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Pediatric shock treatment :open_mouth: (:beginner: Initial therapy (:tada:…
Pediatric shock
treatment
:open_mouth:
:goal_net:
Goal
Reverse circulatory insufficiency & Correct hypoperfusion state
:stars:
early regconition & timely intervention
:!: compensatory mechanism may
mask
signs of tissue hypoperfusion esp young host
:heartbeat:
Principle
:arrow_up: O2 delivery & :arrow_down: O2 demand
by O2, Fluid, Temp control, Empirical ATBs, Correct metabolic abnormalities, Inotropes, Spare WOB (work of breathing)
:beginner:
Initial therapy
A
irway
#
O2 therapy
must be first step
:grey_question:Intubation & ventilation decision?
based on
:arrow_up: work of breathing
Note that: up to 40% of CO is used for WOB
Hypoventilation
Impaired mental status
B
reathing: supply 100%FiO2 via bag valve mask
C
irculation
Must obtain vascular access + give
fluid
ทันที
:potable_water:
Fluids
Consider scene time
Consider
intraosseous access
Fluid bolus 20cc/kg load
➯ may give up to
60-80 ml/kg of fluid
as needed
M/C error: Too little fluid
Reassess for Improved perfusion & Respiratory distress
Septic
shock: ให้ได้มากถึง
200cc/kg in 1st hour
:coffee:
Choices of Fluid
Isotonic crystalloid: Extravascular volume (interstitial space) & Correct Na
but intracellular volume 25%
:star: NSS - 1st line for initial resus 20 cc/kg/dose ➯ if 3 doses แล้วไม่ขึ้น ➯ uses Colloid
Colloid solution: Hold intravascular volume
5% Albumin
Fresh frozen plasma (FFP) - ดีสุด หาง่ายสุด ช่วย hold volume
Synthetic plasma expander
: Dextran, Hetastarch
!!! Coagulopathy when use > 40 ml/kg
Effectively restore BP esp in young neonate
:warning: Concern adverse effects of natural or synthetic colloids eg. Allergic reaction, Bleeding
if low Hct ➯
packed RBCs
:goal_net:
goal
: to maintain perfusion pressure above the critical pt of individual organs
:star:
Reassess ABCs
(vital signs & PE)
ATBs
for Septic shock (
within 1 hr after pt comes to hospital)
or Unclear etio
Laboratory
:warning: for
DIC
:!:
:tada::
End points
of Resuscitation of Septic shock
Cap refill ≤ 2 secs
Normal CVP for age
Normal BP or MAP for age
Normal pulses (no differential between peripheral & central pulses)
Urine output > 1 mL/kg/1 hr and Normal mental status
Superior vena cava Oxygenation saturation (ScvO2) 70%
Mixed venous Oxygenation saturation (SvO2) 65%
:pill:
Medications
— TBC
:heartpulse:
Rapid cardiopulmonary assessment
PE — Circulation
Age 0-1 mo: 5th percentile SBP = 60 mmHg
Age >1 mo to 1 yr: 5th percentile SBP = 70 mmHg
Age > 1 yr: 70 + (2 x age in year)
:pear:
Supportive care
Tredelenberg position
:arrow_up: O2 content: O2, blood transfusion, intubation
Fluid bolus (as I/C)
Following 60 ml/kg of fluid ➯ strongly consider
positive inotropic agents
(peripheral inotrope, no vasopressors) until central line access
Early broad-spectrum ATBs — obtained in Suspected sepsis
Glycemic control
:shamrock:
Def
Fluid refractory
Shock: pt still in shocked condition ขณะที่ alrdy received fluid 40-60 ml/kg
Catecholamine resistant
Shock: pt still in shocked condition ขณะที่ alrdy received catecholamine — Dopamine 10 mcg/kg/min or Epinephrine 0.3 mcg/kg/min or Norepinephrine 0.1 mcg/kg/min
Refractory
Shock: pt still in shocked condition ขณะที่ได้รับ inotropic agent, vasopressor, vasodilator including การรักษาสมดุลของร่างกายทั้งด้าน Metabolic
:izakaya_lantern:
Vasoactive support
:snowflake:
Cold shock
Shock type that :arrow_down: CO & :arrow_up: SVR
Clinical
picture: ตัวลาย, มือเท้าเย็น, cap refill > 2 sec, pulse เบาเร็ว, Altered mental status or Urine output < 1 ml/kg/hr
:four_leaf_clover:
Mx
Consider starts
Epinephrine
0.05-0.3 mcg/kg/min peripheral IV or
Dopamine
5-9 mcg/kg/min
If Cold Shock that receive both
fluid & catecholamine
then found
Hypotension & ScvO2 < 70% & Hb > 10 gm/dL ➯
consider
Norepinephrine
0.05 mcg/kg/min
Normal BP
but
ScvO2 < 70% & Hb > 10 mg/dL ➯
consider
vasodilator
like
Milrinone
0.25-0.75 mcg/kg/min
or
Levosimendan
0.05-0.2 mcg/kg/min
:fire:
Warm shock
Shock type that :arrow_up: CO & :arrow_down: SVR
Clinical
picture: ตัวแดง, มือเท้าอุ่น, ชีพจรเต้นเร็ว + แรง (bounding pressure), wide pulse pressure with
Low DBP
—(DBP < 1/2 of SBP), Altered mental status or Urine output < 1 ml/kg/hr
:four_leaf_clover:
Mx
Consider starts
Norepinephrine
0.05 mcg/kg/min or
Dopamine
> 10 mcg/kg/min
:question:
Not sure which type of Septic Shock
Consider starts
Epinephrine
0.05-0.3 mcg/kg/min ไปก่อน
:rice_ball:
Catecholamine resistant shock
Def: Pt sill shock despite receiving catecholamine & normal BP
but also got cardiac pumping problem
(or Cardiac index < 3.3 L/min/m2)
Consider starts
Dobutamine
5-20 mcg/kg/min
:zzz:
Sedation/Analgesia
Consider Ketamine & Atropine
before procedure
Consider use of Fentanyl > Morphine
Appropriate sedation & analgesia for children who are mechanically ventilated —are standard care
Etomidate
— not recommended for intubation (induced adrenal insufficiency)
Not recommended propofol & barbiturate drugs
:red_circle:
Blood products administration
Transfusion threshold in children still unknown (> 10g/dL)
Prolonged INR recommended
FFP
Not recommended Activated protein C
DVT prophylaxis
is recommended
:yellow_heart:
Steroid
Relative adrenal insufficiency - common in PICU
Routine Rx of ped. pt with steroid
can’t be recommended
:check:
I/C
Catecholamine-refractory shock
Risk factors
— eg. Hx of Chronic or Recent high dose steroid Rx, Purpura fulminans
Adrenal insufficiency
:gift:
Renal Replacement Therapy
If Pediatric nephrologistis available
Should
starts CRRT when
AKI stage II
Suggest
starts CRRT when
AKI stage III, Untreated metabolic acidosis, Untreated pulmonary edema or Severe hyperkalemia
Type of CRRT
Unstable pt: CRRT, PD
Stable pt: CRRT, IHD
:small_red_triangle:
Blood replacement
PRBC 10 ml/kg
(keep Hb > 10 gm/dL)
Plt 0.2 U/kg
If plt < 50,000 + Active bleeding/invasive procedure
If plt < 20,000 + Coagulopathy
If plt < 10,000
FFP 10 ml/kg
Coagulopathy with bleeding or invasive procedure
:candy:
Glycemic control
10% Dextrose containing Isotonic solution can be run for maintenance IV
Titrating glucose/insulin for targeting blood glucose 80-180 mg/dL
:purple_heart:
Stress ulcer prophylaxis
For bleeding risk pt
Early enteral feeding
should be used if tolerate
:snowman:
ATBs therapy
Starts ATB within 1 hr
after Dx sepsis
(Empirical ATBs)
Blood culture at least 1 specimen
Pt inserted central line
> 48 hrs
➯ consider take Blood culture fr central line
If suspected UTI in pt
below 2 yr old
➯ rec. UA & U/C by urine catheterization