Management of Pediatric Shock

Shock is a life-threatening emergency characterized by circulatory failure and impaired tissue

perfusion. In addition to clinical and hemodynamic condition, oxygen utilization and/or cellular

variables have been used to define shock.(1) Hypotension is neither a constant nor an early finding in pediatric shock and prompt recognition requires clinical assessment for tissue hypoperfusion and a high index of suspicion.(2)(3) Involved pathophysiological mechanisms include a combination of reduced intravascular volume, abnormal myocardial function, reduced vascular tone with inappropriate vasodilatation (vasoplegia) and/or circulatory obstruction associated with conditions such as cardiac tamponade, tension pneumothorax or massive pulmonary embolism. Clinical conditions often associated with shock include hypovolemia (eg bleeding and severe dehydration), severe sepsis, cardiogenic shock and anaphylaxis.(4-8)

Severe sepsis and septic shock represent a dysregulated immune response to an invasive infection. (9) Even without shock, children with infections frequently develop fever, tachycardia and vasodilatation as a result of an inflammatory response. Septic shock should be suspected if these manifestations are associated with a change in mental status, and the diagnosis made when tissue perfusion is impaired. Patients with septic shock may present with predominantly low cardiac output, vasoconstriction, delayed capillary refill and cold extremities (cold shock); or with predominantly vasodilatation, wide pulse pressure, warm extremities and increased cardiac output (warm shock).(1)(5) Contrary to the case in adults and some adolescents, most cases of septic shock in infants and children present as cold shock, with low cardiac output associated with hypovolemia (deficient intake and capillary leak) and/or myocardial insufficiency.(2)(5) The clinical distinction between cold and warm shock is not always clear-cut and has sometimes been disputed as a guide to initial inotropic/ vasopressor support. (10)

While cardiogenic etiology of shock may be quite obvious, such as following cardiac surgery and in those with cardiac disease, cardiogenic shock should be suspected in patients with signs such as a gallop rhythm, heart murmur, evidence of circulatory congestion (pulmonary rales, jugular venous distension, hepatomegaly or worsening with volume expansion) or arrhythmia. (4)

Bedside cardiac ultrasonography can be helpful in diagnosis and assessment of myocardial function. (11)

Anaphylaxis is a life-threatening systemic hypersensitivity reaction to triggers such as parenteral medications, insect venoms and food allergens. Prompt intervention is critical and early injection of epinephrine (adrenaline) is essential as it is the only drug shown to reduce mortality and hospitalization. (12-15)

An immediate stepwise approach with ongoing monitoring and clear end-points is necessary for successful management of shock. (1)(7) Initial evaluation and resuscitation should occur irrespective of patient location (emergency department, intensive care unit, general ward), even if it is clear that transfer to a higher level of care will be needed (5)

While most patients with shock benefit from intravascular volume expansion, the required amount and frequency of fluid administration can vary significantly and should depend on assessment of fluid responsiveness. The role of inotropes, vasopressors and vasodilators also varies depending on the prevailing pathophysiology, which can change even in the same patient. (4)(5)(16)(17) There is an increasing role for objective non-invasive hemodynamic assessment using tools such as point-of care ultrasound, electrical impedance cardiometry and

measurement of central venous oxygen saturation (ScvO2) (10)(11)(16)(18) to supplement clinical assessment and enable treatment appropriate to the actual pathophysiological derangements present. Other critical aspects of management include support of other systems and treatment of the underlying cause. (5)

Purpose and Scope

These guidelines have been developed to standardize the delivery of services and to implement the guidance on the management of Pediatric shock. It provides guidance to primary health care providers, pediatricians and specially trained nurses.

The guidelines aimed to

1)    To promote effective and timely management of pediatric patients with shock.

2)    To improve survival of pediatric patients with shock.

This version of the guideline includes recommendations and good practice statements for Management of Pediatric shock.