neonatal shock
TRANSCRIPT
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The Mystery of The Shocked BabyThe Mystery of The Shocked Baby
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History
A 10-day-old female infant born at 39 weeks of gestation. She was born by normal spontaneous vaginal delivery and was discharged home.
The mother has a history of primary infertility 3 years.
The mother’s pregnancy, labor were unremarkable.
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History This infant was feeding and voiding appropriately
in first days of life.
But parental account that their infant became progressively “fussy”. She breathed faster and required a longer time for each bottle-feeding.
On the day of presentation she fed no more than 30ml of formula and hadn’t voided since the night before.
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Vital signs
Temperature 36.8 C Heart rate 190 b/min
CRT = 5 Sec
RR = 69 b/min Blood pressure from the right arm 78/50 mmHg
Sao2 from the right hand is 96% Weight is 3.3 kg
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Examination
CNS: conscious but confused with decreased spontaneous movements and weak crying.
CVS: precordium is hyperdynamic, pulmonary component S2 is loud, no murmurs and Lower extremity pulses are difficult to palpate.
Chest: RD Grade ІІ, Equal breath sounds bilaterally with fine rales at both lung bases.
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Examination
The liver is palpable 4 cm below the right costal margin.
Her feet are cool to touch.
Baby was pale.
There are no skin lesions.
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What is the problem with this baby ?
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Shock:Shock:
Shock is the inadequate perfusion Shock is the inadequate perfusion of the body’s vital organsof the body’s vital organs
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Indices of tissue perfusion
Pallor & skin mottling Capillary refill time (>3 sec) Heart rate ( > 170 B\min ) Toe-core temperature difference (>2ºC) Urine output (<1 mL/kg/hr) Blood lactate (>2.5 mmol/L)
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Which one is shocked ?
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Causes of neonatal shock
O2
Pump
Pipes
Circulation
Tank
Non Vital
Vital organs
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Remember !!
Once shock is suspected start supportive measures as soon as possible:
airway and assuring its patency. providing oxygen or positive pressure
ventilation. achieving intravascular ( peripheral or
central )or intraosseous access.
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Algorithm for management of shock:
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Algorithm for management of shock:
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Fluid Boluse
Excessive volume expansion may be potentially harmful in Cardiogenic Shock.
Preterm babies can not deal with
Excessive volume expansion which increase likelihood of PDA & NEC.
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Why not more than 20ml/kg ?
Clinical signs of hypovolemic shock depend on the degree of intravascular volume depletion:
25% in compensated shock 25-40% in uncompensated shock ( But with myocardial depression)
more than 40% in irreversible shock.
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Dopamine Doses
New school Effect Old school
0.5 to 2 μg/kg/min Renal and mesenteric vasodilatation
2.5 to 5 μg/kg/min
2 to 8 μg/kg/min Increased myocardial contractility and heart rate
5 to 10 μg/kg/min
> 8 μg/kg/minSignificant peripheral VC & increase in PVR and blood
pressure10 to 20 μg/kg/min
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Dobutamine
Mech: produces vasodilation and increases Cardiac muscle contration.
1st line in: Preterm < 48 hrs PPHN Heart failure
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Adrenalin (The most potent inotrope)
Adrenalin results in significant increases in:
Myocardial contractility Cardiac output Peripheral vascular resistance Blood pressure
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Milrinone = Primacor
Mech: Improve contractility Improve diastolic function Systemic and pulmonary vasodilation= Decrease
after load & Decrease Pulmonary BP
Indication: Shock post Cardiac Surgery Septic Shock Severe PPHN
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When to response ??
Reassess within 10 min of fluid bolus
Reassess every 15–20 min of new dose of Inotropes
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Caution !!
Inotropic agents: contraindicated in hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is common in IDMs
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Caution !!
Catecholamines : Never administer intra-arterially
Dopamine shown to suppress TSH secretion
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Remember !!
Correction of negative inotropic factors:
as hypoxia, hypoglycemia, hypocalcemia, acidosisand electrolytes imbalance,
if present.
Digoxin is used in non-critically ill infants.
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What about NaHco3 ?
Indications: To correct normal anion gap metabolic acidosis caused
by Renal (RTA) or GI Losses (Diarrhea, Surgery for NEC,ileostomy).
Treatment of life-threatening hyperkalemia.
In significant metabolic acidosis (pH<7.20 or BD > 10), it may be useful to give NaHco3.
(very controversial)
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Textbook of Neonatal Resuscitation, 7th Edition
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NaHco3 Dose
Dose (in mEq) based on Base Deficit = 0.3 X Base deficit (mEq/L) X weight (kg).
Give ½ dose then assess need for remainder
Dose is given over 30 minutes at least. Sodium Bicarbonate 8.4 % contains 1 mEq NaHCO3 / mL
Incompatible with dobutamine, dopamine, epinephrine, midazolam.
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NaHco3 side effects
IVH (with rapid infusion)
Increase PCO2 so decrease pH (if given during inadequate ventilation)
Local tissue necrosis Hypocalcemia Hypernatremia and hypokalemia
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Caution !!
Do not treat metabolic acidosis with hyperventilation.
NaHCO3 is not a recommended therapy in NRP
It is best to correct the underlying cause of the metabolic acidosis.
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Corticosteroid therapy
Mech: up-regulate adrenergic receptor & as replacement in adrenal insufficiency.
When: in extremely PT with hypotension refractory to volume & vasopressors (high dose dopamine or epinephrine).
Hydrocortisone: 1 mg/kg every 8-12 hrs for 2-3 days.
Dexamethasone: 0.1 mg/kg followed by 0.05 mg/kg IV every 12 H for 5 doses.
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Back to our case
Baby was placed on O2 and received one fluid bolus plus Dopamine 10 μg/kg/min + Dobutamine 10 μg/kg/min without any improvement in perfusion.
This bad news was told to the parents in an appropriate way.
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Investigations
Serum glucose Blood gases Hematocrit (Hct) Electrolyte CBC, CRP, and cultures Chest x-ray Echocardiography & ECG Renal functions & Liver function tests
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Investigations
CBC: Hct 41%, WBC 15 × 103, platelet count 23 × 103.
PH 7.18, CO2 30, NaHCO3 10 mEq/L, BE -16. Na 145 mEq/L, K 5 mEq/L, Ca 9 mg/dl.
RBS = 69 mg/dl. CRP -Ve Urea 40 mg/dl, Creatinine 1.0 mg/dl.
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Chest X-ray: Cardiomegaly, increased pulmonary vascularity.
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Case progression
Dopamine increased to 20 μg/kg/min + Dobutamine 20 μg/kg/min without any improvement in perfusion.
After senior consultant PGE1 infusion was started and Echocardiogram was being arranged.
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Duct dependent systemic circulation
Neonates who present with shock within the first 3 weeks of life are likely to have CHD with duct dependent systemic flow.
It is appropriate to begin PGE-1, even if before A diagnosis made by echocardiography.
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PGE1 infusion:
Dose: 0.05-0.1μg/kg/min, start with 0.05μg/kg/min, if no improvement increase to 0.1 μg/kg/min.
Adverse effects: Hypotension, flushing, tachycardia, apnea, fever, and Hypokalemia.
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When Baby respond to PGE-1 ?
Maximum effect seen within 30 min in cyanotic lesions,
may take several hours in acyanotic lesions
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Echocardiogram: HLHS
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Left-sided obstructive heart disease (Duct-dependent systemic circulation)
These diseases include:
Hypoplastic left heart syndrome (HLHS)(most common and severe)
Critical aortic stenosis (AS) Co-arctation of the aorta (COA) Interrupted aortic arch (IAA)
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Approaches to HLHS
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What about Entral feeding ?
Infants in shock should not be fed.
Intestines will require 2 days or more for recovery before small feedings can be attempted.
Initiate total parenteral nutrition as soon as possible.
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Shock & Assisted Ventilation
NCPAP is Contraindicated in Severe cardiovascular instability.
Ventilation is an excellent inotrope
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Shock & Ventilatory setting
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Refractory Shock
Hypopituitarism Hypoadrenalism (Congenital adrenal hyperplasia, Addison disease)
Large PDA Central line leakage GIT problems (e.g. NEC, perforation)
Drugs ( e.g. muscle relaxants ) Poor myocardial contractility (e.g. cardiomyopathy)
Inborn errors of metabolism (e.g. Organic acidemia )
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Refractory Shock:
Hidden Hemorrhage
Subgaleal HemorrhageAdrenal hemorrhage
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Refractory Shock:
Hidden Hemorrhage
Fractured Humerus Fractured femur
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Refractory Shock:
Periventricular hemorrhage / intraventricular hemorrhage
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Refractory Shock:
Pneumothorax
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Refractory Shock:
Pneumopericardium
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Refractory Shock:
Pneumothorax & Pneumopericardium
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Recent Approach :Recent Approach :
Functional Echocardiography and Doppler Flow Velocimetry:
Assessment of global heart contractility
Assessment of superior vena cava flow
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Take Home Massage
Once shock is suspected start supportive measures as soon as possible.
Thereafter, treatment is directed by
the underlying pathology.
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Take Home Massage
In Shock: Obtain vascular access including arterial line, better through
umbilical vessels.
BP is maintained until very late Hypotension is a pre-terminal sign
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Take Home Massage
PGE1 is considered before diagnosis is confirmed if duct-dependent systemic
blood flow is suspected.
NaHCO3 is not a recommended therapy in NRP.
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Thank youThank you
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