What is the management of shock in a newborn?

Management of Shock in Newborns

Immediate aggressive fluid resuscitation with 10 mL/kg isotonic crystalloid boluses up to 60 mL/kg within the first 5 minutes, followed by dopamine (5-9 mcg/kg/min) plus dobutamine (up to 10 mcg/kg/min) if shock persists at 15 minutes, then escalation to epinephrine (0.05-0.3 mcg/kg/min) by 60 minutes if unresponsive—this time-sensitive algorithmic approach reduces mortality in neonatal septic shock. 1

Initial Recognition and Stabilization (0-5 Minutes)

Recognize shock immediately by identifying decreased perfusion, poor tone, poor color, tachypnea, respiratory distress, or cyanosis—do not wait for hypotension as newborns maintain blood pressure until late decompensated shock. 1

• Maintain airway according to NRP guidelines and begin high-flow oxygen 1
• Establish IV or intraosseous access immediately 1
• Start prostaglandin infusion until ductal-dependent congenital heart disease is ruled out—any newborn with shock plus hepatomegaly, cyanosis, cardiac murmur, or differential upper/lower extremity pulses requires prostaglandin until echocardiography excludes complex congenital heart disease 1
• Measure preductal and postductal oxygen saturations—a difference >5% indicates right-to-left shunting through the ductus arteriosus, suggesting persistent pulmonary hypertension of the newborn (PPHN) 1, 2

Fluid Resuscitation (First 5 Minutes)

Administer 10 mL/kg boluses of isotonic saline or colloid, repeating up to 60 mL/kg total until perfusion improves—stop only if hepatomegaly develops, indicating fluid overload. 1

• Use crystalloid if hemoglobin >12 g/dL; transfuse packed red blood cells if hemoglobin <12 g/dL 1
• Correct hypoglycemia with D10%-containing isotonic IV solution at maintenance rate 1
• Correct hypocalcemia immediately 1
• Begin empiric antibiotics within 5 minutes unless rales or hepatomegaly develop 1

Critical pitfall: Unlike older children who may require 20 mL/kg boluses, newborns receive smaller 10 mL/kg boluses due to immature myocardial compliance, but total volume up to 60 mL/kg may still be necessary. 1

Fluid-Refractory Shock (15 Minutes)

If shock persists after adequate fluid resuscitation:

Start dopamine 5-9 mcg/kg/min plus dobutamine up to 10 mcg/kg/min as first-line inotropic therapy. 1

• Dopamine is superior for improving blood pressure in hypotensive infants 3
• Dobutamine improves systemic blood flow, especially in very low birth weight infants 3
• Do not use high-dose dopamine (>10 mcg/kg/min) as it increases pulmonary vascular resistance and worsens PPHN 2
• Obtain central venous access if not already established 1
• Consider intubation and mechanical ventilation if work of breathing is excessive 1

Catecholamine-Resistant Shock (60 Minutes)

Escalate to epinephrine 0.05-0.3 mcg/kg/min if shock persists despite dopamine/dobutamine. 1, 4

• Epinephrine provides both alpha and beta-adrenergic stimulation, increasing vascular tone and cardiac output 5
• Monitor for tachyarrhythmias and excessive vasoconstriction 1
• Add hydrocortisone if absolute adrenal insufficiency is suspected—defined as peak cortisol after ACTH <18 μg/dL, or basal cortisol <18 μg/dL in an appropriately volume-loaded patient requiring epinephrine 1
• Monitor central venous pressure and target ScvO2 >70% 1

PPHN-Specific Management

If preductal-postductal oxygen saturation differential >5% or echocardiography confirms PPHN:

• Start inhaled nitric oxide (iNO) at 20 ppm immediately—this is first-line therapy for PPHN and improves oxygenation by selective pulmonary vasodilation 1, 2
• Optimize lung recruitment with mechanical ventilation as this is critical for iNO efficacy 2
• Target >95% arterial oxygen saturation and <5% preductal-postductal gradient 1, 2
• In newborns with poor left ventricular function and normal blood pressure, add nitrosovasodilators or type III phosphodiesterase inhibitors (milrinone) to epinephrine—but volume load carefully when using systemic vasodilators 1

Very Low Birth Weight Infants

Administer IV pentoxifylline (5-day course, 6 hours per day) to reverse septic shock in VLBW babies. 1

Refractory Shock Management

Rule out reversible causes before escalating to ECMO:

• Pericardial effusion (perform pericardiocentesis) 1
• Pneumothorax (perform thoracentesis) 1
• Ongoing blood loss (replace blood and achieve hemostasis) 1
• Hypothyroidism (administer triiodothyronine) 1
• Inborn errors of metabolism (treat with glucose and insulin infusion or ammonia scavengers) 1
• Hemodynamically significant patent ductus arteriosus (consider closure) 1

Consider advanced hemodynamic monitoring with echocardiography, Doppler ultrasound, or measurement of superior vena cava (SVC) flow to guide therapy—target SVC flow >40 mL/kg/min and cardiac index >3.3 L/min/m². 1

Rescue vasopressors: Norepinephrine can be effective for refractory hypotension but ScvO2 must be maintained >70%—add additional inotrope if needed. 1 Vasopressin, terlipressin, or angiotensin can be considered only with adequate cardiac output and ScvO2 monitoring. 1

ECMO Indications

Consider ECMO when refractory shock persists despite maximal medical therapy or PaO2 <40 mmHg—current ECMO survival rate for newborn sepsis is 80%. 1

• ECMO flows >110 mL/kg/min should be avoided due to hemolysis risk 1
• Normalize calcium concentration in red blood cell pump prime (300 mg CaCl2 per unit of packed red blood cells) 1
• With veno-venous ECMO, persistent hypotension requires dopamine/dobutamine or epinephrine 1
• If fluid overload >10% develops despite diuretics, perform continuous renal replacement therapy (CRRT) on the ECMO circuit 1

Therapeutic Endpoints

Target the following goals to ensure adequate tissue perfusion:

• Capillary refill ≤2 seconds 1, 2
• Normal pulses without differential between peripheral and central 1
• Warm extremities 1
• Urine output >1 mL/kg/hr 1
• Normal mental status 1
• Normal blood pressure for age 1

• 95% arterial oxygen saturation 1

• <5% difference in preductal and postductal oxygen saturation 1, 2
• ScvO2 >70% 1
• SVC flow >40 mL/kg/min 1
• Cardiac index >3.3 L/min/m² 1, 6, 2

Monitoring Requirements

Continuous monitoring should include: preductal and postductal pulse oximetry, intra-arterial blood pressure (umbilical or peripheral), electrocardiogram, temperature, glucose and calcium concentrations, fluid balance, urine output, central venous pressure/oxygen saturation, cardiac output or SVC flow, INR, anion gap, and lactate. 1

Common Pitfalls

• Do not delay epinephrine if dopamine/dobutamine is ineffective—prolonged trials of inadequate therapy increase mortality 2
• Do not administer excessive fluid boluses in the absence of hypovolemia—myocardial dysfunction is common in extremely preterm infants and term infants with perinatal asphyxia, and excessive fluids worsen outcomes 3, 7
• Do not use diuretics in hypovolemic shock—diuretics are indicated only in hypervolemic patients with >10% fluid overload who cannot achieve fluid balance 1