title: Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study*.
abstract: OBJECTIVE
  To evaluate the cardiovascular aberrations using multimodal monitoring in fluid refractory pediatric septic shock and describe the clinical characteristics of septic myocardial dysfunction.
  
  
  METHODS
  Prospective observational study of patients with unresolved septic shock after infusion of 40 mL/kg fluid in the first hour.
  
  
  METHODS
  Two tertiary care referral Indian PICUs.
  
  
  METHODS
  Patients aged 1 month to 16 years who had fluid refractory septic shock.
  
  
  METHODS
  Changes in therapy were based on findings of clinical assessment, bedside echocardiography, and invasive blood pressure monitoring within 6 hours of recognition of septic shock.
  
  
  RESULTS
  Over a 4-year period, 48 patients remained in septic shock despite at least 40 mL/kg fluid infusion. On clinical examination, 21 patients had cold shock and 27 had warm shock. Forty-one patients (85.5%) had vasodilatory shock on invasive blood pressure; these included 14 patients who initially presented with cold shock. The commonest echocardiography findings were impaired left ± right ventricular function in 19 patients (39.6%) and hypovolemia in 16 patients (33%). Three patients who had normal myocardial function on day 1 developed secondary septic myocardial dysfunction on day 3. Echocardio graphy, along with invasive arterial pressure monitoring, allowed fluid, inotropy, and pressors to be titrated more precisely in 87.5% of patients. Shock resolved in 46 of 48 patients (96%) and 44 patients (91.6%) survived to discharge.
  
  
  CONCLUSIONS
  Bedside echocardiography provided crucial information leading to the recognition of septic myocardial dysfunction and uncorrected hypovolemia that was not apparent on clinical assessment. With invasive blood pressure monitoring, echocardiography affords a simple noninvasive tool to determine the cause of low cardiac output and the physiological basis for adjustment of therapy in patients who remain in shock despite 40 mL/kg fluid.
authors.affiliation: 1Pediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, Tamil Nadu, India. 2Pediatric Intensive Care Unit, Manipal Hospital, Bangalore, Karnataka, India. 3Emergency Department and Intensive Care Unit, British Columbia Children's Hospital and the University of British Columbia, Vancouver, BC, Canada. 4Pediatric Intensive Care Unit, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India.
authors.forename: Suchitra
authors.initials: S
authors.lastname: Ranjit
authors.forename: Gnanam
authors.initials: G
authors.lastname: Aram
authors.forename: Niranjan
authors.initials: N
authors.lastname: Kissoon
authors.forename: Mhd Kashif
authors.initials: MK
authors.lastname: Ali
authors.forename: Rajeshwari
authors.initials: R
authors.lastname: Natraj
authors.forename: Sharad
authors.initials: S
authors.lastname: Shresti
authors.forename: Indira
authors.initials: I
authors.lastname: Jayakumar
authors.forename: Deepika
authors.initials: D
authors.lastname: Gandhi
mesh_terms: D000293:Adolescent; D001795:Blood Pressure Determination; D002316:Cardiotonic Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography; D005260:Female; D005440:Fluid Therapy; D006439:Hemodynamics; D006801:Humans; D020896:Hypovolemia / Q000209:etiology; D007223:Infant; D008297:Male; D008991:Monitoring, Physiologic; D010865:Pilot Projects; D019095:Point-of-Care Systems; D011446:Prospective Studies; D012772:Shock, Septic / Q000145:classification* / Q000503:physiopathology* / Q000628:therapy; D015996:Survival Rate; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D018497:Ventricular Dysfunction, Right / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology
chemical_list: D002316:Cardiotonic Agents; D014662:Vasoconstrictor Agents