Pediatric Hemodynamic monitoring

Posted on by Jesse Shriki, DO, MS RDMS FACEP
Source: American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med 2017; 45:1061–1093
Monitoring Goals:
  1. Capillary refill <2 or equal to 2 seconds
  2. Normal pulses with no differential between the peripheral and central pulses,
  3. Warm extremities,
  4. Urine output greater than 1mL/kg/hr,
  5. Normal mental status,
  6. Normal blood pressure for age (only reliable when pulses palpable)
    1. Normal SBP ranges (lowest 5th percentile)
      1. 0-1mos          >60 mmHg
      2. 1 mos-1 yr     >70 mmHG
      3. 1 yr -10 yr      >70+ 2 x Age mmHg
      4. >10 yr            >90 mmHg
  8. Blood Markers:
    1. glucose concentration
      1. Neonates < 45 mg/dL; infants/children < 60 mg/dL
      2. Rule of 50 (or 100)
    3. ionized calcium concentration
      1. Calcium gluconate 100 mg/kg IV/IO (max 2g) PRN
Airway/Breathing
  1.     Etomidate not recommneded
    1. Ketamine with consideration of atropine
Circulation
  1.     IO if pt >3kg
  2. Fluid Bolus
    1. 10 ml/kg unto 1 mos old
    2. 20 ml/kg >1 mos old
    3. May require up to. 60 ml/Kg
  4. Vasopressors
    1. Epinephrine
      1. Considered first line
      2. May run via PIV
      3. Dilute 10x more than central solution
      4. Run at 0.05–0.3 μg/kg/min
    3. Dopamine
Hydrocortisone Therapy
  1. Dose 2 mg/kg to max of 100 mg
  2. If a child is “at risk of absolute adrenal insufciency or adrenal pituitary axis failure”
  3. e.g., purpura fulminans, congenital adrenal hyperplasia, prior steroid exposure, hypothalamic/pituitary abnormality, intubation with etomidate induction
  4. remains in shock despite epinephrine or norepinephrine infusion
  5. after attaining a blood sample for subsequent determination of baseline cortisol concentration.

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