Shock: Akbar Sepadan / Andhika Pangestu / Andhiny Rezkia Enhas / Annisa Zakiroh

SHOCK Akbar Sepadan / Andhika Pangestu / Andhiny Rezkia Enhas / Annisa Zakiroh

Epidemiology • Shock occurs in approximately 2% of all hospitalized infants, children, and adults in developed countries, and the mortality rate varies substantially • Depending on the etiology and clinical circumstances. Most patients who do not survive, do not die in the acute hypotensive phase of shock, but rather as a result of associated complications and multiple organ dysfunction syndrome (MODS).

Types of Shock

Pathophysiology

Hypotension Blood pressure is maintained

Hypovolemic Shock

Hypovolemic Shock • Most common shock in pediatric, etiology: – Vomitting, – Diarrhea, – Plasma leakage (e.c. DHF), – Sepsis, – Trauma, – Burn wound, – Gastrointestinal bleeding, – Intracranial bleeding.

Hypovolemic Shock • Loss of fluid  ↓ preload  ↓ cardiac output  ↓ stroke volume  Baroreseptor  ↑ heart rate and vasoconstriction to maintain stroke volume and blood pressure. • Long hypovolemic shock  multiorgan disfunction. – Renal, – Heart, – Hepar

Therapy • Crystaloid 10-20 ml/kg in 10-30 minutes, while assessing respond of the body. • ↑ intracellular volume  ↑ cardiac output and ↓ heart rate. • In severe cases, add more crystaloid 10 ml/kg while assessing patients’ respond. • Give the fluid until it comes to normovolemic, you can also use koloid.

Septic Shock

Septic Shock • Septic shock is often a unique combination of distributive, hypovolemic, and cardiogenic shock. • Hypovolemia from intravascular fluid losses occurs through capillary leak. • Cardiogenic shock results from the myocardialdepressant effects of sepsis • Distributive shock is the result of decreased SVR. preload, afterload, and myocardial contractility.

Pathophysiology of septic shock

Management of Septic Shock

Initial Resuscitation • Respiratory distress and hypoxemia  face mask oxygen, high flow nasal cannula oxygen, nasopharyngeal CPAP (NP CPAP) • Circulation  peripheral intravenous access or intraosseous access can be used for fluid resuscitation and inotrope infusion when a central line is not available

• Initial therapeutic end points of resuscitation of septic shock: - capillary refill of ≤2 sec, - normal blood pressure for age - normal pulses with no differential between peripheral and central pulses - warm extremities - urine output >1 mL kg−1 hr−1 - normal mental status - ScvO2 saturation ≥70% - cardiac index between 3.3 and 6.0 L/min/m2

Antibiotics and Source control • Empiric antibiotics should be administered within 1 hour of the identification of severe sepsis. *Blood cultures should be obtained before administering antibiotics when possible but this should not delay administration of antibiotics.

• Clindamycin and antitoxin therapies for toxic shock syndromes with refractory hypotension. • Early onset neonatal sepsis  broad-spectrum antibiotics: ampicillin and gentamicin or amikacin. • Late onset neonatal sepsis  broad-spectrum antibiotics, if meningitis suspected  cefotaxime, suspected central line sepsis  Vancomycin.

Fluid Resuscitation • initial resuscitation of hypovolemic shock begins with infusion of isotonic crystalloids or albumin with boluses of up to 20 mL/kg crystalloids (or albumin equivalent) over 5-10 minutes.

Inotropes/Vasopressors/Vasodilators

• Begin peripheral inotropic support until central venous access can be attained in children who are not responsive to fluid resuscitation. • Patients with low cardiac output and elevated systemic vascular resistance states with normal blood pressure should be given vasodilator therapies in addition to inotropes.

Extracorporeal Membrane Oxygenation (Ecmo)

• Consider ECMO for refractory pediatric septic shock and respiratory failure.

CORTICOSTEROIDS • Hydrocortisone therapy is reserved in children with catecholamine resistant shock and suspected or proven absolute (classic) adrenal insufficiency.

Protein C And Activated Protein Concentrate

Blood Products And Plasma Therapies

• Use of APC is not recommended due to a lack of evidence of benefit and an increase in bleeding complications.

• Consider targeting transfusion to a Hb goal of greater than 10 g/dl to achive an ScvO2 > 70%, so enhancing oxygen delivery.

Mechanical Ventilation • Lung-protective strategies during mechanical ventilation.

SEDATION/ANALGESIA/DRUG TOXICITIES

• We recommend use of sedation with a sedation goal in critically ill mechanically ventilated patients with sepsis. • Monitor drug toxicity labs because drug metabolism is reduced during severe sepsis, putting children at greater risk of adverse drugrelated events.

Glycemic Control • Control hyperglycemia using a similar target as in adults (≤180 mg/dL). Glucose infusion should accompany insulin therapy in newborns and children because some hyperglycemic children make no insulin whereas others are insulin resistant.

Diuretics And Renal Replacement Therapy

• Use diuretics to reverse fluid overload when shock has resolved, and if unsuccessful then continuous venovenous hemofiltration (CVVH) or intermittent dialysis to prevent >10% total body weight fluid overload.

Deep Vein Thrombosis (DVT) Prophylaxis

• No recommendation on the use of DVT prophylaxis in prepubertal children with severe sepsis.

Stress Ulcer (SU) Prophylaxis • Early enteral feeding is not possible  H2 bolckers or PPI should be used in patients with severe sepsis.

NUTRITION • Enteral nutrition given to children who can be fed enterally, and parenteral feeding in those who cannot.

Anaphylaxis Shock

Anaphylaxis shock • Anaphylaxis is defined as a serious allergic reaction that is rapid onset and may cause death. • Anaphylaxis occurs when there is a sudden release of potent biologically active mediators from mast cells and basophils, leading to cutaneous (urticaria, angioedema, flushing), respiratory (bronchospasm, laryngeal edema), cardivascular (hypotension, dysarhytmias, myocardial ischemia), and gastrointestinal (nausea, colickly abdominal pain, vomiting, diarrhea) symptoms.

Patohysiology • Mediator inflammatory has been released from mast cell and basofil after patient has been exposed allergen that has been sensitized.

Manifestasi klinis

Treatment

Cardiogenic Shock

Shock Cardiogenic • The clinical definition of cardiogenic shock is decreased cardiac output and evidence of tissue hypocia in the presence of adequate intravascular volume

• The sign and symptoms of cardiogenic shock is – Hypotension - Absence hypovolemia - Clinical sign of poor tissue perfusion ex: oliguria, cyanosis, cool extremities, altered mentation

• -

Physical examination in cardiogenic shock Skin is cyanotic and cool Peripheral pulses are rapid and faint Jugular venous distention and crackles in the lung Patient show sign of hypoperfusion, such as altered mental status and decreased urine output - Systemic hypotension

Treatment

References • Kliegman MD, Robert M. 2016. Nelson Textbook of Pediatrics, Twentieth Edition. Canada: Elsevier. • Ikatan Dokter Anak Indonesia. 2011. Buku Ajar Pediatri Gawat Darurat. Jakarta: Badan Penerbit Ikatan Dokter Anak Indonesia.