Sections

Workup

Approach Considerations

Stabilization of the airway and breathing as well as aggressive intervention to improve the circulatory function of any patient in clinical shock always takes precedence over any further diagnostic evaluation.

After the initial stabilization, certain objective measures may help to solidify or better define the diagnosis. These measures initially may include obtaining the following laboratory studies:

Point-of-care glucose levels
Comprehensive metabolic panel (CMP)
Arterial (ABG) or venous blood gas (VBG) measurements
Serum lactate levels
Complete blood count (CBC) with differential
Prothrombin (PT) and partial thromboplastin (PTT) times
Fibrinogen and D-dimer levels
Fluid culture(s) (eg, blood, urine, cerebrospinal fluid [CSF])

Additional studies may help to identify an etiology and ultimately guide therapy of the patient in shock. Subsequent ancillary evaluation may also include the following:

Chest radiography
Mixed venous oxygen saturation
Central venous pressure measurement
Cardiac output (CO) monitoring
Near-infrared spectroscopy
B-type natriuretic peptide (BNP) levels
Serum biomarker profile

Comprehensive Metabolic Panel

A CMP may provide a wealth of information about the patient in shock. A decreased serum carbon dioxide level suggests a metabolic acidosis that may reflect a significant lactic acidosis from anaerobic metabolism associated with shock. Diarrhea also leads to direct bicarbonate loss, which may exacerbate metabolic acidosis in a patient with shock due to dehydration from diarrhea. Measurement of serum lactate levels may help to distinguish bicarbonate loss from lactic acidosis due to shock.

Hypernatremia suggests intravascular volume contraction that is consistent with hypovolemic shock. Hypoglycemia is common in shock and can rapidly be identified and treated with point-of-care testing. Elevated blood urea nitrogen (BUN) and creatinine levels and/or elevated aspartate transaminase (AST) and alanine transaminase (ALT) levels suggest secondary hypoxic-ischemic end-organ injury. Disturbed calcium homeostasis may result in low serum ionized calcium levels that can further depress myocardial function.

Blood Gas Analysis

An ABG study helps to determine the arterial oxygen tension (PaO₂) of the blood, assisting in titration of supplemental oxygen delivery to the patient in shock. In addition, ABG findings help to determine the patient's acid-base status, which reflects the degree of systemic shock and the patient's response to therapy.

VBGs may also be used to determine mixed venous oxygenation saturation (discussed below).

Complete Blood Count and Coagulation Studies

In assessing the CBC, the hemoglobin (Hb) concentration is particularly important, because it determines the blood's oxygen-carrying capacity. In patients with anemia who present in severe shock, early transfusion should be considered as soon as possible.

A significantly elevated or depressed white blood cell (WBC) count, along with a WBC differential that is suggestive of infection, could support the diagnosis of septic shock. Similarly, thrombocytopenia may herald a bleeding disorder that could result in internal hemorrhage or disseminated intravascular coagulation (DIC), which may accompany septic shock. Disordered coagulation cascade activation may be further evidenced by prolonged PT and partial PTT, low fibrinogen levels, and an elevated D-dimer level.

Fluid Culture

Sepsis must be ruled out as the cause of shock, especially in children younger than 3 months, those who are immunocompromised, and those who are unvaccinated.

To exclude a serious bacterial infection, blood cultures should be obtained at presentation for all febrile children younger than 3 months.^{[15, 16, 17]}Leukocyturia, procalcitonin, C-reactive protein, and absolute neutrophil count are lab markers that can help risk stratify which children would benefit from a lumbar puncture and empiric antibiotic treatment.^[18]In children older than 3 months and immunocompromised patients with fever, hypothermia, leukocytosis, or other concerns for bacterial infection, blood cultures should also be obtained and sent for analysis.

CSF and urine cultures should also be considered as dictated by the child's clinical presentation and host risk factors.

Chest Radiography

Evaluation of the cardiac silhouette on a chest radiograph may help to delineate cardiogenic shock, which may feature cardiomegaly (see the image below), from hypovolemic shock, in which the heart size appears small.

Chest radiograph in a patient with cardiomegaly, which may accompany cardiogenic shock.

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The chest radiograph may also reveal signs of pneumonia or other pulmonary disorders. Respiratory distress in a patient in shock may result from acute respiratory distress syndrome (ARDS), which may develop in any patient in shock or result from pneumonia and sepsis.

Point-of-Care Ultrasound

Point-of-care ultrasound (POCUS) continues to gain greater attention and use as it allows for the rapid and systematic evaluation of pediatric shock while avoiding risks associated with conventional radiographic techniques.{ref 62} Evaluation of shock is based on step-wise imaging of the heart, IVC, intraperitoneal cavity, and lung/pleura . Evaluation of the heart in the subxiphoid or parasternal long axis views allow for assessment of ventricular filling and function. Evaluation of the IVC is used a surrogate for central venous pressure and intravascular volume. On inspiration, negative thoracic pressure pulls blood form the IVC to the right atrium which can result in IVC collapse in volume depleted patients. An IVC-to-aorta ratio of greater than 0.8 suggest normal volume status. Evaluation of the pleural cavities allows for identification of pneumothoraces, pulmonary edema, and pleural effusions. Similarly, evaluation of the abdominal cavity can aid in rapid identification of free fluid and abdominal hemorrhage.

Mixed Venous Oxygen Saturation

Mixed VBG analysis can be utilized to determine the venous Hb oxygen saturation, or it can be directly measured by co-oximetry. A true mixed venous sample (SvO₂) from the pulmonary artery may be obtained from the distal port of a Swan-Ganz catheter—however, these catheters are infrequently utilized in pediatric patients. More often, the oxygen saturation of a sample of mixed central venous blood (ScvO₂) returning to the heart that is taken from a central venous catheter can be used as an SvO₂ surrogate.

By comparing the mixed venous oxygen saturation (ie, SvO₂) with the arterial oxygen saturation (SaO₂), the arteriovenous oxygen saturation difference and oxygen extraction ratio (O₂ ER) can be determined. In a patient with a relatively normal SaO₂ (93-100%), the normal SvO₂ is 65-77%, as the tissues typically extract 23-35% of oxygen delivered to them. If the oxygen extraction difference is greater than 35%, perfusion to the tissue capillary beds may be inadequate, reflecting a state of shock. Alternatively, if the oxygen extraction difference is less than 23%, oxygenated blood may be shunting past tissue capillary beds as a result of inappropriate distribution of blood flow (ie, distributive shock, with arteriovenous shunts resulting from vasodilation). Sepsis can also inhibit the cellular metabolic machinery, decreasing oxygen extraction and leading to an increase in venous saturation.

Central Venous Pressure

A central venous catheter in the superior vena cava may transduce the pressure generated by the blood in that vessel, the central venous pressure (CVP), which represents the back-pressure into the systemic venous circulation. Care must be taken to not rely entirely on such measurements. The cardiac filling pressure measured by these catheters reflects ventricular function and compliance—not necessarily intravascular volume alone. Nevertheless, such values, taken in context with the clinical examination findings, may help to determine the patient's clinical status. A normal CVP in a normal, compliant heart is typically 8-12 cm H₂ O. Higher pressures may reflect volume overload or poor right-sided heart compliance or function.

Cardiac Output Monitoring

Classically, the cardiac index (CI) is determined by pulmonary artery catheter measurement of the CO, although pulmonary artery catheterization is now infrequently done in pediatric patients. Instead, many innovative invasive or noninvasive surrogate technologies for CO determination are increasingly available and utilized in this patient population. These include Doppler echocardiography, the pulse contour cardiac output (PiCCO) catheter, and the femoral artery thermodilution catheter (FATD).

The CI is calculated by dividing the CO by the body surface area (BSA). Normal CI is 3.5-5.5 L/min/m², and values between 3.3 and 6 L/min/m² have been associated with optimal outcomes from pediatric septic shock.^{[19, 20]}Monitoring changes in CI during intravascular volume or cardiotropic infusions may help to guide and optimize administration of these therapies.

Near-Infrared Spectroscopy

A relatively new technology currently used in many pediatric intensive care units (PICUs) is near-infrared spectroscopy (NIRS).^{[21, 22, 23]}An optical probe placed over a patient's skin, such as the forehead, the flank over the kidneys, or the abdomen, sends an infrared signal through the skin and measures the pooled-tissue oxygen saturation. Because most of the blood in any given region is predominantly venous, the oxygen saturation is close to that of the tissue venous oxygen saturation in that region. This allows for a noninvasive measurement and an observation of the trend of an increased or decreased tissue oxygen saturation to be followed in critical tissue beds, such as the brain, kidneys, or mesenteric region. Such information may help to identify adequate or inadequate oxygen delivery. It is analogous to determining SvO₂ and may help to guide evaluation and response to therapy.

B-Type Natriuretic Peptide

BNP is a hormone produced by ventricular myocytes that is released in response to myocardial wall stress. In adult and pediatric studies, plasma BNP levels have been shown to be elevated in sepsis and in congestive heart failure with cardiogenic shock. Elevated levels of BNP reflect myocardial stress, and improvement in cardiac function is associated with normalization of BNP levels.^{[24, 25]}

Sepsis Biomarker Risk Model

Studies in recent years have focused on identification of serum protein biomarkers which may serve as prognostic indicators for pediatric sepsis. One such model, the PEdiatRic SEpsis biomarkEr Risk modEl (PERSEVERE), includes five proteins: C-C chemokine ligand 3 (CCL3), heat shock protein 70 kDa 1B (HSPA1B), interleukin-8 (IL-8), elastase 2 (ELA2), and lipocalin 2 (LCN2). This model estimated mortality with a sensitivity of 83% and a specificity of 75%.^{[26, 27]}

Treatment & Management

Epstein D, Randall CW. Cardiovascular physiology and shock. Nichols DG, ed. Critical Heart Disease in Infants and Children. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2006. 17-72.
Nadel S, Kissoon N, Ranjit S. Recognition and initial management of shock. Nichols DG, ed. Roger’s Textbook of Pediatric Intensive Care. Philadelphia, PA: Lippincott, William & Wilkins; 2008. 372-83.
Smith LS, Hernan LJ. Shock states. Fuhrman BP, Zimmerman J, eds. Pediatric Critical Care. 4th ed. Philadelphia, PA: Elsevier Saunders; 2011. 364-78.
American Academy of Pediatrics. Policy statement--child fatality review. Pediatrics. 2010 Sep. 126(3):592-6. [QxMD MEDLINE Link].
Ward A, Iocono JA, Brown S, Ashley P, Draus JM Jr. Non-accidental trauma injury patterns and outcomes: a single institutional experience. Am Surg. 2015 Sep. 81(9):835-8. [QxMD MEDLINE Link].
[Guideline] Simons FE, Ardusso LR, Dimov V, et al, for the World Allergy Organization. World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol. 2013. 162(3):193-204. [QxMD MEDLINE Link]. [Full Text].
Ackerman AD, Singhi S. Pediatric infectious diseases: 2009 update for the Rogers' Textbook of Pediatric Intensive Care. Pediatr Crit Care Med. 2010 Jan. 11(1):117-23. [QxMD MEDLINE Link].
Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan. 6(1):2-8. [QxMD MEDLINE Link].
Naghavi M, Wang H, Lozano R, et al, for the GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Jan 10. 385(9963):117-71. [QxMD MEDLINE Link]. [Full Text].
Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics. 2009 Aug. 124(2):500-8. [QxMD MEDLINE Link].
Fisher JD, Nelson DG, Beyersdorf H, Satkowiak LJ. Clinical spectrum of shock in the pediatric emergency department. Pediatr Emerg Care. 2010 Sep. 26(9):622-5. [QxMD MEDLINE Link].
Balamuth F, Weiss SL, Neuman MI, et al. Pediatric severe sepsis in U.S. children's hospitals. Pediatr Crit Care Med. 2014 Nov. 15(9):798-805. [QxMD MEDLINE Link]. [Full Text].
American Heart Association. Part 2: Systematic approach to the seriously ill or injured child. Chameides L, Samson RA, Schexnayder SM, Hazinski MF, eds. Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2011.
Carcillo JA. Capillary refill time is a very useful clinical sign in early recognition and treatment of very sick children. Pediatr Crit Care Med. 2012 Mar. 13(2):210-2. [QxMD MEDLINE Link].
Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics. 1994 Sep. 94(3):390-6. [QxMD MEDLINE Link].
Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993 Nov 11. 329(20):1437-41. [QxMD MEDLINE Link]. [Full Text].
Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr. 1992 Jan. 120(1):22-7. [QxMD MEDLINE Link].
Gomez B, Mintegi S, Bressan S, et al, for the European Group for Validation of the Step-by-Step Approach. Validation of the "Step-by-Step" approach in the management of young febrile infants. Pediatrics. 2016 Aug. 138(2):[QxMD MEDLINE Link]. [Full Text].
[Guideline] Davis AL, Carcillo JA, Aneja RK, et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med. 2017 Jun. 45(6):1061-93. [QxMD MEDLINE Link].
[Guideline] Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017 Mar. 43(3):304-77. [QxMD MEDLINE Link]. [Full Text].
Ferrari M, Mottola L, Quaresima V. Principles, techniques, and limitations of near infrared spectroscopy. Can J Appl Physiol. 2004 Aug. 29(4):463-87. [QxMD MEDLINE Link].
Adcock LM, Wafelman LS, Hegemier S, et al. Neonatal intensive care applications of near-infrared spectroscopy. Clin Perinatol. 1999 Dec. 26(4):893-903, ix. [QxMD MEDLINE Link].
Ghanayem NS, Wernovsky G, Hoffman GM. Near-infrared spectroscopy as a hemodynamic monitor in critical illness. Pediatr Crit Care Med. 2011 Jul. 12(4 Suppl):S27-32. [QxMD MEDLINE Link].
Post F, Weilemann LS, Messow CM, Sinning C, Munzel T. B-type natriuretic peptide as a marker for sepsis-induced myocardial depression in intensive care patients. Crit Care Med. 2008 Nov. 36(11):3030-7. [QxMD MEDLINE Link].
Domico M, Liao P, Anas N, Mink RB. Elevation of brain natriuretic peptide levels in children with septic shock. Pediatr Crit Care Med. 2008 Sep. 9(5):478-83. [QxMD MEDLINE Link].
Wong HR, Salisbury S, Xiao Q, et al. The pediatric sepsis biomarker risk model. Crit Care. 2012 Oct 1. 16(5):R174. [QxMD MEDLINE Link]. [Full Text].
Wong HR, Weiss SL, Giuliano JS Jr, et al. Testing the prognostic accuracy of the updated pediatric sepsis biomarker risk model. PLoS One. 2014. 9(1):e86242. [QxMD MEDLINE Link]. [Full Text].
[Guideline] de Oliveira CF, de Oliveira DS, Gottschald AF, et al. ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Med. 2008 Jun. 34(6):1065-75. [QxMD MEDLINE Link].
Sankar J, Sankar MJ, Suresh CP, Dubey NK, Singh A. Early goal-directed therapy in pediatric septic shock: comparison of outcomes "with" and "without" intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*. Pediatr Crit Care Med. 2014 May. 15(4):e157-67. [QxMD MEDLINE Link].
Dias CR, Leite HP, Nogueira PC, Brunow de Carvalho W. Ionized hypocalcemia is an early event and is associated with organ dysfunction in children admitted to the intensive care unit. J Crit Care. 2013 Oct. 28(5):810-5. [QxMD MEDLINE Link].
Broner CW, Stidham GL, Westenkirchner DF, Watson DC. A prospective, randomized, double-blind comparison of calcium chloride and calcium gluconate therapies for hypocalcemia in critically ill children. J Pediatr. 1990 Dec. 117(6):986-9. [QxMD MEDLINE Link].
Meert KL, Donaldson A, Nadkarni V, et al. Multicenter cohort study of in-hospital pediatric cardiac arrest. Pediatr Crit Care Med. 2009 Sep. 10(5):544-53. [QxMD MEDLINE Link]. [Full Text].
Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA. 1991 Sep 4. 266(9):1242-5. [QxMD MEDLINE Link].
Ranjit S, Kissoon N, Jayakumar I. Aggressive management of dengue shock syndrome may decrease mortality rate: a suggested protocol. Pediatr Crit Care Med. 2005 Jul. 6(4):412-9. [QxMD MEDLINE Link].
Oliveira CF, Nogueira de Ss FR, Oliveira DS, et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008 Dec. 24(12):810-5. [QxMD MEDLINE Link].
Voigt J, Waltzman M, Lottenberg L. Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis. Pediatr Emerg Care. 2012 Feb. 28(2):185-99. [QxMD MEDLINE Link].
Cole ET, Harvey G, Urbanski S, Foster G, Thabane L, Parker MJ. Rapid paediatric fluid resuscitation: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques in a simulated setting. BMJ Open. 2014 Jul 3. 4(7):e005028. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Stoner MJ, Goodman DG, Cohen DM, Fernandez SA, Hall MW. Rapid fluid resuscitation in pediatrics: testing the American College of Critical Care Medicine guideline. Ann Emerg Med. 2007 Nov. 50(5):601-7. [QxMD MEDLINE Link].
Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30. 364(26):2483-95. [QxMD MEDLINE Link].
Abulebda K, Cvijanovich NZ, Thomas NJ, et al. Post-ICU admission fluid balance and pediatric septic shock outcomes: a risk-stratified analysis. Crit Care Med. 2014 Feb. 42(2):397-403. [QxMD MEDLINE Link]. [Full Text].
Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med. 2014 Nov. 42(11):2409-17. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Kleinman ME, Chameides L, Schexnayder SM, et al, for the American Heart Association. Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010 Nov. 126(5):e1361-99. [QxMD MEDLINE Link].
Alejandria MM, Lansang MA, Dans LF, Mantaring JB 3rd. Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock. Cochrane Database Syst Rev. 2013 Sep 16. 9:CD001090. [QxMD MEDLINE Link].
Kissoon N, Carcillo JA, Espinosa V, et al, for the Global Sepsis Initiative Vanguard Center Contributors. World Federation of Pediatric Intensive Care and Critical Care Societies: Global Sepsis Initiative. Pediatr Crit Care Med. 2011 Sep. 12(5):494-503. [QxMD MEDLINE Link].
Pugni L, Ronchi A, Bizzarri B, et al. Exchange transfusion in the treatment of neonatal septic shock: a ten-year experience in a neonatal intensive care unit. Int J Mol Sci. 2016 May 9. 17(5):[QxMD MEDLINE Link].
Zimmerman JJ, Williams MD. Adjunctive corticosteroid therapy in pediatric severe sepsis: observations from the RESOLVE study. Pediatr Crit Care Med. 2011 Jan. 12(1):2-8. [QxMD MEDLINE Link].
Atkinson SJ, Cvijanovich NZ, Thomas NJ, et al. Corticosteroids and pediatric septic shock outcomes: a risk stratified analysis. PLoS One. 2014. 9(11):e112702. [QxMD MEDLINE Link]. [Full Text].
Menon K, McNally D, Choong K, Sampson M. A systematic review and meta-analysis on the effect of steroids in pediatric shock. Pediatr Crit Care Med. 2013 Jun. 14(5):474-80. [QxMD MEDLINE Link].
Wong HR, Atkinson SJ, Cvijanovich NZ, et al. Combining prognostic and predictive enrichment strategies to identify children with septic shock responsive to corticosteroids. Crit Care Med. 2016 Oct. 44(10):e1000-3. [QxMD MEDLINE Link].
Pizarro CF, Troster EJ, Damiani D, Carcillo JA. Absolute and relative adrenal insufficiency in children with septic shock. Crit Care Med. 2005 Apr. 33(4):855-9. [QxMD MEDLINE Link].
Schotola H, Toischer K, Popov AF, et al. Mild metabolic acidosis impairs the ß-adrenergic response in isolated human failing myocardium. Crit Care. 2012 Aug 13. 16(4):R153. [QxMD MEDLINE Link]. [Full Text].
Mathieu D, Neviere R, Billard V, Fleyfel M, Wattel F. Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Crit Care Med. 1991 Nov. 19(11):1352-6. [QxMD MEDLINE Link].
Aschner JL, Poland RL. Sodium bicarbonate: basically useless therapy. Pediatrics. 2008 Oct. 122(4):831-5. [QxMD MEDLINE Link].
Paden ML, Rycus PT, Thiagarajan RR. Update and outcomes in extracorporeal life support. Semin Perinatol. 2014 Mar. 38(2):65-70. [QxMD MEDLINE Link].
DiCarlo JV, Dudley TE, Sherbotie JR, Kaplan BS, Costarino AT. Continuous arteriovenous hemofiltration/dialysis improves pulmonary gas exchange in children with multiple organ system failure. Crit Care Med. 1990 Aug. 18(8):822-6. [QxMD MEDLINE Link].
Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med. 2004 Aug. 32(8):1771-6. [QxMD MEDLINE Link].
Vogt W, Laer S. Prevention for pediatric low cardiac output syndrome: results from the European survey EuLoCOS-Paed. Paediatr Anaesth. 2011 Dec. 21(12):1176-84. [QxMD MEDLINE Link].
Hoffman TM. Newer inotropes in pediatric heart failure. J Cardiovasc Pharmacol. 2011 Aug. 58(2):121-5. [QxMD MEDLINE Link].
Hoffman TM, Wernovsky G, Atz AM, et al. Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation. 2003 Feb 25. 107(7):996-1002. [QxMD MEDLINE Link].
Meyer S, Gortner L, Brown K, Abdul-Khaliq H. The role of milrinone in children with cardiovascular compromise: review of the literature. Wien Med Wochenschr. 2011 Apr. 161(7-8):184-91. [QxMD MEDLINE Link].
Bassler D, Kreutzer K, McNamara P, Kirpalani H. Milrinone for persistent pulmonary hypertension of the newborn. Cochrane Database Syst Rev. 2010 Nov 10. CD007802. [QxMD MEDLINE Link].
Hanna W, Wong HR. Pediatric sepsis: challenges and adjunctive therapies. Crit Care Clin. 2013 Apr. 29(2):203-22. [QxMD MEDLINE Link]. [Full Text].
Park DB, Presley BC, Cook T, Hayden GE. Point-of-care ultrasound for pediatric shock. Pediatr Emerg Care. 2015 Aug. 31(8):591-8; quiz 599-601. [QxMD MEDLINE Link].
Joynt C, Cheung PY. Cardiovascular supportive therapies for neonates with asphyxia - a literature review of pre-clinical and clinical studies. Front Pediatr. 2018. 6:363. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Duff JP, Topjian A, Berg MD, et al. 2018 American Heart Association focused update on pediatric advanced life support: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2018 Dec 4. 138(23):e731-e739. [QxMD MEDLINE Link]. [Full Text].
Samransamruajkit R, Limprayoon K, Lertbunrian R, et al. The utilization of the surviving sepsis campaign care bundles in the treatment of pediatric patients with severe sepsis or septic shock in a resource-limited environment: a prospective multicenter trial. Indian J Crit Care Med. 2018 Dec. 22(12):846-51. [QxMD MEDLINE Link]. [Full Text].
Carreiro S, Miller S, Wang B, et al, for the ACMT Toxicology Investigators Consortium (ToxIC). Clinical predictors of adverse cardiovascular events for acute pediatric drug exposures. Clin Toxicol (Phila). 2019 Jul 3. 1-7. [QxMD MEDLINE Link].

Media Gallery

Chest radiograph in a patient with cardiomegaly, which may accompany cardiogenic shock.
Determinants of cardiac function and oxygen delivery to tissues. FiO2 = fraction of inspired oxygen. Adapted from Strange GR. APLS: The Pediatric Emergency Medicine Course. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1998:34.
Hemodynamic response to shock hemorrhage model (based on normal data). Adapted from Adapted from Schwaitzberg SD, Bergman KS, Harris BH. A Pediatric Trauma Model of Continuous Hemorrhage. J Pediatr Surg. Jul 1988;23(7):605-9.
Pediatric shock management algorithm. ACTH = adrenocorticotropic hormone; CI = cardiac index; ECMO = extracorporeal membrane oxygenation; MAP-CVP = mean arterial pressure-central venous pressure; PALS = Pediatric Advanced Life Support; PDE = phosphodiesterase; PICU = pediatric intensive care unit; SVC O2 = superior vena cava oxygen saturation.

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Author

Eric A Pasman, MD Staff Pediatric Gastroenterologist, Division Officer, Pediatric Gastroenterology Division, Naval Medical Center San Diego; Associate Program Director, General Pediatrics Residency, Navy Medicine Readiness and Training Command San Diego; Associate Professor of Pediatrics, Uniformed Services University of the Health Sciences School of Medicine

Eric A Pasman, MD is a member of the following medical societies: American Academy of Pediatrics, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher M Watson, MD, MPH Professor, Department of Pediatrics, Medical College of Georgia at Augusta University

Christopher M Watson, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Dale W Steele, MD, MS Professor of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Warren Alpert Medical School of Brown University; Attending Physician, Department of Pediatric Emergency Medicine, Rhode Island Hospital

Dale W Steele, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American Statistical Association, Society for Medical Decision Making

Disclosure: Nothing to disclose.

Additional Contributors

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Adam J Schwarz, MD Consulting Staff, Critical Care Division, Pediatric Subspecialty Faculty, Children's Hospital of Orange County

Adam J Schwarz, MD is a member of the following medical societies: American Academy of Pediatrics and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

The views expressed are those of the authors and do not reflect the official policy or position of the US Navy, Department of Defense, or the US Government.