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Electrolyte Abnormalities
Electrolyte abnormalities such as hypoglycemia or hypocalcemia may precipitate
or worsen existing shock. Blood glucose and ionized calcium can both be
measured rapidly via bedside point of care testing and should be measured during
the initial resuscitation. If present, hypoglycemia and hypocalcemia should be
corrected during the initial resuscitation.
If an inborn error of metabolism is known or suspected, diagnostic evaluation
should also include measurement of serum ammonia levels. This includes
neonates with shock of unknown etiology, as their initial presentation may be due
to metabolic crisis. With the exception of children with glucose-6-phosphate
dehydrogenase deficiency, all children with inborn errors of metabolism in shock
should receive dextrose-containing fluids (at least D10 ) to aid in the conversion
from catabolic to anabolic state. Any center treating a patient with known or
suspected inborn error of metabolism should consult immediately with a specialty
center while resuscitating with volume and dextrose as above.
As mentioned above, hyperchloremia may develop with large-volume fluid
resuscitation using 0.9% saline. Hyperchloremia can induce a metabolic acidosis
and has been shown to reduce renal blood flow in animal studies. Recently,
hyperchloremia has been associated with a greater risk of organ dysfunction, in
particular acute kidney injury, and increased risk of mortality in pediatric septic
shock. Transition from 0.9% saline to resuscitation using balanced fluids, such as
LR or Plasma-Lyte, may help to limit the degree of hyperchloremia although
whether this contributes to improved clinical outcomes is not clear.