Sneha Sood, MD

ObjectivesTo discuss the causes of neonatal shockTo discuss management of shock in the

delivery room and nurseryTo understand the placement of a

stabilization umbilical vein catheter in emergency management of shock

Definition Circulatory failure with inadequate organ and

tissue perfusion resulting in impaired delivery of oxygen and substrates as well as impaired excretion of metabolic waste products.

Can result in cellular dysfunction and deathMay be accompanied by hypotension

Most Common Causes of Shock

HypovolemiaCardiogenicSepsis

Intrapartum HemorrhagePlacenta previa/abruptionUmbilical cord injuryTwin-twin transfusionMaternal-fetal hemorrhageFetal hemorrhage

Postpartum

Brain hemorrhageLungsAdrenal glandsScalp

Cardiogenic ShockCongenital heart diseaseArrhythmiaSevere hypoglycemiaAsphyxiaBacterial or viral infectionSevere metabolic/electrolyte abnormalitiesHypoxemia and metabolic acidosis

Septic ShockBacterial or viralExtremely illUsually require significant respiratory and blood

pressure supportHigh risk of development of Persistent Pulmonary

Hypertension of the Newborn (PPHN)

Other Causes of ShockVasoactive shock without sepsis due to

endothelial injury, mediator release Obstruction due to cardiac tamponade,

pneumothoraxInadequate oxygen releasing capacity

such as severe anemia or methemoglobinemia.

Signs of Shock

Observation of overall status of neonate: Does baby appear sick or well based on respiratory status, color, activity, tone. Are there any obvious abnormalities.

Problem focused physical examinationExtent of exam may be limited by degree of

distress

Cyanotic NeonateFrom: University of Missouri Health Systems Web Site

Pale BabyFrom: University of Missouri Health Systems]and New York Presbyterian Morgan Stanley Children’s Hospital

Signs of Shock: Cardiorespiratory

Examine heart and lungs first; important to identify and manage cardiorespiratory problems as one of the first priorities per NRP and basic ABCs.

Signs of Shock: RespiratoryAssessment on physical exam:

Breathing comfortably or signs of respiratory distress

Chest symmetryAuscultation for equality of breath sounds,

aeration, quality of breath soundsRespiratory manifestations of shock could include:

Respiratory distress/failureApneaGasping respirations

Respiratory FailureFrom:tumj.tums.ac.ir/archive/vol65/no2/issue.html

Signs of Shock: CardiacCardiac exam to include heart rate, heart

sounds, pulses, perfusion. Blood pressure if able to measure.

Signs of Shock: CardiacHeart Rate

Cardiac output determined: stroke volume x HR; neonates with little capacity to increase stroke volume so more likely to compensate via HR.

Normal: 120-160 bpm; may range 80-200Bradycardia: < 100

Cardiac: Congenital Heart block Metabolic derangements: Metabolic acidosis,

Hypoxemia, hypotension may depress myocardium Well baby may have low resting HR

Tachycardia: > 180 (sustained) Cardiac arrhythmia Volume depletion Heart failure, decreased cardiac output Activity can increase HR in well baby

Signs of Shock: Cardiac

Rhythm: normal sinus vs arrhythmiaPresence of heart murmur

Innocent vs. pathologic due to CHDNot all CHD associated with heart murmur

Signs of shockPerfusion

Prolonged capillary refill > 3 secondsCoolMottling

Capillary RefillFrom: EMS Responder.com

Mottled skin in Neonate

Signs of Shock: CardiacPulses

Weak pulsesDifferential between upper and lower

extremity pulses could suggest coarctation or hypoplasia of aorta

HypotensionMean blood pressure (MBP) used for reference in

NeonatesDefinition of hypotension: < 5th percentile for

gestational ageGood estimate of lower limit of MBP is gestational

age, especially in premature infant≥ 30 mmHg by 72 hours, even in the premature

infantControversy as to whether to treat if MBP low but

perfusion and pulses good.Blood pressure may not be abnormal in the early

stage of shock

Blood Pressure ParametersPicture from Kliegman, Nelson Textbook of Pediatrics, 18th ed

Neurological StatusActivityToneCrySymmetry of movements

ManagementImportant to recognize neonatal shock based on brief

physical exam.Volume expansion will be the primary therapy.

Normal saline is the volume expander of choice. Other volume expanders included Ringer’s lactate and O- PRBCs if fetal anemia is expected.

Limited physical exam will focus on general observation, auscultation, and perfusion/pulses. Accept limitations based on physical environment in DR. BP cannot be immediately measured.

Address basics of NRP first: Stimulation, drying, warmth, airway stabilization. A cold, wet baby can mimic one in shock.

Assess need for chest compressions and emergency drugs.

Babies may also manifest signs of shock in the post-resuscitation phase.

Management

Place stabilization UVC in the delivery room if baby too unstable to transfer to the nursery. Obviously a baby requiring chest compressions or other intensive resuscitation cannot be taken to the nursery.

Stabilization UVC can provide a site to give emergency drugs and volume expanders.

ManagementFor shock give NS, 10 ml/kg over 5-10 min;

repeat x 2 every 5-10 minutes depending on clinical response. In small babies at risk for IVH consider giving 10 ml/kg NS over 20-30 min.

Consider early use of dopamine in consultation with the Pediatrician and Neonatologist in small babies at risk for IVH, especially when < 1000 grams.

Obviously if small baby is in shock in the DR and deteriorating then volume must be given more rapidly.

ManagementO- blood can be pushed in DR in

emergency situations for acute blood loss; give in 10 ml/kg aliquots; avoid giving blood electively in the nursery unless at a level II or tertiary care center; blood may not be CMV negative. Base need for transfusion on discussion with Neonatologist.

Management in the NurseryCR monitor and pulse oximeter immediately on

arrival in the nursery. Pulse oximeter can be placed in the DR.

Maintain oxygen saturations*:85-93% if < 32 weeks or < 1500 grams90-98% in all other babies

Consider higher saturations over 95% in late preterm or term/posterm infants if PPHN suspected.

*These are only recommendations and based on personal practice and practice guidelines at Kapi’olani Medical Center

Management in the NurseryCheck VS to include BP, examine baby.PIV, UVC and UAC if needed can be if

skilled personnel are available. Stabilization UVC not usually left in place

for long periods time; however, if unable to place other lines do not remove the stabilization UVC.

Line placement very important before running fluids; obtain abdomen/CXR. Do not run fluids through UVC if placement in liver.

Management

If blood pressure or perfusion still poor after 3 boluses of NS consider starting dopamine .

Epinephrine should be reserved for babies refractory to treatment with dopamine and in consultation with the physician or transport team.

DopaminePremix solutions

800-,1600-,3200 mcg/ml Mix from vial

40 mg/ml, 80 mg/ml, 160 mg/mlCan mix as a variety of concentrationsDA: 400 mg/250 ml=1600 mcg/mlDose 2-20 mcg/kg/min

From Neofax 2008

Dopamine Titration ChartFrom Neofax 2008

Concentration(mcg/ml)

Dose(mcg/kg/min)

IV rateml/kg/hr

1600 2.5 0.094

5 0.19

7.5 0.28

10 0.38

ManagementStart maintenance IVFBaseline labs should include CBC/blood

culture/blood gasObtain bedside glucose as stressed babies may

have either hypoglycemia or hyperglycemiaIf blood sugar < 40 mg% give 2 ml/kg D10W

IVP and repeat blood sugar in 30 min; if blood sugar < 50 mg% repeat glucose in 1 hour.

Start Ampicillin and gentamicin for possible sepsis

Treat metabolic acidosis with NaHCO3 if unresponsive to volume expansion and adequate ventilation.

ManagementRemember that a baby with shock due to

suspected cyanotic congenital heart disease may require prostin to keep PDA open. Suspect in babies with unequal pulses (coarctation or hypoplastic aortic arch) or if unresponsive to oxygen and ventilation.

Placement of Stabilization UVCPicture from American Journal of Roentgenology, Schlesinger et al, 2003

Placement of Stabilization UVCClean umbilical cord quickly with antiseptic. In a

premature infant sterile water is best for cleaning the site.

Prepare single lumen umbilical catheter of the appropriate size by connecting to stopcock

Prefill single lumen umbilical catheter with normal saline using a 3 ml syringe

Make sure that stopcock is closed to the baby so that no free air can enter the catheter.

Place an umbilical tie at the base of the umbilical cord.

Placement of Stabilization UVCCut the umbilical cord leaving about 1-2 cm from

the skin line after tightening umbilical tie.Insert the catheter into the single umbilical vein

until you see blood return when you open the stopcock and aspirate with the syringe. This is usually about 2-4 cm (less in a preterm baby). In a stabilization UVC only insert the catheter far enough to get blood return. You do not want the catheter to be in the liver.

After giving epinephrine or volume expander give 0.5-1 ml NS to clear the drug from the catheter.

Catheter PlacementUAC

T6-T9 = high lineL3-L5 = low line

UVCAbove diaphragm, avoid liver

Stabilization UVC Well below liver

Normal UAC and UVC placement with UAC going downward before ascending and at T9; UVC passes directly into UVC and is at T7. ETT at carina.

UVC very high and entering the heart.UAC high at T3-T4.

UVC in right portal veinPicture from American Journal of Roentgenology, Schlesinger et al, 2003

UVC in left portal vein Picture from American Journal of Roentgenology, Schlesinger et al, 2003

Stabilization UVC