Assessment of hemodynamic conditions is most important in the management of critically ill patients

It is most important to pick up the condition of compensated shock and start treatment

Pediatric patients go into the stage of decompensated shock a bit late in comparasion to adult patients

Patients are managable in condition of decompesated shock if timely intervention is done.

Once the patient passes into irreversible shock it is very very difficult to revive and mortality is very high

How to recognise a patient clinically in a state of shock

STATE OF STABLE HEMODYNAMICS

Patient has clear consciousness

Periphery is warm and pink

Capillary refill time is 2 seconds or less

Pulse volume is good on palpation

Blood pressure is normal( between 5th to 95th centile for the age

Respiratory rate in the normal range for the age

Heart rate in the normal range for the age

Urine output normal for the age,1ml /kg/hour

STATE OF COMPENSATED SHOCK

Conscioussness inact

Periphery cool

Peripheral pulse ,low volume or thready

Capillary refill time more than 2 seconds

Blood pressure ,systolic is normal but diastolic is in rising trend,postural hypotension,narrow pulse pressure

Heart rate increased for the age

Respiratory rate increased for the age

Urine output reduced

STATE OF DECOMPENSATED SHOCK

Conscioussness-Restlessness or the patient is combative

Periphery on touch is cold and clammy

Capillary refill time is very prolonged like 5 seconds or more with or without mottling of skin

Peripheral pulse is very weak or may not be palpable at all even with great effort

Blood pressure -Hypotension,pulse pressure is 20 mm or less.Blood pressure may not be recordable

Heart rate-increased and in late stage decreased

Respiratory rate-Hyperpnea or Kussmaul breathing pattern(deep and sighy)

Urine output-oliguria or anuria

NORMAL RANGE of Respiratory rate

Premie-40-70/minute

0-3 months-30-60/minute

3-6 months-30-45/minute

6-12 months-25-40/minute

1-3 years-20-30/minute

3-6 years-20-25/minute

6-12 years-14-22/minute

>12 years 12-18/minute

NORMAL RANGE of heart rate- per minute

Premie 120-170

0-3 months 110-160

3-6 months 100-150

6-12 months 90-130

1-3 years 80-125

3-6 years 70-115

6-12 years 60-100

>12 years 60-100

HYPOTENSION is called when systolic blood pressure is below

60mm of Hg in NEW BORN,

70 mm of Hg between the age of 1 month to 1 year

70 mmHg+age in years multiplied by 2 ,between the age of 1- 10 years

90 mm Hg above the age of 10 years

Hypotension is also called when mean arterial pressure (MAP)is below 40+age in years multiplied by 1.5

MANAGEMENT:Management should start at the earliest, at the stage of compensated shock

First attention should be on airway and breathing and oxygen should be given if required to keep SPo2 95% and above

Life saving -for the circulation to be maintained, is fluid therapy

20 ml/kg of N/S or R/L shuold be given over 5-15 minutes and it should be pushed.It can be repeated twice if hydration,circulation and perfusion is not adequate.

In the settings of obvious fluid loss like diarrhoea ,vomiting or hemorrhage ,repeated fluid administration should be done till the signs of fluid overload develop, in the form of tachycardia,bilateral deep inspiratory crackles over subscapular region,liver enlargement,engorgement of jugular vein or signs of pulmonary edema on chest X-Ray

R/L shuold not be used in case of a history of repeated vomiting

IV bolus should be repeated ,only when there is sign of improvement clinically and no sign of fluid overload.

Aggressive fluid therapy may be harmful and should not be given in certain situations like shock in the settings of severe acute malnutrition,severe anemia,compensated shock with high fever with no dehydration or obvious fluid loss(Dengue fever),cardiogenic shock(ductal dependent congenital heart disease in newborn),obstructive shock(tension pneumothorax,cardiac temponade,)

SIGHNS OF CARDIOGENIC SHOCK-Tachycardia,engorged jugular vein,bilateral deep inspiratory crackles over subscapular regions,gallop rhythm,liver enlargement,signs of pulmonary edema on chest X-Ray.

In these cicumstances,crystalloids(N/S or R/L) should be given in the dose of 5-10 ml per kg over 15-30 minutes once then switch over to vasopressors

In case of poor response or no response to fluid therapy,swith over to vasopressures without delay.

If the periphery is cold,give DOPAMINE/EPINEPHRINE

If the perphery is warm give NORADRENALINE

In case of myocardial dysfuntion with maintained blood pressure,give DOBUTAMINE

In case of myocardial dysfuntion with increased peripheral resistance,use MILRINONE

Easy preparation and administration of vasopressures

Dopamine/Dobutamine 6 mg/kg-dilute in 100 ml of D5-1 ml/hour of this will deliver 1 mcg/kg/minute=Dose is 5-20 mcg/kg/minute

EPINEPHRINE0.6mg/kg of body weight,dilute in 100 ml of D5-1ml/hour will deliver 0.1mcg/kg/minute=Dose 0.05 to 0.2mcg/kg/minute,in severe cases upto 1mcg/kg/minute

Norepinephrine 0.6 mg/kg,dilute in 100 ml D5,1ml/hour will deliver 0.1mcg/kg/minute=Dose 0.1-1mcg/kg/hour

REFERENCES1.;Harriet Lane 21 edition

2. CDC guideline on management of shock in children

3.Uptodate-management of shock in children,2021