Hemodynamic monitoring and management of pediatric septic shock

Abstract

Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with "usual care". Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.

Keywords: Children; Hemodynamic monitoring; Hemodynamics; Septic shock; Treatment.

Fig. 1

The equations of SVRI and VIS. Abbreviations used: SVRI: systemic vascular resistance index; MAP: mean arterial pressure; CVP: central venous pressure; CI: cardiac index; VIS: vasoactive-inotropic score.

Fig. 2

Modified early-goal directed therapy algorithm. We modified the early-goal directed therapy algorithm based on new concepts and updated data. CVP (the static intravascular volume or preload) is replaced by fluid responsiveness. Preferred resuscitation fluid is lactated Ringer's solution. MAP (afterload) is replaced by perfusion pressure (MAP-CVP) or SVRI. The preferred vasoactive drugs for children are epinephrine or norepinephrine. In addition to Scvo2, CI < 3.5 L/min/m² and lactate clearance are used to represent inadequate cardiac output in children. Milrinone, though not widely used in adult patients, is one of the drugs that may improve microcirculation for children. Abbreviations used: FR: fluid responsiveness; △Vpeak ao: Respiratory variation in aortic blood flow peak velocity; PLR: passive leg raising; MAP: mean artery pressure; CVP: central venous pressure; SVRI: systemic vascular resistance index; CI: cardiac index; ScvO2: central venous oxygen saturation.