Schock in Children

Overview

For decades paediatricians were concerned with shock in children. Originally interest was focused on the solution of critical hypovolaemias caused by loss of extracellular fluid, diarrhoea and vomiting (toxic dyspepsia). From infusion therapy dealing with fluid replacement and modification of the internal environment in particular by infusions of hypoosmolal solutions and alkalination with bicarbonate, attention was focused on problems of tissue hypoxia. Oxygen deficiency was however conceived only as a problem of impaired gas exchange between the lungs and blood („normal gases“ in arterial blood). Gradually attention was focused on disorders of the systemic circulation (normal blood pressures).The concept of hypoxia during shock as tissue, cellular hypoxia with a decline of PaO2 below 0.26 kPa in mitochondria (Pasteur’s point when anaerobic glycolysis begins) along with the pathophysiological view on shock as a systemic inflammatory reaction when cascades of biologically active factors escape control laid the foundations of modern comprehensive treatment of shock.The cornerstones of treatment are: to maintain proper ventilation (do not hesitate to use artificial pulmonary ventilation!), penetration into the venous circulation (bone marrow) and resuscitation of the circulation 20 - 40 ml/kg/h by saline solutions corresponding as to composition blood serum (blood or plasma volume expanders after a blood loss greater than 30% volume) and support of the circulation by catecholamines (dobutamine in different combinations with dopamine in a total dose of cca 10 mg/kg/min). To maintain the proper systemic vascular resistance - significant vasodilatation: adrenalin or noradrenalin 0.05 - 1.0 mg/kg/min, significant vasoconstruction: sodium nitroprusside 1.0 mg/kg/min or amrinon 0.75 - 3 mg/kg followed by 3 - 10 mg/kg/min.In treatment moreover an important place is held by analgosedation (e.g. ketamine 0.5 - 1 mg/kg followed by 10 mg/kg/min). If we decide for corticosteroids then it is useful to administer methyl prednisolone 30 mg/kg or dexamethasone 2 mg/kg. Treatment must be initiated before, due to the action of not inhibited systemic inflammatory reaction organ damage develops.The future of treatment of shock is in blocking trigger mechanisms (antibody against endotoxin) and arrest the systemic inflammatory reaction (corticosteroids, antibodies against cytokines, their soluble receptors, immunoglobulins, non-steroidal antiphlogistics, adenosine, pentophylline, iNOS inhibitors, anticoagulants and procoagulants, antioxidants).Further advances will ensue from artificial pulmonary ventilation incl. non-conventional ones, methods of extracorporal elimination and promotion of substitution of the failing circulation and respiration such as cardiopulmonary bypass, ECMO and others which so far have only an experimental character.

Key words:
shock, children, historical review, pathophysiology - contemporary knowledge, systemic inflammatory reactions, treatment - contemporary views