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Hemodynamic support in fluid-refractory pediatric septic shock
G Ceneviva1, J A Paschall, F Maffei
1Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Insights
Children with persistent septic shock often have low cardiac output and benefit from inotropes and vasodilators. Tailoring therapy to individual hemodynamic states improves outcomes in pediatric septic shock.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Cardiology
- Septic Shock Management
Background:
- Fluid-refractory septic shock in children presents a significant clinical challenge.
- Understanding diverse hemodynamic profiles is crucial for effective treatment.
Purpose of the Study:
- To assess the outcomes of pediatric patients receiving inotrope, vasopressor, and/or vasodilator therapy for persistent, fluid-refractory septic shock.
- To categorize patient responses based on hemodynamic status and therapeutic interventions.
Main Methods:
- A case series design was employed across three pediatric hospitals.
- Fifty consecutive pediatric patients with fluid-refractory septic shock were analyzed.
- Hemodynamic parameters, including cardiac index and systemic vascular resistance, were monitored.
Main Results:
- Patients were classified into three groups based on their hemodynamic state and response to therapy: hypodynamic (responded to inotropes/vasodilators), hyperdynamic (responded to vasopressors), and mixed dysfunction.
- Overall 28-day survival was 80%, with variations across groups (72%-91%).
- A significant proportion of patients required adjustments to their initial therapeutic regimen due to evolving hemodynamic states.
Conclusions:
- Children with fluid-refractory septic shock are often hypodynamic and respond well to inotropic and vasodilator agents.
- Hemodynamic states in pediatric septic shock are heterogeneous and dynamic, necessitating individualized and adaptable treatment strategies.
- Optimizing cardiovascular therapy based on real-time hemodynamic assessment can improve survival rates in pediatric septic shock.
Objective:
Assess outcome in children treated with inotrope, vasopressor, and/or vasodilator therapy for reversal of fluid-refractory and persistent septic shock.
Design:
Survey; case series.
Setting:
Three pediatric hospitals.
Patients:
Fifty consecutive patients with fluid-refractory septic shock with a pulmonary artery catheter within 6 hours of resuscitation.
Interventions:
Patients were categorized according to hemodynamic state and use of inotrope, vasopressor, and/or vasodilator therapy to maintain cardiac index (CI) >3.3 L/min/m2 and systemic vascular resistance >800 dyne-sec/cm/m to reverse shock.
Outcome Measures:
Hemodynamic state, response to class of cardiovascular therapy, and mortality.
Results:
After fluid resuscitation, 58% of the children had a low CI and responded to inotropic therapy with or without a vasodilator (group I), 20% had a high CI and low systemic vascular resistance and responded to vasopressor therapy alone (group II), and 22% had both vascular and cardiac dysfunction and responded to combined vasopressor and inotropic therapy (group III). Shock persisted in 36% of the children. Of the children in group I, 50% needed the addition of a vasodilator, and in group II, 50% of children needed the addition of an inotrope for evolving myocardial dysfunction. Four children showed a complete change in hemodynamic state and responded to a switch from inotrope to vasopressor therapy or vice versa. The overall 28-day survival rate was 80% (group I, 72%; group II, 90%; group III, 91%).
Conclusions:
Unlike adults, children with fluid-refractory shock are frequently hypodynamic and respond to inotrope and vasodilator therapy. Because hemodynamic states are heterogeneous and change with time, an incorrect cardiovascular therapeutic regimen should be suspected in any child with persistent shock. Outcome can be improved compared with historical literature.