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SUMIRAH BUDI PERTAMI

Objectives
 To discuss the causes of neonatal shock
 To discuss management of shock in the delivery room
and nursery
 To 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 death
 May be accompanied by hypotension
Most Common Causes of Shock

 Hypovolemia
 Cardiogenic
 Sepsis
Intrapartum Hemorrhage
 Placenta previa/abruption
 Umbilical cord injury
 Twin-twin transfusion
 Maternal-fetal hemorrhage
 Fetal hemorrhage
Postpartum
 Brain hemorrhage
 Lungs
 Adrenal glands
 Scalp
Subgaleal Hemorrhage
Cardiogenic Shock
 Congenital heart disease
 Arrhythmia
 Severe hypoglycemia
 Asphyxia
 Bacterial or viral infection
 Severe metabolic/electrolyte abnormalities
 Hypoxemia and metabolic acidosis
Septic Shock
 Bacterial or viral
 Extremely ill
 Usually require significant respiratory and blood
pressure support
 High risk of development of Persistent Pulmonary
Hypertension of the Newborn (PPHN)
Other Causes of Shock
 Vasoactive shock without sepsis due to endothelial
injury, mediator release
 Obstruction due to cardiac tamponade,
pneumothorax
 Inadequate 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 examination
 Extent of exam may be limited by degree of distress
Cyanotic Neonate
From: University of Missouri Health Systems Web Site
Pale Baby
From: 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: Respiratory
 Assessment on physical exam:
 Breathing comfortably or signs of respiratory distress
 Chest symmetry
 Auscultation for equality of breath sounds, aeration,
quality of breath sounds
 Respiratory manifestations of shock could include:
 Respiratory distress/failure
 Apnea
 Gasping respirations
Respiratory Failure
From:tumj.tums.ac.ir/archive/vol65/no2/issue.html
Signs of Shock: Cardiac
 Cardiac exam to include heart rate, heart sounds,
pulses, perfusion. Blood pressure if able to measure.
Signs of Shock: Cardiac
 Heart 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 80-200
 Bradycardia: < 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 arrhythmia
 Presence of heart murmur
 Innocent vs. pathologic due to CHD
 Not all CHD associated with heart murmur
Signs of shock
 Perfusion
 Prolonged capillary refill > 3 seconds
 Cool
 Mottling
Capillary Refill
From: EMS Responder.com
Mottled skin in Neonate
Signs of Shock: Cardiac
 Pulses
 Weak pulses
 Differential between upper and lower extremity pulses
could suggest coarctation or hypoplasia of aorta
Hypotension
 Mean blood pressure (MBP) used for reference in Neonates
 Definition of hypotension: < 5th percentile for gestational
age
 Good estimate of lower limit of MBP is gestational age,
especially in premature infant
 ≥ 30 mmHg by 72 hours, even in the premature infant
 Controversy 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 Parameters
Picture from Kliegman, Nelson Textbook of Pediatrics, 18th ed
Neurological Status
 Activity
 Tone
 Cry
 Symmetry of movements
Management
Management
 Important 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.
Management
 For 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.
Management
 O- 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 Nursery
 CR 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 grams
 90-98% 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 Nursery
 Check 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.
Dopamine
 Premix solutions
 800-,1600-,3200 mcg/ml
 Mix from vial
 40 mg/ml, 80 mg/ml, 160 mg/ml
 Can mix as a variety of concentrations
 DA: 400 mg/250 ml=1600 mcg/ml
 Dose 2-20 mcg/kg/min

From Neofax 2008


Dopamine Titration Chart
From Neofax 2008

Concentration Dose IV rate


(mcg/ml) (mcg/kg/min) ml/kg/hr
1600 2.5 0.094

5 0.19

7.5 0.28

10 0.38
Management
 Start maintenance IVF
 Baseline labs should include CBC/blood culture/blood gas
 Obtain bedside glucose as stressed babies may have either
hypoglycemia or hyperglycemia
 If 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.
Management
 Remember 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 UVC
Picture from American Journal of Roentgenology, Schlesinger et al, 2003
Placement of Stabilization UVC
 Clean 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 UVC
 Cut 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 Placement
 UAC
 T6-T9 = high line
 L3-L5 = low line
 UVC
 Above 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 vein
Picture 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