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Management of paediatric

shock fluids and inotropes


Allan Wardhaugh
Paediatric Intensivist
UHW Cardiff
Management of shock
Physiology
Basic clinical assessment
Laboratory and invasive clinical
assessment
Management
Fluid choice
Inotropes and vasopressors
Definition of Shock
Definition of Shock
Inadequate oxygen delivery to
tissues to meet demand because
of circulatory failure
Cause of shock
Not enough fluid in circuit

Sepsis

Haemorrhage

Dehydration

Maldistribution third spacing many causes


Pump failure

Sepsis

Cardiomyopathy/ myocarditis

Arrythmia
Inadequate oxygen carrying capacity

Anaemia

CO poisoning
Very low circuit resistance

AVM

Sepsis
Physiological aims of treatment
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
Physiology oxygen delivery

O2 delivery =[(1.34 Hb O2 sats) + (PO2 0.023)] CO

CO = HR SV
Oxygen supply dependence in
critically ill
Physiology fluid filled circuit and
Ohms Law
I = V/R
Flow = Perfusion pressure/
Resistance
Cardiac Output = MAP-CVP/ SVR

Perfusion pressure = CO
SVR Critical point

Aim of treatment prevent perfusion


pressure dropping below critical
point
Clinical assessment
Recognition - clinical
Tachycardia
Tachypnoea
Energy conservation
Relative inactivity
Vasoconstriction
CRT
Coreperipheral temperature gap
Organ hypoperfusion
Oliguria

Irritability, diminished consciousness


Hypotension
Distribution of cardiac output
Brain 13%

Skeletal Muscle 20%

Abdominal viscera 25%

Skin 10%

Kidneys 20%

Kidneys receive high proportion CO if urine is


flowing >0.5 1ml/kg/hr, cardiac output is
probably adequate
Has enough fluid been given?
Distribution of blood in circulation
Heart 5%
Systemic 80%
Arteries 10%
Veins 65%
Pulmonary 15%
Venous reservoir
Window on venous reservoir
Liver in neonates/ infants
Jugular venous pulse in older children
Response to hepatic pressure simulates
venoconstriction and fluid bolus
beware cardiogenic shock
Recognition - bloods
Base deficit > -4
Hyperchloraemia confounds after volume
resuscitation
Lactate >2.5 mmol/l

May signify poor tissue oxygen delivery


Beware other causes (metabolic, liver failure)
Mixed venous oxygen saturations
Venous PO2 reflects tissue oxygenation
Low values probably more reliable than high
Mixed venous sats > 70% imply adequate tissue
oxygenation
More invasive monitoring?
Once in ICU, clinical
parameters correlate
less well to cardiac
output
Cardiac output
estimation
TOE
PiCCO
Li dilution
et al

Tibby et al. Clinicians abilities to estimate cardiac index in


ventilated children and infants. Archives of Disease in Childhood 1997;77:
Management
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
ABC
Oxygen

A also stands for antibiotics


Ceftriaxone 80mg/kg
Management
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
Volume Volume Volume
Sepsis - >40ml/kg fluid volume in first hour
should almost certainly be ventilated
Early intubation and ventilation easier and safer
Prevents hypoxia
Facilitates line placement for adequate monitoring,
inotrope delivery
Restoring circulating volume
Blood volume 65ml/kg adult, 80-90ml/kg infant
40ml/kg corrects volume in most cases if
ongoing losses have stopped
Ongoing losses hidden in

Intra-abdominal/ intra-thoracic haemorrhage


IVH in neonates
Sepsis
Gut obstruction
Which fluid?
0.9% Saline or 4.5% Albumin
Meta-analysis 1998 flawed
Units reporting improving outcomes in sepsis
use 4.5% albumin routinely
More recent meta-analyses show no increased
mortality with albumin
0.9% saline cheaper
Albumin produces greater expansion in ECF and
plasma volume
Individual responses to this vary
SAFE study
MCRCT of 4% human albumin vs 0.9% saline 16 ICUs
Australia/ New Zealand.
Patients aged >18years and needed fluid resuscitation.
Randomised to have saline or albumin for duration of
stay in ICU, or 28/7.
Burns, liver transplant and cardiac surgery excluded.
Death at 28 days primary outcome.
3499 HAS, 3501 Saline.
Baseline characteristics of both groups similar.
SAFE fluid volume given
Which crystalloid?
Normal saline
Hartmanns solution
Crystalloid electrolyte composition
Na K Cl Other Tonicity

0.9% saline 150 0 150 308

0.45% saline/ 5% 75 0 75
dextrose
0.18% saline/ 4% 30 0 30 286
dextrose
Dextrose 5% 0 0 0 252

Hartmanns 131 5 111 lactate 280


Which colloid?
Albumin
Gelatins
Starches
Dextrans hypertonic
saline
Colloids
Fluid Notes Half life in
circulation
Gelofusine Made from horses. Anaphylaxis 4h

Dextran 70/ Relatively high risk of anaphylaxis compared to 12h


starch.
Saline 0.9%
Tetratsarch Associated with coagulopathy (reduces factor 17 days
VIII and vWF activity)
(Voluven) Hyperchloraemic acidosis.
Accumulates in RES long term effects
uncertain.
May reduce systemic inflammation, but it
needs to be given with additional free water.

Pentastarch Less effect on coagulation 18hr


(HemoHes)
Management
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
Haemodilution
Keep Hb > 10g/dL in resuscitation phase
Clotting factors FFP
Platelets

X Match at presentation
Haemorrhagic shock - lose blood
give blood?
Less O2 carrying capacity, but better than
clear fluid
3 for 1 rule using crystalloid to correct ECF
fluid shifts
Animal models suggest aggressive
volume resuscitation may be harmful
One RCT in adults promoted delayed fluid
resuscitation (Houston 1994)
Houston penetrating trauma study

8% in DR violated protocol (received volume)


Severity of shock varied from pulse barely palpable to systolic bp 90mmHg

Arrival bp higher in DR group
Deaths before theatre removed ( destined to die) no difference in
outcome
Times from injury to theatre short
NNT 12.5 ( 6.4 230) very wide confidence intervals

Bickell et al.Immediate versus Delayed Fluid Resuscitation for


Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med
1994; 331:1105-1109
Hypotensive resuscitation cannot
presently be recommended in
paediatric trauma
How much fluid?
Aggressive volume resuscitation associated
with improved survival in septic children
Only study to show a beneficial intervention in paediatric
septic shock observational study
Recruited all paediatric sepsis patients to ER in
Washington DC Childrens Hospital PA catheter in situ
by 6 hours
34 patients mean age 13.5 months
Divided into 3 groups by volume received in first hour
(post hoc)

Group 1 <20ml/kg

Group 2 20 40ml/kg

Group 3 >40ml/kg
Carcillo et al.

Carcillo et al. Role of early fluid resuscitation in


pediatric septic shock. JAMA. 1991;266:1242-1245
Mortality
Totals in each group
14 11 9
ARDS
Hypovolaemia at 6 hours
Management
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
Inotropes (and pressors)
Inotropes and pressors
Advantages Disadvantages
Improve pump function May increase afterload
Increase SVR Increase myocardial
improving perfusion oxygen demand
pressure Arrythmia
Increase diastolic BP Extravasation danger
improving coronary should go centrally
artery perfusion
When to start inotropes
Sepsis failure to respond to 40ml/kg fluid
in first hour
Mortality in paediatric septic shock
strongly associated with low cardiac
output
Will need adequate monitoring
Invasive BP if possible
Available inotropes and pressors
Natural catecholamines
Adrenaline
Noradrenaline
Dopamine
Synthetic catecholamines
Dobutamine
Phosphodiesterase inhibitors
Milrinone
Pure pressors
Vasopressin, terlipressin
Which inotrope?
Choice of inotrope
Personal preference prejudices common
remember this is class 4 evidence
No RCTs to rely on
Warm shock with good CO and low SVR
less common in children
Cold shock with low CO and normal or
high SVR more common some use
vasodilators
Management
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
Dopamine
Precursor of noradrenaline.
1, 1, 2, DA1, DA2 receptors.
5 15 mcg/kg/min 1 effects dominate
> 15 1 become important
> 25 1 dominates
Renal dose no such thing
Adrenaline
1, 1, 2.
0.05 0.3 g/kg/min 1, 2 > 1,
2 effects may cause balanced effect on SVR.

0.3 1 g/kg/min 1, 2 = 1

> 1 g/kg/min 1, 2 < 1

Disadvantage - increase in myocardial O2


demand and arrythmias
Dobutamine
Synthetic mixture of two stereo-isomers.
One isomer has effects, the other 1.
5 20 g/kg/min 1,2
Increases contractility, increases HR
May unmask hypovolaemia
SVR decreases. Direct coronary vasodilatory
effect.
>20 g/kg/min 1 dominates
Management
Get oxygen into the fluid
Get fluid in the circuit
Make sure the fluid can carry oxygen
Maintain adequate perfusion pressure
Maintain pump pressure
Optimise circuit resistance
Noradrenaline
1 and 1, with dominant 1 effects.
<0.5 g/kg/min 1 = 1
0.5 - 4g/kg/min 1 > 1
Use to maintain MAP improves urine
output and creatinine clearance in
paediatric hyperdynamic septic shock.
Milrinone

PDE III inhibitor


Small X-over trial showed benefit in
catecholamine resistant septic shock
Inotrope, improves diastolic function,
vasodilates
Long half-life, but loading dose usually
avoided by me
Vasopressin
Vasopressin deficiency in vasodilatory
shock
Adult trial showed reduced catecholamine
requirement with vasopressin
May have beneficial effects on coronary
circulation
Putting it all together -
goal directed treatment
Goal directed treatment in sepsis
first hour
Resuscitation goals
Maintain oxygenation
Maintain normal perfusion pressure (MAP CVP)
Maintain threshold heart rates
Therapeutic end points
CRT < 2 secs
Urine output > 1ml/kg/hr
Normal conscious level
Normal bp for age
Threshold values

Age (years) Heart rate MAP CVP MAP CVP


(Carcillo) (ESICM)
Term newborn 120-180 55 40

1 120-180 60 45

2 120-160 65 50

7 100-140 65 55

15 90-140 65 60
Goal directed treatment in sepsis
beyond first hour
Goals
Normal perfusion
Appropriate MAP-CVP (CVP 8 12mmHg)
SVC sats > 70%
CI >3.3 < 6.0 L/min/m2
0 5 mins Recognise shock
Airway support

20ml/kg colloid or 0.9% saline


Correct glucose, calcium
15 mins

Central venous access


Start Dopamine

Titrate Adrenaline (cold shock)


Titrate noradrenaline (warm shock)

60 mins
Hydrocortisone if risk of adrenal
insufficiency

Normal BP cold shock Low BP Cold shock Low BP Warm shock


SVC O2 sat < 70% SVC O2 sat < 70%

More volume More volume plus adrenaline More volume plus noradrenaline
Vasodilator or PDE III inhibitor Consider vasopressin

Cardiac output monitoring direct therapy to


Cardiac Index and MAP-CVP

ECMO
Does goal directed treatment work?
Goal directed treatment in sepsis
evidence of benefit
Detroit, RCT 263 adults
Randomised on arrival A + E and managed first 6 hours
standard vs goal directed
Targets for CVP, MAP, UO, SVC sats
In hospital mortality 46% standard vs 30% goal directed
NNT 4.8 (3 11)

Rivers E, Nguyen B, Havstad S et al. Early Goal-Directed Therapy in


the Treatment of Severe Sepsis and Septic Shock.
N Eng J Med 2001; 345:1368-1377
Goal directed treatment in sepsis
evidence of benefit children
100 consecutive paediatric septic shock (3
different hospitals) patients with PA
catheter by 6 hours
Goals targeted CI, SVR
Overall 80% 28 day survival.
Outcomes improved compared to
historical controls

Ceneviva G, Paschall JA, Maffei F, Carcillo J. Hemodynamic


support in fluid refractory pediatric septic shock. Pediatrics
Ceneviva G et al survival less
likely in low cardiac output group
Early management influences
outcome
9 year retrospective cohort 91 children
septic shock
Audited against standard ACCM septic
shock management guidelines

Han YY, Carcillo JA, Dragotta MA, et al. Early Reversal of Pediatric-Neonatal
Septic Shock by Community Physicians Is Associated With Improved Outcome.
Pediatrics 2003;112 793-799.
Case control study of fatal vs. non-fatal
meningococcal disease 1997-1999
145 cases; 355 controls
Factors associated with death
Not under care of paediatrician
Failure of supervision by a consultant
Failure in administration of inotropes

Ninis N, Phillips C, Bailey L et al. The role of healthcare delivery in


the outcome of meningococcal disease in children: case-control
study of fatal and non-fatal cases. BMJ 2005;330:1475
Practical advice septic shock
Volume paramount following basic ABC
Give 20ml/kg saline or albumin 4.5%,
reassess, repeat as often as needed.
If no response to 40ml/kg in first hour,
prepare to intubate and ventilate, start
dopamine 10mcg/kg/min (centrally if
possible)
Refer PICU
Practical advice
No response to dopamine start
adrenaline at 0.1mcg/kg/min centrally
If low diastolic and bounding peripheries
start noradrenaline echo may help if
available
Keep giving fluid boluses
Haemodilution and clotting factor depletion
will occur have blood, FFP,
cryoprecipitate available