Citation Information :
Rao SS, Lalitha A, Reddy M, Ghosh S. Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study. Indian J Crit Care Med 2021; 25 (2):185-192.
Aim: To evaluate the utility of noninvasive electrocardiometry (ICON®) for hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. Materials and methods: Pilot prospective observational study in a 12-bedded tertiary pediatric intensive care unit (PICU) in children aged between 2 months and 16 years with unresolved septic shock after a 20 mL/kg fluid bolus. Those with cardiac index (CI) <3.3 L/min/m2 and systemic vascular resistance index (SVRI) >1600 dyn sec/cm5/m2 were classified as vasoconstrictive shock–electrocardiometry (VCEC) and those with CI >5.5 L/min/m2 and SVRI <1000 dyn sec/cm5/m2 as vasodilated shock–electrocardiometry (VDEC). Fluid responsiveness was defined as a 10% increase in CI with a 20 mL/kg fluid bolus. Sepsis-induced myocardial dysfunction (SMD) was diagnosed on echocardiography. Outcomes studied included clinical shock resolution, length of PICU stay, and mortality. Results: Thirty children were enrolled over 6 months with a median (interquartile range) age and pediatric risk of mortality (PRISM) III score of 87(21,108) months and 6.75(1.5,8.25), respectively; 14(46.6%) were boys and 4(13.3%) died. Clinically, 19(63.3%) children had cold shock and 11(36.7%) had warm shock; however, 16(53.3%) children had VDEC (including five with clinical cold shock) and 14(46.7%) had VCEC using electrocardiometry. Fluid responsiveness was seen in 16(53.3%) children, 10 in the VCEC group and 6 in the VDEC group. In the VCEC group, the responders had a significant rise in CI and a fall in SVRI, while the responders in the VDEC group had a significant rise in CI and SVRI. Fluid responders, compared to nonresponders, had a significantly higher stroke volume variation (SVV) before fluid bolus (24.1 ± 5.2% vs. 18.2 ± 3.5%, p < 0.001) and a higher reduction in SVV after fluid bolus (10.0 ± 2.8% vs. 6.0 ± 4.5%, p = 0.006), higher lactate clearance (p = 0.03) and lower vasoactive-inotropic score (p = 0.04) at 6 hours, higher percentage of clinical shock resolution at 6 (p = 0.01) and 12 hours (p = 0.01), and lesser mortality (p = 0.002). Five (16.6%) children with VCEC had SMD and were less fluid responsive (p = 0.04) with higher mortality (p = 0.01) compared to those without SMD. Conclusions and clinical significance: Continuous, noninvasive hemodynamic monitoring using electrocardiometry permits hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. This may provide real-time guidance for optimal interventions, and thus, improve the outcomes.
Aneja RK, Carcillo JA. Differences between adult and pediatric septic shock. Minerva Anestesiol 2011;77(10):986–992.
Weiss SL, Fitzgerald JC, Pappachan J, Wheeler D, Jaramillo-Bustamante JC, Salloo A, et al. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med 2015;191(10):1147–1157. DOI: 10.1164/rccm.201412-2323OC.
Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, et al. American college of critical care medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 2017;45(6):1061–1093. DOI: 10.1097/CCM.0000000000002425.
Brierley J, Peters MJ. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. Pediatrics 2008;122(4):752–759. DOI: 10.1542/peds.2007-1979.
Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Hemodynamic support in fluid-refractory pediatric septic shock. Pediatrics 1998;102(2):e19. DOI: 10.1542/peds.102.2.e19.
Ranjit S, Aram G, Kissoon N, Ali MK, Natraj R, Shresti S, et al. Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study. Pediatr Crit Care Med 2014;15(1):e17–e26. DOI: 10.1097/PCC.0b013e3182a5589c.
Teboul JL, Saugel B, Cecconi M, De Backer D, Hofer CK, Monnet X, et al. Less invasive hemodynamic monitoring in critically ill patients. Intensive Care Med 2016;42(9):1350–1359. DOI: 10.1007/s00134-016-4375-7.
Chaiyakulsil C, Chantra M, Katanyuwong P, Khositseth A, Anantasit N. Comparison of three non-invasive hemodynamic monitoring methods in critically ill children. PLoS One 2018;13(6):e0199203. DOI: 10.1371/journal.pone.0199203.
Nguyen LS, Squara P. Non-invasive monitoring of cardiac output in critical care medicine. Front Med 2017;4:200. DOI: 10.3389/fmed.2017.00200.
Klugman D, Berger JT. Echocardiography as a hemodynamic monitor in critically ill children. Pediatr Crit Care Med 2011;12:S50–S54. DOI: 10.1097/PCC.0b013e3182211c17.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41(2):580–637. DOI: 10.1097/CCM.0b013e31827e83af.
Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015;43(1):68–73. DOI: 10.1097/SHK.0000000000000268.
Kattan E, Ospina-Tascón GA, Teboul JL, Castro R, Cecconi M, Ferri G. Systematic assessment of fluid responsiveness during early septic shock resuscitation: secondary analysis of the ANDROMEDA-SHOCK trial. Crit Care 2020;24(1):23. DOI: 10.1186/s13054-020-2732-y.
Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care 2016;6(1):111. DOI: 10.1186/s13613-016-0216-7.
Desgranges FP, Desebbe O, Pereira de Souza Neto E, Raphael D, Chassard D. Respiratory variation in aortic blood flow peak velocity to predict fluid responsiveness in mechanically ventilated children: a systematic review and meta-analysis. Pediatr Anesth 2016;26(1):37–47. DOI: 10.1111/pan.12803.
Osypka MJ, Bernstein DP. Electrophysiologic principles and theory of stroke volume determination by thoracic electrical bioimpedance. AACN Clin Issues 1999;10(3):385–399. DOI: 10.1097/00044067-199908000-00008.
Blohm ME, Obrecht D, Hartwic J, Mueller GC, Kersten JF, Weil J, et al. Impedance cardiography (electrical velocimetry) and transthoracic echocardiography for non-invasive cardiac output monitoring in pediatric intensive care patients: a prospective single-center observational study. Crit Care 2014;18(6):603. DOI: 10.1186/s13054-014-0603-0.
Coté CJ, Sui J, Anderson TA, Bhattacharya ST, Shank ES, Tuason PM, et al. Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients. Pediatr Anesth 2015;25(2):150–159. DOI: 10.1111/pan.12441.
Malik V, Subramanian A, Chauhan S, Hote M. Correlation of electric cardiometry and continuous thermodilution cardiac output monitoring systems. World J Cardiovasc Surg 2014;04:101–108. DOI: 10.4236/wjcs.2014.47016.
Rauch R, Welisch E, Lansdell N, Burrill E, Jones J, Robinson T, et al. Non-invasive measurement of cardiac output in obese children and adolescents: comparison of electrical cardiometry and transthoracic Doppler echocardiography. J Clin Monit Comput 2012;27:187–193. DOI: 10.1007/s10877-012-9412-7.
Sanders M, Servaas S, Slagt C. Accuracy and precision of non-invasive cardiac output monitoring by electrical cardiometry: a systematic review and meta-analysis. J Clin Monit Comput 2019 (published online). DOI: 10.1007/s10877-019-00330-y.
Martin E, Anyikam A, Ballas J, Buono K, Mantell K, Huynh-Covey T, et al. A validation study of electrical cardiometry in pregnant patients using transthoracic echocardiography as the reference standard. J Clin Monit Comput 2016;30(5):679–686. DOI: 10.1007/s10877-015-9771-y.
Schmidt C, Theilmeier G, Aken H, Korsmeier P, Wirtz S, Berendes E, et al. Comparison of electrical velocimetry and transoesophageal doppler echocardiography for measuring stroke volume and cardiac output. Br J Anaesth 2005;95:603–610. DOI: 10.1093/bja/aei224.
Wong J, Agus MSD, Steil GM. Cardiac parameters in children recovered from acute illness as measured by electrical cardiometry and comparisons to the literature. J Clin Monit Comput 2013;27(1):81–91. DOI: 10.1007/s10877-012-9401-x.
Cattermole GN, Leung PYM, Ho GYL, Lau PWS, Chan CPY, Chan SSW, et al. The normal ranges of cardiovascular parameters measured using the ultrasonic cardiac output monitor. Physiol Rep 2017;5(6):e13195. DOI: 10.14814/phy2.13195.
Marty P, Roquilly A, Vallée F, Luzi A, Ferré F, Fourcade O, et al. Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in intensive care unit: an observational study. Ann Intensive Care 2013;3(1):3. DOI: 10.1186/2110-5820-3-3.
McIntosh AM, Tong S, Deakyne SJ, Davidson JA, Scott HF. Validation of the vasoactive-inotropic score in pediatric sepsis. Pediatr Crit Care Med 2017;18(8):750–757. DOI: 10.1097/PCC.0000000000001191.
Hunter JD, Doddi M. Sepsis and the heart. Br J Anaesth 2010;104(1):3–11. DOI: 10.1093/bja/aep339.
Vieillard-Baron A. Assessment of right ventricular function. Curr Opin Crit Care 2009;15(3):254–260. DOI: 10.1097/MCC.0b013e32832b70c9.
Ranjit S, Natraj R, Kandath SK, Kissoon N, Ramakrishnan B, Marik PE. Early norepinephrine decreases fluid and ventilatory requirements in pediatric vasodilatory septic shock. Indian J Crit Care Med 2016;20(10):561–569. DOI: 10.4103/0972-5229.192036.
Suehiro K, Joosten A, Murphy LS, et al. Accuracy and precision of minimally-invasive cardiac output monitoring in children: a systematic review and meta-analysis. J Clin Monit Comput 2016;30:603–620. DOI: 10.1007/s10877-015-9757-9.