Epinephrine for SHOCK

Epinephrine for SHOCKPediatric shock warrants great concern. Whether it is caused by Sepsis, Hypovolemia, Obstructive process (ex, Tamponade, PE, Pneumothorax), Cardiogenic  conditions, or “K“ortisol deficiency (Yes, I know it should be “Cortisol”… but then it wouldn’t spell SHOCK.) there are many management decisions to be made.  How do we detect shock in those tricky kids?  What do we do when access is denied?  When do we need to consider PGE1?  There are so many questions to consider.  Unfortunately, some children in SEPTIC shock will be refractory to your initial therapies and another question will be encountered: Which pressor should we start: Epinephrine or Dopamine?

 

Fluid-Refractory Shock

  • Sepsis is a leading cause of mortality worldwide, although improvements have been made.
    • Once septic shock is present the mortality can be as high as 50%. [Wolfier, 2008]
    • Guidelines published have emphasized the need for:
      • Early recognition and
      • Rapid fluid administration.
  • Keep your Differential open!
    • While ordering empiric antibiotics, consider the other causes of SHOCK in children.
    • The child with fluid-refractory shock deserves a second and third consideration for the other possible culprits!
    • Use your bedside Ultrasound [Doniger, 2010; ALIEM]
      • Pericardial Effusion & Tamponade?
      • Overview of heart function / squeeze / size
      • IVC volume? – perhaps more fluids aren’t the answer
      • Pneumothorax?
      • Free intra-abdominal fluid? – Is there occult trauma??

 

Be Aggressive and Rapid!

  • The goal of the 1st hour of resuscitation is to restore normal perfusion, blood pressure and heart rate. [Brierley, 2009]
    • Vascular access needs to be rapidly attained.
      • Large bore peripheral IVs or IOs.
      • Central lines play a role in the management of the critically ill, but should NOT divert attention away from more time sensitive tasks.
    • Rapidly bolus fluids
      • Do not hang to gravity or on a “pump.”
      • Use syringe pushes or pressure bags
      • Children commonly will require 40-60 ml/kg in the 1st hour, but may require more (some say 200 ml/kg in 1st hour in right clinical setting). [Brierley, 2009]
    • Don’t forget about Glucose!
      • SERIOUSLY… always think about glucose like you are Homer Simpson thinking about donuts!

 

Vasopressors can be Started Peripherally

  • Do not hesitate to start vasopressors.
    • Children with fluid-refractory shock tend to respond to inotropes. [Ceneviva, 1998]
    • Reversing shock is associated with better survival.
  • Common perception is that vasoactive medications (vasopressors) need to be give via central line.
    • In an ideal setting, this is reasonable. That 1st hour of critical illness is often not ideal.
    • There is no data clarifying whether one vasopressor is more harmful when given peripherally than another. [Brierley, 2009]
  • Epinephrine has been shown to be safe and effective when given via peripheral IV or IO in the setting of Septic Shock.  [Ramaswamy, 2016; Ventura, 2015]
  • Time is critical; central lines aren’t easy in children; PIVs and IOs work just fine!

 

Epinephrine vs Dopamine

  • Short answer = there is no perfect vasopressor and no perfect answer.
  • Traditional teaching and prior guidelines have listed Dopamine as 1st line therapy. [Brierley, 2009]
  • Adult literature has raised concerns about safety of Dopamine [De Backer, 2010]
  • Dopamine is known to not be as effective in young children (<6 months). [Brierley, 2009]
  • Not many pediatric studies compare vasopressors, but today two small, RTC trials exist: Ramaswamy, 2016; Ventura, 2015
    • Both compared peripheral Epinephrine vs peripheral Dopamine as 1st choice.
    • For children with Fluid-Refractory Shock:
      • Epinephrine was more effective in resolving the refractory shock
      • Epinephrine resolved shock more rapidly than dopamine
      • Survival rates were higher in cohorts receiving epinephrine. [Ventura, 2015]

 

References

Ramaswamy KN1, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016 Sep 23. PMID: 27673385. [PubMed] [Read by QxMD]

Lalgudi Ganesan S1, Jayashree M. Dopamine in Pediatric Fluid-Refractory Septic Shock: Too Early to Sound the Death Knell? Crit Care Med. 2016 Feb;44(2):e110-1. PMID: 26771804. [PubMed] [Read by QxMD]
Ventura AM1, Shieh HH, Bousso A, Góes PF, de Cássia F O Fernandes I, de Souza DC, Paulo RL, Chagas F, Gilio AE. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med. 2015 Nov;43(11):2292-302. PMID: 26323041. [PubMed] [Read by QxMD]

Sankar J1, Das RR, Jain A, Dewangan S, Khilnani P, Yadav D, Dubey N. Prevalence and outcome of diastolic dysfunction in children with fluid refractory septic shock–a prospective observational study. Pediatr Crit Care Med. 2014 Nov;15(9):e370-8. PMID: 25230313. [PubMed] [Read by QxMD]

Simpson JN1, Teach SJ. Pediatric rapid fluid resuscitation. Curr Opin Pediatr. 2011 Jun;23(3):286-92. PMID: 21508842. [PubMed] [Read by QxMD]

Doniger SJ1. Bedside emergency cardiac ultrasound in children. J Emerg Trauma Shock. 2010 Jul;3(3):282-91. PMID: 20930974. [PubMed] [Read by QxMD]

De Backer D1, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A, Defrance P, Gottignies P, Vincent JL; SOAP II Investigators. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89. PMID: 20200382. [PubMed] [Read by QxMD]

Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009 Feb;37(2):666-88. PMID: 19325359. [PubMed] [Read by QxMD]

Wolfler A1, Silvani P, Musicco M, Antonelli M, Salvo I; Italian Pediatric Sepsis Study (SISPe) group. Incidence of and mortality due to sepsis, severe sepsis and septic shock in Italian Pediatric Intensive Care Units: a prospective national survey. Intensive Care Med. 2008 Sep;34(9):1690-7. PMID: 18500425. [PubMed] [Read by QxMD]

Ceneviva G1, Paschall JA, Maffei F, Carcillo JA. Hemodynamic support in fluid-refractory pediatric septic shock. Pediatrics. 1998 Aug;102(2):e19. PMID: 9685464. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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5 Responses

  1. Casey says:

    Any data in norepinephrine in kids with sepsis. Seems to be winning the popularity stakes in adults. Why not kids too?

    • Sean Fox says:

      None that I have seen. But this is also only two papers on Épi vs Dopa for kids. Many more studies exist for adult patients. Perhaps now with some evidence to base more research on though.

  2. Donna says:

    I am thinking about your quote, “always think about glucose like you are Homer Simpson thinking about donuts!” from your Morsel published 10/07/2016. Could you tell me how you might act in our situation or point me to some valid references?

    The D25W syringes for our pediatric ER kits have been recalled and no replacement supplies can be found (neither the manufacturer or the unscrupulous secondary drug vendors have any product or substitute product to provide). We are a very rural Critical Access Hospital so we don’t offer pharmacy compounding services around the clock. We do have D10W 1000ml and D50W 50ml syringes available in the Emergency Department at this time.

    I know that you are busy with Pediatric EM Morsels and your practice so I thank you in advance for your time.

    Donna

    • Sean Fox says:

      THANK YOU FOR YOUR COMMENT!
      That is a predicament… and one more of us find ourselves in.

      The issue can be dealt with by either:
      1) Diluting your D50W down to D25W, with 1:1 ratio of sterile water.
      2) Using Rule of 50 (volume of dextrose given is the quotient of 50/dextrose content)
      – D10W x 5 ml/kg = 50 (Use for neonates and young infants)
      – D25W x 2 ml/kg = 50 (Use for children)
      – D50W x 1 ml/kg = 50 (Use for adolescents and adults)

      So you could use 5ml/kg of the D10W that you have. That may be best as it will lead to less issues with errors in dilution.

      Hope that that helps.
      -sean

  1. April 28, 2017

    […] “reassures” us.  We have discussed several topics related to shock previously (ex, Epi vs Dopa, Pediatric Shock Index, and Damage Control Resuscitation), but now let us focus on recognizing […]

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