Fluid management in

pediatric shock

Rismala Dewi
Emergency and Pediatric Intensive Care Division
FMUI-CMH

Pediatric Assessment Triangle

Circulation

Hemodynamics
Myocardial
Contractility
Stroke Volume
Cardiac Output
Blood
Pressure

Afterload

Heart Rate
Systemic Vascular
Resistance

Preload

pediatric

Understanding some of physiological

differences will help when working with a
critically ill child

Hypotension is a late
and premorbid sign

Preload

Stroke
Volume

Cardiac Output

Heart Rate
Afterload

Contractility

A state in which there is inadequate

tissue

perfusion

to

meet

metabolic

demands

It is not LOW BLOOD PRESSURE !!!

It is HYPOPERFUSION..

Hypotension is a late
and premorbid sign

Stages of Shock
COMPENSATED

vital organ function is maintained, BP remains

normal, tachycardia

UNCOMPENSATED

microvascular perfusion is compromised; significant

reductions in effective circulating volume

IRREVERSIBLE

inadequate perfusion of vital organs; irreparable

damage; death cannot be prevented

Whatever the cause, the body responds in similar way

The questions must be answered:

Does the child require emergent therapy?
What kind of fluid should be given?
How much fluid and what rate should fluid be
given initially and then in follow-up?

Management

Volume
replacement

Fluid
replacement

Total body water = 60% body weight

Intracellular water
40% body weight

14%

5% 1%

SHOCK

Interstitial
100

Transcellular

200
Plasma

Osmolality mOsm/L

300

Extracellular water
20% body weight

Fluid balance paradigm

Normal heart rate

Normal pulses
Capillary refill time < 2 seconds
Normal blood pressure
Warm extremities
Normal mental status
Urine output >1 mL/kg/hr

Which
fluid?

Cristalloid

Colloid

Advantages

Advantages

Extracellular space expanders

Good intravascular persistence

Lactare buffer

Reduced resuscicitation time

Limited plasma volume expansion

Moderate volume required

Maintain urinee output

Enhancing microvascular flow

Reduced plasma oncotic pressure

Minor risk of tissue oedem

Cheap

Moderation of SIRS

Disadvantages

Disadvantages

Poor plasma volume support

Risk of volume overload

Reduce plasma COP

Adverse effect on haemostasis

Large quantities needed

Tissue accumulation

Risk of overhydration

Adverse effect on renal function

Risk of hyponatremia

Risk of anaphylaxis

More expensive

Initial fluid resuscitation with crystalloid

minimal 20 mL/Kg in children
Goal
directed
(targeted)

Consider addition of albumin in patient

requiring substantial amounts of crystalloid
to maintain adequate MAP

Dont give too much Fluid!!

Hepatomegaly
Rales
Increased WOB
Jugular venous pressure
Chest X-ray
USCOM
Echocardiography
Fluid responsiveness

Problem to be concern
Metabolic
acidosis

Volume
overload

Coagulopathy

Electrolyte
imbalance

Fluid shift
and raised
ICP

Maintenance fluid

Meta- analysis iv fluids in children:

-hypotonic vs. isotonic-

Isotonic solutions

Hyponatremia

Choong, K et al. Arch Dis Child 2006;91:828-835

Monitor

Stable
hemodynamic?

N
Continue volume
replacement

Volume
responsive?

N
Cold extremities?

INOTROPIC

VASOPRESSOR

Conclusion
Recognize compensated shock quickly-have
a high index of suspicion, remember
tachycardia is first sign and hypotension is
late and ominous
Assessment , management of fluid balance
and prescription of appropriate fluid
constitute some of challenges for clinician