SYOK PADA ANAK

D. Setyowireni
RSUP Dr. Sardjito

Introduction

Shock is a syndrome that results from

inadequate oxygen delivery to meet
metabolic demands

Untreated this leads to metabolic

acidosis, organ dysfunction and death

Oxygen Delivery =
[Oxygen Content] x Flow

Glucose Delivery

Insulin sensitive
Glucose transporter

O2 diffusion

Hypoxic
Anemic
Ischemic
Shock

Glucose

ATP
Lack of ATP = Shock

Glycopenic
Shock

HEMOGLOBIN
PRELOAD

OXYGEN SAT

CONTRACTILITY

AFTERLOAD

HEART RATE
OXYGEN CONTENT

STROKE VOLUME

CARDIAC OUTPUT

OXYGEN DELIVERY

Oxygen Delivery

Cardiac Output = Heart Rate x Stroke Volume

CO = HR x SV = volume per minute
SV : volume per cycle determined by preload, afterload
and contractility

Oxygen Content = Oxygen content of the RBC + the

oxygen dissolved in plasma
CaO2 = Hb X SaO2 X 1.34 + (0.003 X PaO2) =
16-22 mL O2/dL

Oxygen delivery = Cardiac Output x Oxygen Content

DO2 = CO x CaO2

Stages of Shock

Compensated

Uncompensated

Vital organ function maintained, BP

remains normal.
Microvascular perfusion becomes marginal.
Organ and cellular function deteriorate.
Hypotension develops.

Irreversible

BARORECEPTOR
MAP

HUMORAL
CATECHOLAMIN

MAP

CHEMORECEPTOR
ACIDOSIS

AUTO
TRANSFUSION
MAP

TEK. HIDROSTATIK

RESORPSI CAIRAN
INTERSTISIIL

VASOLIDATATION
HR, CO, BP

RENINANGIOTENSIN
ANGIOTENSIN

VASOCONSTRICTION
HR, CO, BP

Hemodynamic Response to
Hemorrhage
Vasc Resistance

% of
Control

100

Blood Pressure
Cardiac Output

25%

50%

% Plasma Loss

CLINICAL SIGNS
COMPENSATED
Tachycardia
Skin perfusion
MAP, blood pressure
DECOMPENSATED
Decreased conssiousness
Decreased urine output
Metabolic acidosis
Hypotension

Fluid Resuscitation

HR/SBP

HR

CR

BP

INTRAVASCULAR VOLUME LOSS

(-)20cc/kg

(-) 40cc/kg

(-) 60cc/kg

Tachycardia as a Predictor of Sepsis

(Graves GR et al Ped Inf Dis 1984)

70
60
50
40

Tachycardia

30

Eucardia

20
10
0
Sepsis

Only 21 out of 4350

newborns had
tachycardia
(4.6/1000)
82 newborns
underwent a sepsis
evaluation and 13 had
sepsis.
12/13 had tachycardia
vs 6/69 without sepsis

Capillary refill slide

CAPILLARY REFILL

The PICU fellow was called for respiratory distress in this

5 mos old with RSV bronchiolitis.
What she found was a baby in SHOCK!!!

Patient I

CLINICAL SIGNS OF SHOCK

5 African American male who had been admitted 3 days ago with fever, tachycardia to 160s
He has had no urine output in 12 hours
A Condition C was called for increasing respiratory distress
Patient was breathing in the 50s, tachycardic to the 160s, febrile and with a red rash seen all over his body.
80cc/kg of fluid was pushed and he was transferred to the PICU

Patient B

WARM SHOCK, FLASH CAPILLARY REFILL

Patient F

12 year old developed fever and leg pain and went to

bed.
Awoke the next morning with purpura
Brought to community ER by mother
Did not improve with fluid resuscitation alone

Preload

?
Inotropy

Shock
MAP = (SV x HR) x SVR

Afterload

?
What types of shock will affect each of the cardiac parameters?

Hypovolemic
Hemorrhage
Anemia
Cardiogenic
CHF
ACS
Dysrhythmia
Valve Dz
Cardiac tamponade
Distributive
Sepsis
Anaphylactic
Neurologic
Obat-obatan
Obstructive
Aortic valve stenosis
Kardiomioati

Preload

Shock

Inotropy

MAP = (SV x HR) x SVR

Afterload
Hypovolemic Cardiogenic

Distributive Obstructive

Low CVP

High CVP

Low CVP

Low CVP

Low CO

Low CO

HIgh CO

Low CO

High SVR

High SVR

Low SVR

+/- SVR

MANAGEMENT

Management-General (cont)
Airway
If not protected or unable to be maintained,
intubate.

Breathing
Always give 100% oxygen to start
Sat monitor

Circulation
Establish IV access rapidly
CR monitor and frequent BP

Management-General (cont)
Laboratory studies:
ABG
Blood sugar
Electrolytes
CBC
PT/PTT
Type and cross
Cultures

Management
Volume Expansion

Optimize preload
NS or RL
Except for myocardial failure use 1020cc/kg aliquots q 2-10 minutes
At 40-60cc/kg reassess and consider:
ongoing losses, adrenal, intestinal
ischemia, obstructive shock. Get CXR.
Consider colloid
Further fluid therapy guided by response,
labs, possibly CVP, CXR

Survival after Adjustment for Patient Severity:

Every hour without appropriate

resuscitation and restoration of capillary
refill < 2 s and normal blood pressure
increases mortality risk by 40%!
(Han et al Pediatrics 2003)

10
9
8
7
6
5
4
3
2
1
1 Hour

2 Hours

3 hours

100% survival attained in Dengue Shock when

fluid resuscitation given before hypotension
(Ngo et al Clin Inf Dis 2001, Wills et al NEJM 2006)
100%
90%
80%
70%
60%
Surv
NS

50%
40%
30%
20%
10%
0%
RL

NS

Colloid

Can I Give Too Much Fluid?

(if so give furosemide)

Check for Hepatomegaly

Listen for Rales

Evaluate MAP-CVP

If fluid bolus does not

increase Cardiac Index
and or Mean Blood
Pressure

Inotropes / vasodilators
are required
Kluckow et al J Pediatr 1996)

Management - Cardiotonics II

Epinephrine

0.05-1.5 ug/kg/min
increase HR, SVR,
contractility
End point: adequate BP;
acceptable tachycardia
Norepinephrine
0.05-1.0 ug/kg/min
Increase SVR
End point: adequate BP

Dopamine
2-20 ug/kg/min
Lower doses,
increases renal and
splanchnic blood flow,
& contractility. Higher
doses increases HR
and SVR
End Point: Improved
perfusion, BP, Urine

Management - Cardiotonics III

Dobutamine
1-20 ug/kg/min
increases
contractility, may
reduce SVR, PVR
End Point: Improved
perfusion, may
decrease BP

Prostaglandin E-1
0.05-0.1 ug/kg/min
maintains patency of
ductus

Fluid
resuscitation +
Dobutamine/
Dopamine is
more likely to
increase SVC
flow than
Dobutamine/
Dopamine alone

(Osborn et al J Pediatr 2002)

The Starling Curve

CI > 3.3

More fluid
Vasodilator
Inotrope

Stroke
Volume

Volume bolus

Left Ventricular End Diastolic Volume

70%
SVCO2

Final Thoughts

Recognize compensated shock quickly- have a

high index of suspicion, remember tachycardia
is first sign. Hypotension is late and ominous.
Gain access quickly- if necessary use an IO line.
Administer adequate amounts of fluid rapidly.
Remember ongoing losses.
Correct electrloytes and glucose problems
quickly.
If the patient is not responding the way you
think he should, broaden your differential, think
about different types of shock.