Due to physiological differences and strong compensatory mechanisms, children can lose a significant percentage of their circulating volume within a few hours yet remain in a “compensated” phase of shock as evidenced by normal blood pressures. Decompensated shock, or shock with hypotension, is a late and ominous sign in pediatric patients1, and can indicate imminent cardiovascular collapse.2 Maintaining or restoring adequate perfusion volume with controlled but rapid fluid bolus therapy is a critical component of addressing these patients.3,4 Earlier fluid delivery targeted at shock reversal results in decreased morbidity,5-7 mortality,5,7 and hospital length of stay (LOS).7,8
This blog is the second in a two-part series on pediatric hypovolemic shock. Part one, When Minutes Matter: Treating Pediatric Hypovolemic Shock, discussed the risks, signs and treatment modalities, including early diagnosis and volume resuscitation, related to hypovolemic shock in pediatric patients. The following case is a child who initially presented to an Emergency Department (ED) in compensated hypovolemic shock that appeared to be gastrointestinal in nature, but eventually became hypotensive, had delayed capillary refill, and required rapid fluid resuscitation.
A 6 yr old, 19 kg. previously healthy female presented to the ED with a history of vomiting and bloody diarrhea for 24 hours. In triage her temperature was 98.6, heart rate was 121, respiratory rate was 24, blood pressure was 114/70, and pulse ox was 96% on room air. The child’s mother reported that her daughter had vomited every 20 minutes since waking that day and that the last three episodes of diarrhea had been mixed with blood and mucous.
On presentation to the ED, the child appeared dehydrated based on a visual assessment; she had slightly sunken eyes, pale skin, and was fatigued. However, thanks to her strong compensatory mechanisms in the face of hypovolemic shock, she had relatively normal vital signs and remained normotensive. Within thirty minutes, her perfusion worsened and she became increasingly pale, with cool, dry skin and delayed capillary refill. Her heart and respiratory rates were now 116 and 21 respectively, relatively unchanged, but her blood pressure had decreased to 77/39. The ED team recognized that this child was transitioning into decompensated shock and needed aggressive fluid resuscitation to prevent further clinical deterioration.
Using the LifeFlow rapid infusion device, the providers were able to deliver four 20 ml/kg fluid boluses through her 22 gauge IV within 15 minutes, including set-up time, with continuous assessment of her perfusion and vital signs. Infusing the same amount of fluids through a 22 gauge IV using the “push-pull” technique would have added ten additional minutes to the delivery time, additional complexity and work, and greater risk of bacterial contamination from the repeated use of a single-use syringe.9 Using an IV pump at its highest speed to deliver the same amount of fluid would have taken over 1.5 hours. After a total of 80mls/kg, the child’s perfusion was visibly improved, her heart rate was 123, respiratory rate was 23, blood pressure was 84/50, and pulse ox was 100% on room air. Her blood pressures remained stable for the next hour with systolic in the 80’s-90’s until she was transported to the pediatric floor for observation. She was eventually diagnosed with the norovirus and discharged home within 12 hours.
Children are known for their strong compensatory mechanisms. They have a unique ability to remain in compensated shock longer than adults,1,8 sometimes disguising a precarious underlying situation. It is critical that children in hypovolemic shock be identified and fluid resuscitated in the compensated phase, before hypotension develops, to prevent decompensated shock from occurring that can quickly lead to tissue ischemia, organ failure and death. Careful but aggressive fluid resuscitation for children in compensated hypovolemic shock is key to helping prevent decompensated shock and minimizing the complications associated with it. Using LifeFlow for rapid, controlled IV fluid delivery in this patient allowed the providers to quickly arrest the decreasing blood pressure and other symptoms of decompensated shock. Traditional methods of rapid IV fluid delivery, including IV pumps, mechanical rapid infusers and push-pull, can be too slow or complex for situations where patients are in shock and need perfusion restored immediately.
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- Emergency Nurses Association (2019). Emergency Nursing Pediatric Course Provider Manual Fifth Edition. Jones & Bartlett Learning. Des Plaines, IL.
- Piehl, M., Smith-Ramsey, C., & Teeter, W. A. (2019). Improving fluid resuscitation in pediatric shock with LifeFlow®: a retrospective case series and review of the literature. Open access emergency medicine : OAEM, 11, 87–93. doi:10.2147/OAEM.S188110
- Fuchs CS, Tomasek J, Yong CJ, et al; Investigators RT. Ramucirumab monotherapy for previously treated advanced gas- tric or gastro-oesophageal junction adenocarcinoma (REGARD): an international, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet. 2014;383:31–39. doi:10.1016/S0140- 6736(13)61719-5
- Martin K, Weiss SL. Initial resuscitation and management of pedia- tric septic shock. Minerva Pediatr. 2015;67:141–158.
- Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional mor- bidity after use of PALS/APLS by community physicians. Pediatrics. 2009;124:500–508. doi:10.1542/peds.2008-1967
- Balamuth F, Weiss SL, Fitzgerald JC, et al. Protocolized treatment is associated with decreased organ dysfunction in pediatric severe sepsis. Pediatr Crit Care Med. 2016;17:817–822. doi:10.1097/ PCC.0000000000000858
- Akcan Arikan A, Williams EA, Graf JM, Kennedy CE, Patel B, Cruz AT. Resuscitation bundle in pediatric shock decreases acute kidney injury and improves outcomes. J Pediatr. 2015;167:1301– 1305 e1301. doi:10.1016/j.jpeds.2015.08.044
- Lane RD, Funai T, Reeder R, Larsen GY. High reliability pediatric septic shock quality improvement initiative and decreasing mortality. Pediatrics. 2016;138:e20154153.
- Robertson, G., Lane, A., Piehl, M., Whitfill, T., & Spangler, H. (2018). Comparison of a novel rapid fluid delivery device to traditional methods. 410 Medical, Inc; Durham, NC.