Management of Pediatric Shock

Table 3. Recommendations

A.     Recognition of shock

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

A1

In pediatric patients with suspected shock/ at risk for shock, when should shock be diagnosed?

ACCM

Shock should be recognized when there are clinical signs of inadequate tissue

perfusion; including:

Prolonged capillary refill greater than 2 seconds, diminished pulses, mottled cool

extremities (or flash capillary refill, bounding peripheral pulses and wide pulse

pressure), decreased or altered mental status, decreased urine output.

Hypotension is not necessary; however, its presence is confirmatory.

High

Weak (conditional)

Table 4. Recommendations

B. Determination of type/ likely etiology

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

B1

In pediatric patients with shock, how could the likely etiology be determined?

ACCM

US

EDP-Ana;

Endorsed

by EAACI

US

·       Consider hypovolemic shock when there is intravascular fluid loss (eg., hemorrhage, vomiting, diarrhea, osmotic diuresis or capillary leak).

·  The clinical diagnosis of septic shock is made in children who have clinical signs of inadequate tissue perfusion AND have a suspected infection.

·  Consider cardiogenic shock 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. Arrhythmias should be appropriately managed.

· The use for cardiac ultrasonography is recommended to assess the etiology of cardiogenic shock.

· Base the diagnosis of anaphylaxis on the history and physical examination, using scenarios described by the National Institutes of Allergy and Infectious Disease (NIAID) Panel (fig 2, p 28 ), recognizing that there is a broad spectrum of anaphylaxis presentations that require clinical judgment.

·  Life-threatening obstructive causes of shock should be identified and treatment initiated for the underlying cause:

Pericardiocentesis for cardiac tamponade, anticoagulation and thormbectomy for pulmonary embolus, chest tube thoracostomy or needle thoracentesis for pneumothorax, or prostaglandin E1 for ductal dependent circulation.

·  The use of cardiac ultrasonography is recommended to recognize/ rule out cardiac Tamponade.

High

Moderate

Low

Moderate

Good practice statement

Weak (conditional)

Good practice statement

weak (conditional)

weak (conditional)

Good practice statement

Strong

Table 5. Respiratory support

C. What respiratory support is needed for pediatric patients with shock?

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

C1

What respiratory support is needed for pediatric patients with shock?

ACCM

EDP-Ana C

ACCM

SSC

ACCM

·       Airway and breathing should be rigorously monitored and maintained. Supplemental oxygen should be given as initial therapy.

· In children with anaphylaxis, prepare for airway management,including intubation if necessary, if there is any suggestion of airway edema (eg, hoarseness or stridor).

· The decision to intubate and ventilate should be based on clinical assessment of

increased work of breathing, hypoventilation, or impaired mental status. Waiting for confirmatory laboratory tests is discouraged.

·  Intubation may be performed for children with fluid-refractory, catecholamine resistant

shock without respiratory failure.

· If possible, volume loading and peripheral or central inotropic/vasoactive drug support is recommended before and during intubation;

because of relative or absolute hypovolemia, cardiac dysfunction, and the risk of suppressing endogenous stress hormone response with agents that facilitate intubation.

Etomidate is not recommended. Ketamine with atropine pretreatment should be considered the induction combination of choice.

A short-acting neuromuscular blocking agent can facilitate intubation if the provider is confident and skilled.

High

Moderate

High

High

Weak (conditional)

Weak (conditional)

Weak (conditional)

Good practice Statement

(weak (conditional)

Table 6. Vascular access

D. In pediatric patients with shock, how could the likely etiology be determined?

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

D1

In pediatric patients with shock, how could the likely etiology be determined?

ACCM

US

US

US

SSC

·       Vascular access should be rapidly attained. Intraosseous access should be established if reliable intravenous line cannot be attained in minutes.

· The use of ultrasonography is recommended for central venous access.

·       Real-time, single operator approach is recommended.

· Ultrasonography is operator dependent and vascular access should not be delayed in shocked patient.

·  A dilute concentration of the initial vasoactive medication (including epinephrine or norepinephrine) may be administered through a peripheral vein or intraosseous line if central venous access is not readily accessible.

High

High

High

High

Weak (conditional)

Strong

Strong

Weak (conditional)

Good practice statement

Table 7. Recommendations

E. Fluid management

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

E1

In pediatric patients with shock, when and how should fluid resuscitation be given?

ACCM

EAACI

US

ACCM

SSC

ACCM

ACCM

ACCM

ACCM

SSC

SSC

ACCM

·       Patients with hypovolemic shock or distributive shock (including septic &

anaphylactic shock) should receive fluid resuscitation:

Amount: 20 mL/Kg per bolus, Type: isotonic crystalloid (eg normal saline) DuraIon: push or rapid infusion over 5-10 min

· Patients with cardiogenic shock should only receive fluid resuscitation if they are judged to have preload insufficiency.

· Cardiac ultrasonography evaluation is recommended during such assessment.

· Patients with poor cardiac function may also be volume depleted. Smaller boluses (5-10 mL/kg) should be given more slowly (over 10-20 min) for these patients.

· Fluid resuscitation should be avoided or discontinued when there is evidence of intravascular volume overload.

· During fluid resuscitation, monitor for the development of increased work of

breathing, rales, hypoxemia, cardiac gallop rhythm, hepatomegaly or a diminishing MAP-CVP.

· IniIal volume resuscitaIon requirements may be 0 mL/kg if rales or hepatomegaly are present.

· Fluid boluses may be repeated with the goal of normal perfusion, cardiac output and blood pressure provided there are no signs of fluid overload.

·  A total of up to 60 mL/Kg may be needed during the first hour

· For patients with sepsis In low resource settings with no availability of intensive care: in the absence of hypotension, maintenance fluids should be started without prior bolus fluid administration.

Overly aggressive fluid boluses may be harmful in patients with cardiogenic shock,

DKA, syndrome of inappropriate antidiuretic hormone secretion, severe

malnutrition, or, in resource-limited settings, severe febrile illness in the absence of

dehydration, hemorrhage or hypotension.

· When children with presumed hypovolemia have not improved after receiving a total of 60 mL/kg over 30 to 60 minutes, the following should be considered:

-The amount of fluid loss may have been underestimated (eg burn injury)

-There may be significant ongoing fluid loss (eg hemorrhage from blunt abdominal trauma or capillary leak with bowel obstruction)

-Other conditions may be causing or contributing to shock (eg spinal cord injury in a child with multiple trauma, sepsis, myocardial dysfunction, etc).

· After the first hour, ongoing fluid replacement should be directed at clinical endpoints including perfusion as well as available tools of hemodynamic monitoring as CO, global end-diastolic volume and PAOP (pulm A occlusion P)

In pediatric patients with sepsis, fluid losses and persistent hypovolemia secondary to diffuse capillary leak can continue for days.

High

Very low

High

Low

High

High

High

Low

High

High

Weak (conditional)

Weak (conditional)

Good practice statement

Weak (conditional)

Good practice statement

(weak (conditional)

Weak (conditional)

Weak (conditional)

Weak (conditional)

Weak (conditional)

Strong

Good practice statement

Weak (conditional)

E2

Following initial resuscitation, what is the role and methods of fluid removal?

ACCM

SSC

·       Following shock resuscitation, diuretics, peritoneal dialysis or high flux CRRT can be used to remove fluid in paAents who are 10% fluid overloaded and unable to maintain fluid balance with native urine output/ extra-renal losses.

·  In children with fluid overload and ventricular dysfunction diuretics (such as furosemide) should be used to return to euvolemic state while monitoring clinical criteria and cardiac output.

·  High-volume hemofiltration (HVHF) is not preferred over standard hemofiltration in children with septic shock or other sepsis-associated organ dysfunction who are treated with renal replacement therapy.

High

Low

Weak (conditional)

Good practice statement

Weak (conditional)

Table 8. Recommendations

F. Colloids and blood products

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

F1

What is the role of colloids for volume expansion in shock?

SSC

SSC

·       Crystalloids, rather than 5% albumin, are recommended for the initial resuscitation of children with septic shoc

·  Although controversial, colloid is a reasonable option for patients with hypoalbuminemia (albumin <3g /dL) or hyperchloremic metabolic acidosis who have not improved after initial crystalloid volume expansion

· In the acute resuscitation of children with septic shock or other sepsis associated organ dysfunction, it is NOT recommended to use: Starches; or

Gelatin

Moderate

Moderate

Low

Weak (conditional)

Good practice statement

Strong

Weak (conditional)

F2

What is the role of blood products in shock?

SSC

ACCM

SSC

SSC

·       Patients with hemorrhagic shock who have not improved should receive blood and require definitive treatment for the cause of hemorrhage,

· Transfusion of RBCs is not routinely indicated if the blood hemoglobin concentration is greater than or equal to 7 g/dL in hemodynamically stabilized children with septic shock or other sepsis-associated organ dysfunction.

· RBC transfusion may be given to children with Hgb less than 10 g/dL. and poor tissue perfusion despite volume expansion (low CI, low ScvO2).

·Prophylactic plasma or platelet transfusions are not routinely recommended in nonbleeding children with septic shock or other sepsis associated organ dysfunction solely on the basis of laboratory abnormalities.

·  IV immune globulin (IVIG) should not be routinely used in children with septic shock or other sepsis associated organ dysfunction.

N.B. Although therapies may not be routinely recommended, select patients may benefit

Low

High

Very low

Low

Good practice statement

Weak (conditional)

Weak (conditional)

Weak (conditional)

Weak (conditional)

Table 9. Recommendations

G. Metabolic abnormalities

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

G1

What is the target blood glucose in patients with shock?

ACCM

ACCM

SSC

SSC

·       Hypoglycemia must be rapidly diagnosed and promptly treated.

·  In paIents with sepsis, a 10% dextrose containing IV solution can be run at maintenance rate to provide age appropriate glucose delivery and to prevent hypoglycemia.

·  Blood glucose levels below 180 mg/dL (10 mmol/L) should be targeted.

· Insulin therapy targeting a blood glucose at or below 140 mg/dL (7.8 mmol/L) is NOT recommended

High

High

Moderate

Weak (conditional)

Weak (conditional)

Good practice statement

Strong

G2

What is the target calcium concentration in patients with shock?

ACCM

·  Calcium replacement should be directed to normalize ionized calcium concentration

High

Weak (conditional)

G3

What is the role of thyroid replacement in patients with shock?

ACCM

SSC

·  Thyroid replacement can be lifesaving in children with thyroid insufficiency and

catecholamine-resistant shock.

·  The routine use of levothyroxine in children with septic shock and other sepsis associated organ dysfunction in a sick euthyroid state is not recommended.

High

Low

Weak (conditional)

Weak (conditional)

Table 10. Recommendations

H. TherapeuAc end-points and hemodynamic assessment/ monitoring

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

H1

What are the end-points/ resuscitation goals denoting successful resuscitation & stabilization during the first hour of management of shock (primarily in the ED)?

ACCM

·  The management goals in the first hour should be to maintain/ restore:

*Airway, oxygenation, and ventilation

*Circulation

-normal blood pressure for age (only reliable when pulses palpable)

-normal pulses with no differential between the quality of peripheral & central pulses

-threshold HR

-perfusion: Capillary refill less than or equal to 2 seconds, warm extremities, urine output greater than 1mL/kg/hr, normal mental status

*Normal glucose concentration, normal ionized calcium concentration.

High

Weak (conditional)

H2

What additional end-points/ therapeutic goals are applicable after the first hour of management of shock (primarily in

the PICU/ HDU)?

ACCM

·  The following additional goals are applicable beyond the first hour:

-Perfusion pressure (MAP-CVP or MAP-IAP) appropriate for age.

-ScvO2 greater than 70%

-CI greater than 3.3 and less than 6.0L/min/m2

-Normal INR, anion gap, and lactate.

High

Weak (conditional)

H3

What are the methods of hemodynamic assessment/ monitoring needed to guide the management of shock?

ACCM

SSC

US

·       On-going resuscitation should be guided by hemodynamic assessment & monitoring including:

- Heart rate, blood pressure, pulse pressure, capillary refill/ skin perfusion analysis and temperature

- Pulse-oximetry and continuous ECG monitoring

- CVP

- Urine output

- Laboratory (Arterial blood gases, ScvO2, lactate, glucose and ionized Ca.

·  Assessment of CI and SVRI using advanced hemodynamic monitoring is recommended when available. Methods include:

- invasive arterial BP monitoring with pulse-contour analysis

- serial ultrasonographic assessment.

· The use of cardiac ultrasonography to assess the efficacy of fluid resuscitation, ventricular function and inotropic support.

- electrical impedance cardiometry.

·  In patients with cardiogenic shock, repeated determination of troponin levels can be used to assess the severity of myocardial involvement as well as the response to treatment.

High

Low

High

Weak (conditional)

Weak (conditional)

Weak (conditional)

Good practice statement

Good practice statement

Table 11. Recommendations

I. Inotropes, vasopressors and vasodilators

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

I1

When should inotropic/ vasopressor support be initiated?

SSC

ISHLT

·       It is reasonable to begin vasoacAve infusions aNer 40–60 mL/kg of fluid resuscitation if the patient continues to have evidence of abnormal perfusion, or sooner if fluid overload develops or other concerns for fluid administration are present.

·  Use of intravenous inotropic agents in the absence of clinical evidence of hypotension, low CO and/or decreased end-organ perfusion is potentially harmful.

Moderate

Good practice statement

Strong

I2

Which inotropes/ vasopressors should initially be used?

ACCM

ISHLT

·       In septic shock:

-Central epinephrine can be started for “cold shock” (0.05–0.3 μg/kg/min) or

norepinephrine can be titrated for “warm shock”.

-Central dopamine can be Atrated to a maximum of 10 μg/kg/min.

-Epinephrine or norepinephrine is more likely to be beneficial.

N.B. In children, “cold shock” is more common.

· In cardiogenic shock:

-Milrinone and /or dobutamine can be used as first- line therapy

-It is probably advisable to use milrinone in post- cardiac surgery patients and in

cases with impaired RV function and/or associated pulmonary hypertension.

High

Low

Weak (conditional)

Weak (conditional)

I3

How should inotropic/ vasoactive support be modified in patients with shock not responding to first-line agents?

ACCM

ACCM

ACCM

ISHLT

When a patient requires the use of inotropes/ vasopressors, frequent evaluation of BP, CO, SVR and peripheral perfusion is needed to guide further combination of drugs and/or fluids.

· Septic shock With Low CI, Normal Blood Pressure, and High SVR:

- Milrinone is considered the first-line inodilator in patients with epinephrine resistant

shock and normal blood pressure.

- Additional volume loading may be necessary to prevent hypotension.

- Norepinephrine can partly reverse hypotension associated with inodilators.

- Nitroprusside or nitroglycerin may be considered as second-line vasodilators.

- Levosimendan and enoximone may have a role with persistently low CO.

·  Septic shock With Low CI, Low Blood Pressure, and Low SVR:

-Norepinephrine can be added to/or substituted for epinephrine to increase DBP and SVR.

-Once an adequate blood pressure is achieved, dobutamine, milrinone,

enoximone or levosimendan may be added to norepinephrine to improve CI and

ScvO2 .

·  Septic shock With High CI and Low SVR:

- When titration of norepinephrine and fluid does not resolve hypotension,

vasopressin, angiotensin, or terlipressin can be helpful in restoring blood

pressure

- These drugs can reduce CO so CO/ScvO2 monitoring is necessary. Low-dose

epinephrine or dobutamine may be added to improve CO.

· Cardiogenic shock with low CI refractory to milrinone &/or dobutamine:

-Epinephrine has a role in the face of refractory hypotension and poor end-organ

perfusion.

-Levosimendan may be considered in children unresponsive to traditional

inotropic therapy.

High

High

High

Low

Weak (conditional)

Weak (conditional)

Weak (conditional)

Weak (conditional)

Table 12. Recommendations

J. Refractory shock

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

J1

What is the management of pediatric shock refractory to fluids and pharmacological support?

ACCM

ACCM

SSC

·       Children with refractory shock must be suspected to have unrecognized morbidities; such as:

-Inappropriate source control of infection (remove nidus and use effective antibiotics)

-Pericardial effusion (pericardiocentesis)

-Pneumothorax (thoracentesis)

-Hypoadrenalism (adrenal hormone replacement)

-Hypothyroidism (thyroid hormone replacement)

-Ongoing blood loss (blood replacement/hemostasis)

-Increased IAP (peritoneal catheter or abdominal release)

-Necrotic tissue (nidus removal)

-Excessive immunosuppression (wean immunosuppressants), or immunocompromise (restore immune function; e.g., white cell growth factors/transfusion for neutropenic sepsis).

·       ECMO is an important option to consider in refractory shock when potentially reversible causes are addressed.

· Venovenous ECMO is suggested in children with sepsis-induced PARDS and refractory hypoxia.

Venoarterial ECMO is suggested in children with septic shock refractory to all other treatments.

Moderate

High

Very low

Weak (conditional)

Weak (conditional)

Weak (conditional)

Table 13. Recommendations

K. Coticosteroids and antibiotics

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

K1

What is the role of corticosteroids and antibiotics in septic shock?

SSC

ACCM

ACCM

·       IV hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.

·  Ideally after attaining a blood sample for subsequent determination of baseline

cortisol concentration.

· In septic shock, broad spectrum antibiotics should be initiated within 60 minutes

After obtaining blood culture if it does not delay antibiotic administration

Low

High

High

Weak (conditional)

Weak (conditional)

Weak (conditional)

Table 14. Recommendations

L. Specific management of anaphylactic shock

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

L1

What is the specific management of anaphylactic shock?

EAACI

EAACI

EDP-Ana

EAACI

EDP-Ana

EAACI

EDP-Ana

·       Positioning: patients experiencing anaphylaxis should be positioned supine with elevated lower extremities if they have circulatory instability, sitting up if they have respiratory distress, and in recovery position if unconscious.

·  Adrenaline:

Adrenaline must promptly be administered as the first-line treatment for the emergency management of anaphylaxis.

- By intramuscular injection into the mid-outer thigh.

- In patients requiring repeat doses of adrenaline, these should be administered at least 5 min apart.

- If the patient is not responding to epinephrine injections, IV infusion of epinephrine should be given in a monitored setting.

- Do not routinely administer antihistamines or corticosteroids instead of epinephrine. There is no substitute for epinephrine in the treatment of anaphylaxis.

·       Other therapies:

-Trigger of the anaphylaxis episode should be remove.

- Administer additional vasopressors If parenteral epinephrine and fluid resuscitation fail to restore blood pressure.

- Administer an inhaled b-agonist if bronchospasm is a component of anaphylaxis.

- Administration of antihistamines and corticosteroids should be considered adjunctive therap.

- Systemic glucocorticosteroids may be used as they may reduce the risk of late phase respiratory symptoms.

- High-dose nebulized glucocorticoids may be beneficial for upper airway obstruction.

·  Strongly consider observing patients who have experienced anaphylaxis for at least 4 to 8 hours and observe patients with a history of risk factors for severe anaphylaxis (such as asthma, previous biphasic reactions, or protracted anaphylaxis) for a longer period.  Patients who have experienced anaphylaxis should consult an allergist/ immunologist.after discharge.

Very low

Very low

Moderate

Very low

Moderate

Moderate

Very low

Moderate

Moderate

Moderate

Very low

Very low

Moderate

Weak (conditional)

Weak (conditional)

Strong

Weak (conditional)

Strong

Weak (conditional)

Weak (conditional)

Strong

Strong

Weak (conditional)

Weak (conditional)

Weak (conditional)

Weak (conditional)