Neonatal shock

The Mystery of The Shocked BabyThe Mystery of The Shocked Baby

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.

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.

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

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.

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.

What is the problem with
this baby ?

Shock:Shock:
Shock is the inadequate perfusionShock is the inadequate perfusion
of the body’s vital organsof the body’s vital organs

Indices of tissue perfusion
 Pallor & skin mottling
 Capillary refill time (>3 sec)
 Heart rate ( > 170 Bmin )
 Toe-core temperature difference (>2ºC)
 Urine output (<1 mL/kg/hr)
 Blood lactate (>2.5 mmol/L)

Causes of neonatal shock
O2
Pump
Pipes
Circulation
Tank
Non
Vital
Vital
organs

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.

Algorithm for management of shock:

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.

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.

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/min
Significant peripheral VC &
increase in PVR and blood
pressure
10 to 20 μg/kg/min

Dobutamine
Mech: produces vasodilation and increases
Cardiac muscle contration.
1st line in:
 Preterm < 48 hrs
 PPHN
 Heart failure

Adrenalin (The most potent inotrope)
Adrenalin results in significant
increases in:
 Myocardial contractility
 Cardiac output
 Peripheral vascular resistance
 Blood pressure

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

When to response ??
Reassess within 10 min
of fluid bolus
Reassess every 15–20 min of new dose
of Inotropes

Caution !!
Inotropic agents: contraindicated in
hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is
common in IDMs

Caution !!
Catecholamines : Never administer intra-
arterially
Dopamine shown to suppress TSH
secretion

Remember !!
Correction of negative inotropic
factors:
as hypoxia, hypoglycemia, hypocalcemia, acidosis
and electrolytes imbalance,
if present.
Digoxin is used in non-critically ill infants.

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)

Textbook of Neonatal
Resuscitation, 7th Edition

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.

NaHco3 side effects
 IVH (with rapid infusion)
 Increase PCO2 so decrease pH
(if given during inadequate ventilation)
 Local tissue necrosis
 Hypocalcemia
 Hypernatremia and hypokalemia

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.

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.

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.

Investigations
 Serum glucose
 Blood gases
 Hematocrit (Hct)
 Electrolyte
 CBC, CRP, and cultures
 Chest x-ray
 Echocardiography & ECG
 Renal functions & Liver function tests

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.

Chest X-ray: Cardiomegaly, increased
pulmonary vascularity.

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.

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.

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.

When Baby respond to PGE-1 ?
Maximum effect seen within 30 min
in cyanotic lesions,
may take several hours in acyanotic
lesions

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)

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.

Shock & Assisted Ventilation
NCPAP is Contraindicated in Severe
cardiovascular instability.
Ventilation is an excellent inotrope

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 )

Refractory Shock:
Hidden Hemorrhage
Subgaleal HemorrhageAdrenal hemorrhage

Refractory Shock:
Hidden Hemorrhage
Fractured Humerus Fractured femur

Refractory Shock:
Periventricular hemorrhage / intraventricular hemorrhage

Refractory Shock:
Pneumothorax

Refractory Shock:
Pneumopericardium

Refractory Shock:
Pneumothorax & Pneumopericardium

Recent Approach :Recent Approach :
Functional Echocardiography and
Doppler Flow Velocimetry:
 Assessment of global heart contractility
 Assessment of superior vena cava flow

Take Home Massage
Once shock is suspected start
supportive measures as soon as
possible.
Thereafter, treatment is directed by
the underlying pathology.

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

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.

Neonatal shock

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Editor's Notes