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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
*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
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