Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 17 , ISSUE 4 ( August, 2013 ) > List of Articles

RESEARCH ARTICLE

Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock

Niranjan Kissoon, Suchitra Ranjit

Keywords : Children, diagnosis, echocardiography, myocardial dysfunction, outcome, sepsis, septic shock, therapy

Citation Information : Kissoon N, Ranjit S. Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock. Indian J Crit Care Med 2013; 17 (4):224-230.

DOI: 10.4103/0972-5229.118426

License: CC BY-ND 3.0

Published Online: 01-08-2013

Copyright Statement:  Copyright © 2013; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Objective: To report changes in the cardiovascular management of fluid and inotropic resistant septic shock in children based on echocardiography. Design: Retrospective case series. Setting: Tertiary care Pediatric Intensive Care Unit (PICU), Chennai. Patients: Twenty-two patients with unresolved septic shock after 60 ml/kg fluid plus inotropic agents in the first hour. Interventions: Bedside echocardiography (echo) within 6 h of admission to the PICU. Results: Over a 28-month period, of 37 patients with septic shock, 22 children remained in shock despite 60 ml/kg fluid and dopamine and/or dobutamine infusions as per guidelines. On clinical exam, 12 patients had warm shock and ten had cold shock, however, six exhibited an unusual pattern of cold shock with wide pulse pressures on invasive arterial monitoring. The most common echocardiographic finding was uncorrected hypovolemia in 12/22 patient while ten patients had impaired left ± right ventricular function. Echocardiography permitted an appreciation of the underlying disordered pathophysiology and a rationale for adjustment of treatment. Shock resolved in 17 (77%) and 16 patients (73%) survived to discharge. Conclusions: Bedside echo provided crucial information that was not apparent on clinical assessment and affords a simple noninvasive tool to determine the cause of low cardiac output in patients who remain in shock despite 60 ml/kg fluid and inotropic support. Most patients in our series had vasodilatory shock with wide pulse pressures and most common finding on echo was uncorrected hypovolemia. The echo findings allowed adjustment of therapy which was not possible based on clinical examination alone.


PDF Share
  1. Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009;37:666-88.
  2. Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Hemodynamic support in fluid-refractory pediatric septic shock. Pediatrics 1998;102:e19.
  3. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. International Surviving Sepsis Campaign Guidelines Committee, American Association of Critical-Care Nurses, American College of Chest Physicians, American College of Emergency Physicians, Canadian Critical Care Society, European Society of Clinical Microbiology and Infectious Diseases. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.
  4. Melendez E, Bachur R. Advances in the emergency management of pediatric sepsis. Curr Opin Pediatr 2006;18:245-53.
  5. Khilnani P, Singhi S, Lodha R, Santhanam I, Sachdev A, Chugh K, et al. Pediatric Sepsis Guidelines: Summary for resource-limited countries. Indian J Crit Care Med 2010;14:41-52.
  6. Tibby SM, Hatherill M, Marsh MJ, Murdoch IA. Clinicians′ abilities to estimate cardiac index in ventilated children and infants. Arch Dis Child 1997;77:516-8.
  7. Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2-8.
  8. Choong K, Bohn D, Fraser DD, Gaboury I, Hutchison JS, Joffe AR, et al. Vasopressin in pediatric vasodilatory shock: A multicenter randomized controlled trial. Am J Respir Crit Care Med 2009;180:632-9.
  9. Brown JM. Use of echocardiography for hemodynamic monitoring. Crit Care Med 2002;30:1361-4
  10. Vignon P, Chastagner C, François B, Martaillé JF, Normand S, Bonnivard M, et al. Diagnostic ability of hand-held echocardiography in ventilated critically ill patients. Crit Care 2003;7:R84-91.
  11. Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, et al. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics 2004;114:e667-71.
  12. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 2003;10:973-7.
  13. Beaulieu Y. Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med 2007;35:S144-9.
  14. Ranjit S, Kissoon N, Jayakumar I. Aggressive management of dengue shock syndrome may decrease mortality rate: A suggested protocol. Pediatr Crit Care Med 2005;6:412-9.
  15. Foland FA, Fortenberry JD, Warshaw BL, Pettignano R, Merritt RK, Heard ML, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: A retrospective analysis. Crit Care Med 2004;32:1771-6.
  16. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134:172-8.
  17. Parrillo JE, Parker MM, Natanson C, Suffredini AF, Danner RL, Cunnion RE, et al. Septic shock in humans. Advances in the understanding of pathogenesis, cardiovascular dysfunction, and therapy. Ann Intern Med 1990;113:227-42.
  18. Brierley J, Peters MJ. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. Pediatrics 2008;122:752-9.
  19. Hunter JD, Doddi M. Sepsis and the heart. Br J Anaesth 2010;104:3-11.
  20. Kumar A, Haery C, Parrillo JE. Myocardial dysfunction in septic shock: Part I. Clinical manifestation of cardiovascular dysfunction. J Cardiothorac Vasc Anesth 2001;15:364-76.
  21. Court O, Kumar A, Parrillo JE, Kumar A. Clinical review: Myocardial depression in sepsis and septic shock. Crit Care 2002;6:500-8.
  22. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010;126:e1361-99.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.