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Refractory shock in children

A short presentation
by

Usha Pratap

on 31 January 2014

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Transcript of Refractory shock in children

Refractory shock
Dr Usha Pratap Paediatric Cardiologist Pune
Some books are to be tasted, others swallowed, few to be chewed and digested.....Sir Francis Bacon
and-this is true for some articles too
2002 Guidelines -Goal directed therapy
2007-Update
1st hour--fluids and inotropes to achieve
-Threshold HR
-Normal BP
-CRT<2 sec
Subsequent therapies to achieve
-MVO2 >70%
-CI 3.3-6.6 L/min/m
Threshold HR MAP-CVP

Term newborn 120-180 55

Upto 1 yr 120-180 60

Upto 2 yrs 120-160 65

Upto 7 yrs 100-140 65

Upto 15 yrs 90-140 65







Refractory shock despite goal directed use of inotropic agents
vasopressors
vasodilaters
metabolic homeostesis(glucose,Ca)
hormonal homeostasis(thyroid/steroid/insulin)
ACCM -Hemodynamic definitions of
shock
Fluid refractory/dopamine resistant shock-Shock despite >60 ml/kg fluid+dopamine at 10
Catecholamine resistant shock-Shock despte direct acting catecholamines
Cold or warm shock-Decreased perfusion/altered mental status/abnormal CRT/decreased UOP
PDE inhibitors-Milrinone
BP=SVR*CO
HR*SV
Recognize decreased perfusion/cyanosis/RDS
Maintain airway and establish access
Initial resuscitation
Push NS 20 ml/kg~upto 60ml/kg(Watch liver)
Correct glucose/give Ca
Start antibiotics

Fluid refractory shock
Cold shock-Dopamine 5-9mcg/kg/min


Fluid refractory dopamine resistant shock
Add adrenaline~0.05-0.3mcg/kg/min

Warm shock(check MVO2)-add noradrenaline
Catecholamine resistant shock
Monitor CVP
Attain normal MAP-CVP
Check MVO2-70%
SVC flow > 40ml/kg/min
CI 3.3L/m2/min
Start hydrocortiisone(random cortisol levels)
1st hour goals
Restore and maintain HR threshold
CRT<2
Normal BP
Cold shock with normal BP
if MVO2 < 70%
SVC flow < 40ml/kg/min
CI <3.3L/m2/min
Add vasodilater(Milrinone/SNP)
? Levosimendan
Cold shock with low BP
Titrate fluids/adrenaline to- MVO2>70%
Consider milrinone
Noradrenaline-once MVO2 better ONLY
Warm shock with low BP
Add volume and noradrenaline
Consider vasopressin to keep SVC flow > 40ml/kg/minCI 3.3L/m2/min
Low dose adrenaline

Refractory shock
Rule out pericardial effusion, pneumothorax
Get monitoring lines-
Start T3 for relative hypothyroidism


ECMO-extracorporeal membrane
oxygenation
Goals after 1st hour
Restore and maintain HR threshold
Normal BP
Neonatal circulation
SVC flow > 40 ml/kg/min
CI > 3.3
Therapeutic end points
CRT< 2
Normal pulses with no difference between peripheral and central pulses
Warm extremities
Normal mental status,
Sats > 95%
MVO2 > 70%
Normal lactate levels
Hb > 12
UOP> 1 ml/k/hr(Good cardiac output needs 3-4 ml/kg hr)
Normal glucose and ionised Ca
Fluid overload < 10%

Tight glycemic control-use insulin if required
Immune paralysis-happens 3 days after presentation
? Dopamine related
GM CSF treats it

Hemophagocytic syndrome
Thrombocytopenia,inc LDH,inc ferritin--plasmapheresis

Sequential diuretics-to acheive UOP of 3-4 ml/kg/hr-Peritoneal dialysis-to reduce fluid overload
Hydrocortisone-stress dose/shock dose
Thyroxine-T3 is an inotrope(makes beta receptors)
Preload
Afterload
Contractility
Dopamine,dobutamine
Adrenaline
PDE 3 inhibitor-Milrinone
Unusual in neonates
In utero-85% CO bypasses lungs
PVR high--can remain high~6 wks
RV failure can occur easily
Mechanical ventilation
Supports circulation-as 40% of CO used for breathing when sick
Get central access
Monitoring
Pulse oximetry
ABG
VBG /lactates/anion gap
Echo
Doppler-SVC flows in VLBW
Input-output
ECG
Continuous intra arterial BP
Glucose and Ca( ABG values are fine)

Survival-80%
Indication-Refractory shock+
PaO2 < 40
Avoid secondary infection
Prevent gut colonisation with hospital bugs
HAND WASHING
Strict antibiotic policies
Maintain a culture of getting cultures
Check and correct vitamin D status

Thank you :)
V1a receptor stimulationBaroreceptor inactivation in sepsis/autonomic failure enhances vasopressin-induced vasoconstrictionPotentiation of vasopressor effects of catecholaminesDirect inactivation of KATP channels in vascular smooth muscleAVP blunts NO- and ANP-induced increases in cGMPAVP inhibits the function of iNOSOrgan-specific heterogeinity of vascular responsiveness: at low doses, AVP stimulates oxytocin receptor-induced endothelial production of NO in the brain and coronary arteries
Increase in the rate of - and -adrenoreceptor and adenylate cyclase gene transcription Increased density of - and -adrenoreceptors and enhanced expression of adenylate cyclase Inhibition of iNOS gene activation and cytokine/chemokine production
Genomic effects of steroids
Crit care Medicine 2009-vol 37, No 2
Beta receptor
Zero minutes
Five minutes
15 minutes
6o minutes
Stimulate a beta receptor
-->
activates adenylate cyclase
-->
increase calcium entry
-->
chronotropy
-->
inotropy
-->
Adenylate cyclase degraded by PDE
-->
end of effect
Sympathomimetics
PDE inhibitors
Calcium
Full transcript