What is the management of shock in a newborn?

Management of Shock in Newborns

Immediately administer 10 mL/kg isotonic crystalloid boluses up to 60 mL/kg within the first hour while simultaneously securing airway and vascular access, then escalate to dopamine/dobutamine if perfusion does not normalize, as this approach reduces mortality in neonatal shock. 1, 2

Initial Recognition and Differential Diagnosis

Recognize shock early by identifying tachycardia, respiratory distress, poor feeding, poor tone, poor color, reduced perfusion, or tachypnea—do not wait for hypotension to develop, as newborns compensate until late decompensation occurs. 1

Critical pitfall: Any newborn presenting with shock plus hepatomegaly, cyanosis, cardiac murmur, or differential upper/lower extremity blood pressures or pulses requires immediate prostaglandin infusion until ductal-dependent congenital heart disease is excluded by echocardiography. 1

Check for inborn errors of metabolism causing hyperammonemia or hypoglycemia, as these can mimic septic shock and require different management. 1

Measure preductal versus postductal oxygen saturation—a differential >5% indicates right-to-left shunting through the ductus arteriosus from persistent pulmonary hypertension of the newborn (PPHN), which complicates newborn septic shock and requires specific therapy. 1, 3

Airway and Breathing Management

Intubate and ventilate based on increased work of breathing, inadequate respiratory effort, or marked hypoxemia—do not delay if any of these are present. 1

Administer volume loading before intubation because positive pressure ventilation reduces preload and can precipitate cardiovascular collapse. 1

Optimize lung recruitment as this is critical for PPHN management and improves inhaled nitric oxide efficacy if needed. 3

Target 100% oxygen saturation initially and maintain <5% preductal-postductal gradient. 3

Vascular Access and Monitoring

Establish umbilical arterial and venous line access as preferred routes per neonatal resuscitation program guidelines. 1

Continuously monitor temperature, preductal and postductal pulse oximetry, intra-arterial blood pressure, electrocardiogram, arterial pH, urine output, glucose, and ionized calcium concentrations. 1

Fluid Resuscitation Protocol

Administer 10 mL/kg isotonic crystalloid boluses (saline or lactated Ringer's), repeating as needed up to 60 mL/kg total in the first hour. 1, 2

Stop fluid boluses immediately if hepatomegaly or increased work of breathing develops, as these indicate fluid overload. 1, 2

Run D10%-containing isotonic IV solution at maintenance rate to provide age-appropriate glucose delivery and prevent hypoglycemia. 1

If hemoglobin is low, transfuse packed red blood cells instead of crystalloid to maintain adequate oxygen delivery. 4

Therapeutic Endpoints to Target

• Capillary refill ≤2 seconds 1, 2
• Normal pulses with no differential between peripheral and central 1, 2
• Warm extremities 1, 2
• Urine output >1 mL/kg/hour 1, 2
• Normal mental status 1
• Normal blood pressure for age 1, 2
• Normal glucose and calcium concentrations 1
• Arterial oxygen saturation >95% 1
• Preductal-postductal oxygen saturation difference <5% 1, 3

Inotropic Support for Fluid-Refractory Shock

Start dopamine and dobutamine as first-line inotropic therapy if shock persists after adequate fluid resuscitation. 2, 5

Dobutamine improves systemic blood flow especially in very low birth weight infants, while dopamine is superior for correcting hypotension. 5

Critical pitfall: Do not use high-dose dopamine as it significantly increases pulmonary vascular resistance and worsens PPHN. 3

Escalate to epinephrine if shock persists despite dopamine and dobutamine—do not delay with prolonged trials when the infant remains unstable. 2, 3

Consider milrinone or levosimendan as newer inodilators in selected settings, particularly when myocardial dysfunction is prominent. 5

PPHN-Specific Management

Initiate inhaled nitric oxide (iNO) at 20 ppm immediately if preductal-postductal oxygen saturation differential is >5% or if echocardiography confirms PPHN. 2, 3

Titrate iNO based on response, as this is first-line therapy for PPHN. 2, 3

Refractory Shock Management

Suspect occult morbidities including pericardial effusion (requiring pericardiocentesis), pneumothorax (requiring thoracentesis), hypoadrenalism (requiring adrenal hormone replacement), hypothyroidism (requiring thyroid hormone replacement), ongoing blood loss (requiring blood replacement/hemostasis), increased intra-abdominal pressure (requiring peritoneal catheter or abdominal release), or necrotic tissue (requiring nidus removal). 1

Consider advanced hemodynamic monitoring with echocardiography, Doppler ultrasound, or measurement of superior vena cava flow to guide therapy and select appropriate interventions. 2, 6

Use point-of-care cardiac ultrasound to individualize assessment, select appropriate therapy (fluid versus inotrope versus vasopressor), and monitor response. 5, 6

Consider norepinephrine as a rescue vasopressor if refractory hypotension persists despite maximal medical therapy. 2, 4

ECMO Indications

Consider extracorporeal membrane oxygenation (ECMO) if refractory shock persists despite maximal medical therapy or if oxygenation index exceeds 25. 2, 3

Calculate oxygenation index as: (Mean airway pressure × FiO2 × 100) / PaO2. 3

Expected survival with ECMO is approximately 50%, so carefully weigh risks versus benefits. 1

If ECMO is initiated, maintain flows <110 mL/kg/min to avoid hemolysis, measure free hemoglobin and keep <10 μg/dL, normalize calcium concentration in red blood cell pump prime (usually requires 300 mg CaCl2 per unit of packed red blood cells), and verify cannula placement with chest radiograph and ultrasound. 1