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Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care
1Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, England. brierj@gosh.nhs.uk
Insights
Pediatric septic shock has distinct hemodynamic patterns based on its cause. Differentiating between catheter-associated infections and community-acquired sepsis can guide targeted vasoactive drug selection for better outcomes.
Area of Science:
- Pediatric critical care medicine
- Hemodynamics in critical illness
- Septic shock management
Background:
- Early aggressive resuscitation is standard for severe pediatric sepsis.
- Individualized hemodynamic assessment is recommended but challenging early in sepsis.
- New technologies may aid early hemodynamic assessment to guide vasoactive drug choices in fluid-resistant shock.
Purpose of the Study:
- To investigate distinct hemodynamic patterns in pediatric fluid-resistant septic shock based on etiology.
- To determine if hemodynamic profiles differ between community-acquired sepsis and central venous catheter-associated infections.
- To inform potential targeted vasoactive therapy based on identified hemodynamic patterns.
Main Methods:
- Prospective observational study of 30 children with fluid-resistant septic shock.
- Classification based on admission diagnosis: community-acquired sepsis or catheter-associated infection.
- Noninvasive cardiac output device used within 4 hours of shock onset to measure cardiac index and systemic vascular resistance index.
Main Results:
- Fluid-resistant septic shock from catheter-associated infections predominantly showed "warm shock" (high cardiac index, low systemic vascular resistance index).
- Community-acquired sepsis more frequently presented with normal or low cardiac index.
- Distinct hemodynamic patterns were observed with little overlap between the two groups.
Conclusions:
- Hemodynamic patterns in pediatric fluid-resistant septic shock are distinct and depend on the underlying cause.
- Findings suggest potential for targeting vasoactive infusions: vasopressors for catheter-associated infections and inotropes for community-acquired sepsis.
- Further studies are needed to reproduce these findings and confirm the clinical utility of targeted therapy.
Objective:
Early aggressive resuscitation is accepted best practice for severe pediatric sepsis. Targeting of therapy to individual hemodynamic patterns is recommended, but assessment of patterns is difficult early in the disease process. New technologies enabling earlier hemodynamic assessment in shock may inform choices for vasoactive drugs in fluid-resistant cases.
Methods:
This was a prospective observational study of 30 children with suspected fluid-resistant septic shock (minimum: 40 mL/kg) admitted to the PICU of a tertiary care children's hospital between July 2004 and July 2005. Children were classified according to admission diagnosis (community-acquired sepsis or central venous catheter-associated infection) and assessed within 4 hours after the onset of shock with a noninvasive cardiac output device. Cardiac index and systemic vascular resistance index were measured for all patients. Central venous oxygen saturation was measured for patients with accessible central venous lines at the time of hemodynamic measurements (typically at the superior vena cava-right atrium junction).
Results:
Fluid-resistant septic shock secondary to central venous catheter-associated infection was typically "warm shock" (15 of 16 patients; 94%), with high cardiac index and low systemic vascular resistance index. In contrast, this pattern was rarely seen in community-acquired sepsis (2 of 14 patients; 14%), where a normal or low cardiac index was predominant.
Conclusions:
The hemodynamic patterns of fluid-resistant septic shock by the time children present to the PICU are distinct, depending on cause, with little overlap. If these findings can be reproduced, then targeting the choice of first-line vasoactive infusions in fluid-resistant shock (vasopressors for central venous catheter-associated infections and inotropes for community-acquired sepsis) should be considered.
