20ml/kg over 5-10mint.(3 TIMES) Reassess and repeat bolus on basis of assessment of HR, pulse volume, capillary refill time, level of consciousness If suspecting cardiogenic shock ,monitor for worsening tissue perfusion, stop infusion if there is hepatomegaly, basal crepitations and worsening level of consciousness.

22. Failure To Improve After 3 Boluses Indicate 1.Extent of fluid is underestimated 2.Type of fluid replacement to be altered 3.There are on going loses 4.Etiology of shock is other than hypovolemia

23. AFTER FLUID THERAPY, IF THERE IS- Deterioration in child’s condition ↓ Cardiogenic or Obstructive shock Increased work of breathing ↓ Pulmonary Edema Persistently delayed CRT ↓ Ongoing Hemorrhage Or Fluid Loss

24. INDICATION FOR BLOOD PRODUCTS Known significant blood loss Anemia (<7gm) Use 10 ml/kg PC or 20 ml/kg whole blood.

25. 5.MONITORING IN SHOCK Oxygen Saturation Heart Rate Pulse volume Blood Pressure Mental status Temperature Urine Output

26. 6.SUPPORTIVE MANAGEMENT A)REDUCE OXYGEN DEMAND Decrease work of breathing by using assisted ventilation when indicated Control fever by cooling & antipyretics Decrease pain & anxiety: use analgesics & sedatives judiciously B) CORRECT METABOLIC DERANGEMENTS Correct hypoglycemia / hyperglycemia , hypocalcemia with iv calcium gluconate and metabolic acidosis with sodium bicarbonate.

27. FLUID REFRACTORY SHOCK If there is no improvement in hypotension & perfusion despite rapid and aggressive administration of isotonic fluid. Administer vasopressor or vasoactive therapy

28. PHARMACOLOGICAL AGENTS CLASS DRUG EFFECT INOTROPES DOPAMINE EPINEPHRINE DOBUTAMINE ↑ Cardiac contractility ↑ Heart rate Produce variable effects on SVR PHOSPHODIESTERASE INHIBITORS (INODILATORS) MILRINONE AMRINONE ↓ Afterload Improve coronary artery blood flow Improve contractility VASODILATORS NITROGLYCERINE NITROPRUSSIDE ↓ Afterload ↓ Venous tone VASOPRESSORS EPINEPHRINE NOREPINEPHRINE DOPAMINE VASOPRESSIN ↑ SVR Vasopressin is a pure vasoconstrictor

29. INOTROPIC SUPPORT DRUGS EFFECTS DOSE RANGE COMMENTS DOPAMINE 1ml=40mg Strengthen contractions(in all dose range) Increases renal blood flow (low/intermediate dose) Vasoconstriction(high dose) Low dose=0.5-4mcg/kg/min D1/D2 augmentation of renal, mesenteric and coronary vasodilatation Intermediate dose=5-15 μ g/kg/min (beta receptor) increase myocardial contractility High dose=15-25 μ g/kg/min (alpha receptor)increase systemic and pulmonary artery pressure. Increase myocardial oxygen consumption and risk of arrythmia at high doses. DOBUTAMINE 1ml=50mg Increases strength of heart contraction ,peripheral vasodilator. 1-20 μ g/kg/min Good for cardiogenic shock, ideal for myocardial dysfunction.

30. DRUGS EFFECTS DOSE RANGE COMMENTS EPINEPHRINE 1ml=1mg Increase cardiac contractility & heart rate. Potent vasoconstrictor. DOSE 0.05-3 μ g/kg/min may lessen renal perfusion. causes high O2 consumption in heart. high risk of arrhythmia, peripheral gangrene, NOR EPINEPHRINE 1ml=1mg Potent vasoconstriction No significant effect on cardiac contractility. 0.05-1.5 μ g/kg/min increase in blood pressure secondary to inc in SVR. high risk of arhythymia MILRINONE Increases Myocardial Contractility and Reduces preload and afterload by relaxation of Vascular Smooth Muscle. Load 50 mcg/kg over 15 mins followed by 0.5-1 mcg/kg/min . Can cause Hypoxemia, Hypotension, Angina, Hepatotoxic, Thrombocytopenia

31. GOALS: Increase Effectiveness of Cardiac Function Minimizing Metabolic Demand. It has to be wisely judged that many children with cardiogenic shock have high preload and do not require additional fluid therapy , while others require cautious fluid therapy to increase preload. O ne effective way to increase stroke volume is to reduce afterload(SVR)(however pt has to be normotensive) rather than giving inotropic agents. MANAGEMENT OF CARDIOGENIC SHOCK

32. MANAGEMENT OF CARDIOGENC SHOCK Cautious Fluid Administration : 5-10 ml/kg over 20-30 mins Medications 1. Dobutamine-1-10mcg/kg/min 2. Dopamine-5-20 mcg/kg/min 3. Epinephrine-0.05-3mcg/kg/min

33. 4 . Milrinone--50 mcg/kg loading over 15 mins than 0.5-1 mcg/kg/min 5 . Amrinone - loading dose 0.75-1mg/kg than infusion @ 5-10 μ g/kg/min 6 . Nitroprusside-0.5-4mcg/kg/min 7 . Nitroglycerine-1-20 mcg/kg/min

34. Management of Neurogenic shock Position the child flat or head- down to improve venous return. Administer a trial of fluid therapy ( isotonic crystalloid) and assess response. For fluid – refractory hypotension , use vasopressor (e.g.; NE, epinephrine) as indicated. Provide supplementary warming or cooling as needed.

35. MANAGEMENT OF ANAPHYLACTIC SHOCK Initiate supplemental oxygen. Fluid bolus Treatment of choice – intramuscular epinephrine by 0.1ml/kg of 1: 10,000 dilution every 3-5 minutes with maximum dose of 1mg. If hypotension is refractory to epinephrine bolus; start epinephrine infusion at 0.1mcg/kg/min. Supplementary warming/cooling

36. SPECIFIC MANAGEMENT OF OBSTRUCTIVE SHOCK Ductal Dependent CHD- Prostaglandin E1 Tension Pneumothorax –Needle thoracotomy in the 2 nd intercostal space in mid clavicular line at 90 degrees angle using under water seal. Definitive treatment- ICD placement. Cardiac Tamponade - Pericardiocentesis Pulmonary Embolism- Thrombolysis +Anticoagulants or thrombectomy.

37. Q. An 3 year old presents to the ER with a c/o fever 8 days. O/E – Pt is irritable, axillary temp is 103.7 , heart rate 164, RR is 56 with increased work of breathing, blood pressure 70/50 , pulses are bounding with peripheries that are warm and flushed, capillary refill <3sec . blood chemistry drawn on arrival shows lactic acidosis . The child is most likely in: i ) Hypovolemic shock ii) Distributive, neurogenic shock iii) Distributive, septic shock iv) Obstructive shock CASE SCENARIO

38. SEPTIC SHOCK Sepsis is defined as SIRS resulting from a suspected or proven infectious etiology . Severe sepsis- presence of sepsis combined with organ dysfunction. Septic shock- severe sepsis plus the persistence of hypoperfusion or hypotension despite adequate fluid resuscitation or a requirement of vasoactive agents. It can lead to MODS and possibly death .

39. PRINCIPLES OF MANAGEMENT OF SEPTIC SHOCK Early goal directed therapy (EGDT) Antimicrobial therapy and source removal Interventions to enhance host responses. Management of organ dysfunction .

40. SURVIVING SEPSIS CAMPAIGN GUIDELINES FOR MANAGEMENT OF SEPTIC SHOCK

41. SURVIVING SEPSIS CAMPAIGN : CARE BUNDLES To be completed within 1 hr: Measure lactate level Obtain blood cultures Administer broad spectrum antibiotics Administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L.

42. To be completed within 6 hr Apply vasopressors to maintain a MAP ≥65 mmHg. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mol/L: Measure central venous pressure Measure central venous oxygen saturation Remeasure lactate if initial lactate was elevated.

43. ANTIMICROBIAL THERAPY AND SOURCE REMOVAL Recommended to administer broad spectrum antibiotics within 1 hour of presentation with septic shock. Blood cultures should be withdrawn before administration of an antibiotic. Start with a 3 rd gen cephalosporin and an aminoglycoside. Vancomycin should be added if suspecting staphylococcus infection. Clindamycin is recommended in toxic shock syndromes.

44. Role Of Steroids If hemodynamic stability is not restored after administration of fluids and vasoactive drugs, administration of inj hydrocortisone can be considered. Children at risk for adrenal insufficiency. (who have received steroids for chronic illness in the past and those with pituitary and adrenal abnormalities) Give i.v.HYDROCORTISONE 1-2mg/kg or 50-100mg/m2 (max 100 mg) either given continuously or divided every four to six hours. Adrenal insufficiency may be present if random cortisol level is<18mcg/dl (496nmol/L)

45. THERAPEUTIC END POINTS OF RESUSCITATION Normalisation of heart rate Normal BP and pulse pressure. Normovolumic peripheral pulses. CRT<3 seconds Warm extremities Urine output >1ml/kg/hr Decreased Serum Lactate and scvo2 >/= 70% Reduced Base Deficit Return to baseline mental status.

46. PROGNOSIS Aggressive management of shock especially hypovolemic , can be quite rewarding. However, septic shock still has a case fatality rate of more than 50 percent. Adverse outcome is anticipated in following situations : Multiple organ failure Major myocardial damage Coagulopathy and DIC Renal failure Respiratory failure Uncontrolled sepsis Ongoing blood loss

47. REFERENCE NELSON – 21 st edition volume 1 PALS – Pediatric advanced life support EMERGENCY IN PEDIATRICS – Meharban singh AIIMS PICU PROTOCOL.

48. THANK YOU