title: Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock.
abstract: OBJECTIVE
  To report changes in the cardiovascular management of fluid and inotropic resistant septic shock in children based on echocardiography.
  
  
  METHODS
  Retrospective case series.
  
  
  METHODS
  Tertiary care Pediatric Intensive Care Unit (PICU), Chennai.
  
  
  METHODS
  Twenty-two patients with unresolved septic shock after 60 ml/kg fluid plus inotropic agents in the first hour.
  
  
  METHODS
  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.
authors.affiliation: Pediatric Intensive Care and Emergency Services, Apollo Children's Hospital, Chennai, Tamil Nadu, India.
authors.forename: Suchitra
authors.initials: S
authors.lastname: Ranjit
authors.forename: Niranjan
authors.initials: N
authors.lastname: Kissoon
keywords: Children; diagnosis; echocardiography; myocardial dysfunction; outcome; sepsis; septic shock; therapy