title: Characterization of Myocardial Dysfunction in Fluid- and Catecholamine-Refractory Pediatric Septic Shock and Its Clinical Significance.
abstract: Myocardial dysfunction is a known complication in patients with pediatric septic shock (PSS); however, its clinical significance remains unclear. The purpose of this study was to characterize left ventricular (LV) and right ventricular (RV) dysfunction and their prevalence in patients with PSS using echocardiography (echo) and to investigate their associations with the severity of illness and clinical outcomes.
  Retrospective chart review between 2010 and 2015 from 2 tertiary care pediatric intensive care units. Study included 78 patients (mean age 9.3 ± 7 years) from birth up to 21 years who fulfilled criteria for fluid- and catecholamine-refractory septic shock. Echocardiographic parameters of systolic, diastolic, and global function were measured offline. They were correlated with admission Pediatric Risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction scores, vasoactive-inotrope score (VIS), β-type natriuretic peptide (BNP), lactate, type of shock, duration of mechanical ventilation (MV), intensive care unit and hospital length of stay, and mortality.
  Overall, 28-day mortality was 26%, and 88% patients required MV. Prevalence of LV dysfunction was 72% and RV dysfunction was 63%. LV systolic dysfunction (fractional shortening z score <-2) was significantly associated with PRISM III, VIS, and BNP. RV systolic dysfunction (tricuspid annular plane systolic excursion z score <-2) was significantly associated with cold shock. LV and RV diastolic dysfunction did not have any significant clinical associations. No echocardiographic measures were associated with mortality.
  Myocardial dysfunction is highly prevalent in PSS but is not associated with mortality. LV systolic dysfunction is associated with a higher severity of illness, use of vasoactives, and BNP, whereas RV systolic dysfunction is associated with cold shock. Further studies are needed to determine the utility of echo in the bedside management of patients with PSS.
authors.affiliation: 1 Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Feifei Z
authors.initials: FZ
authors.lastname: Williams
authors.affiliation: 2 Division of Pediatric Cardiology, Emory University of School of Medicine, Atlanta, GA, USA.|3 Children's Healthcare of Atlanta, Atlanta, GA, USA.|4 Sibley Heart Center Cardiology, Atlanta, GA, USA.
authors.forename: Ritu
authors.initials: R
authors.lastname: Sachdeva
authors.affiliation: 5 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Curtis D
authors.initials: CD
authors.lastname: Travers
authors.affiliation: 3 Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Karen H
authors.initials: KH
authors.lastname: Walson
authors.affiliation: 1 Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA.|3 Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Kiran B
authors.initials: KB
authors.lastname: Hebbar
mesh_terms: D000293:Adolescent; D002395:Catecholamines / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003422:Critical Care; D004452:Echocardiography; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D000067716:Point-of-Care Testing; D012189:Retrospective Studies; D012772:Shock, Septic / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology*; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology*; D018497:Ventricular Dysfunction, Right / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology*; D055815:Young Adult
chemical_list: D002395:Catecholamines
keywords: echocardiography; myocardial dysfunction; pediatric septic shock; severity of illness; tricuspid annular plane systolic excursion; β-type natriuretic peptide