Etiology, clinical manifestations, evaluation, and management of neonatal shock
- Beau Batton, MD
Beau Batton, MD
- Associate Professor of Pediatrics and Chief of Neonatology
- Southern Illinois School of Medicine
- Section Editor
- Richard Martin, MD
Richard Martin, MD
- Section Editor — Neonatology
- Professor, Pediatrics, Reproductive Biology, and Physiology & Biophysics
- Case Western Reserve University School of Medicine
Shock is a dynamic and unstable pathophysiologic state characterized by inadequate tissue perfusion. Although the effects of inadequate perfusion are reversible initially, prolonged hypoxemia leads to the disruption of critical biochemical processes, which if not addressed results in cell death, end-organ failure, and, possibly, death.
While the classification and underlying pathogenetic mechanisms of neonatal shock are the same as those seen in pediatric and adult shock, the etiology and clinical manifestations vary and are often unique to neonates. (See "Initial evaluation of shock in children" and "Definition, classification, etiology, and pathophysiology of shock in adults".)
The pathogenesis, etiology, stages, clinical presentation, evaluation, and management of neonatal shock will be reviewed here.
●Shock, or circulatory failure, is defined as a physiologic state characterized by tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization. It is manifested by physical findings of tissue hypoperfusion (eg, cold extremities, acrocyanosis, and poor capillary refill), hypotension, and metabolic acidosis. It is important to recognize that hypotension, which is commonly used to define shock states in adults, is generally a late finding of shock in neonates. Shock is often initially reversible, but must be recognized and treated immediately to prevent progression to irreversible organ dysfunction.
Of note, blood pressure (BP) values vary significantly based on gestational age (GA) and postnatal age (figure 1 and figure 2), particularly for extremely preterm infants born <28 weeks GA. As such, defining hypotension in this population is challenging. (See "Etiology, clinical manifestations, evaluation, and management of low blood pressure in extremely preterm infants".)
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- ETIOLOGIC CLASSIFICATION
- Hypovolemic shock
- Distributive shock
- Cardiogenic shock
- Obstructive shock
- Multifactorial shock
- CLINICAL MANIFESTATIONS
- Physical findings
- - Vital signs
- - Decreased peripheral perfusion
- Other clinical manifestations
- Laboratory findings
- INITIAL STABILIZATION
- DIAGNOSTIC EVALUATION
- Physical examination
- Basic laboratory studies
- Additional studies
- GOAL-DIRECTED THERAPY
- - Physiologic goal-oriented parameters
- Monitoring response
- SUBSEQUENT THERAPY
- THERAPEUTIC INTERVENTIONS
- Fluid resuscitation
- - Type of solution
- - Volume and rate
- Vasoactive agents
- - Dopamine
- - Epinephrine
- - Dobutamine
- - Milrinone
- SUMMARY AND RECOMMENDATIONS