Department of Clinical-Surgical Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
Pediatr Crit Care Med. 2021 Mar 1;22(3):262-274. doi: 10.1097/PCC.0000000000002658.
To assess focused cardiac ultrasound impact on clinician hemodynamic characterization of patients with suspected septic shock as well as expert-generated focused cardiac ultrasound algorithm performance.
Retrospective, observational study.
Single-center, noncardiac PICU.
Less than 18 years old receiving focused cardiac ultrasound study within 72 hours of sepsis pathway initiation from January 2014 to December 2016.
Hemodynamics of patients with suspected septic shock were characterized as fluid responsive, myocardial dysfunction, obstructive physiology, and/or reduced systemic vascular resistance by a bedside clinician before and immediately following focused cardiac ultrasound performance. The clinician's post-focused cardiac ultrasound hemodynamic assessments were compared with an expert-derived focused cardiac ultrasound algorithmic hemodynamic interpretation. Subsequent clinical management was assessed for alignment with focused cardiac ultrasound characterization and association with patient outcomes.
Seventy-one patients with suspected septic shock (median, 4.7 yr; interquartile range, 1.6-8.1) received clinician performed focused cardiac ultrasound study within 72 hours of sepsis pathway initiation (median, 2.1 hr; interquartile range, -1.5 to 11.8 hr). Two patients did not have pre-focused cardiac ultrasound and 23 patients did not have post-focused cardiac ultrasound hemodynamic characterization by clinicians resulting in exclusion from related analyses. Post-focused cardiac ultrasound clinician hemodynamic characterization differed from pre-focused cardiac ultrasound characterization in 67% of patients (31/46). There was substantial concordance between clinician's post-focused cardiac ultrasound and algorithm hemodynamic characterization (33/48; κ = 0.66; CI, 0.51-0.80). Fluid responsive (κ = 0.62; CI, 0.40-0.84), obstructive physiology (к = 0.87; CI, 0.64-1.00), and myocardial dysfunction (1.00; CI, 1.00-1.00) demonstrated substantial to perfect concordance. Management within 4 hours of focused cardiac ultrasound aligned with algorithm characterization in 53 of 71 patients (75%). Patients with aligned management were less likely to have a complicated course (14/52, 27%) compared with misaligned management (8/19, 42%; p = 0.25).
Incorporation of focused cardiac ultrasound in the evaluation of patients with suspected septic shock frequently changed a clinician's characterization of hemodynamics. An expert-developed algorithm had substantial concordance with a clinician's post-focused cardiac ultrasound hemodynamic characterization. Management aligned with algorithm characterization may improve outcomes in children with suspected septic shock.
评估心脏超声重点评估对疑似感染性休克患者的临床医生血流动力学特征的影响，以及专家生成的心脏超声重点评估算法的性能。
回顾性、观察性研究。
单中心非心脏 PICU。
2014 年 1 月至 2016 年 12 月，在感染途径启动后 72 小时内接受心脏超声重点评估的疑似感染性休克的年龄小于 18 岁的患者。
在进行心脏超声重点评估之前和之后，临床医生对疑似感染性休克患者的血流动力学特征进行了评估，评估结果包括液体反应性、心肌功能障碍、阻塞性生理学和/或全身性血管阻力降低。临床医生在进行心脏超声重点评估后的血流动力学评估结果与专家得出的心脏超声重点评估算法的血流动力学解释进行了比较。随后评估了临床管理与心脏超声重点评估特征的一致性以及与患者结局的相关性。
71 例疑似感染性休克患者（中位数年龄为 4.7 岁；四分位距为 1.6-8.1 岁）在感染途径启动后 72 小时内接受了临床医生进行的心脏超声重点评估（中位数为 2.1 小时；四分位距为-1.5 至 11.8 小时）。两名患者没有进行心脏超声重点评估前的评估，23 名患者没有进行临床医生进行的心脏超声重点评估后的血流动力学特征评估，因此被排除在相关分析之外。在 67%的患者中（31/46），心脏超声重点评估后的临床医生血流动力学特征与心脏超声重点评估前的特征不同。临床医生在进行心脏超声重点评估后的血流动力学特征与算法的血流动力学特征之间具有高度一致性（33/48；κ=0.66；CI，0.51-0.80）。液体反应性（κ=0.62；CI，0.40-0.84）、阻塞性生理学（к=0.87；CI，0.64-1.00）和心肌功能障碍（1.00；CI，1.00-1.00）具有高度到完全一致性。在 71 例患者中，有 53 例（75%）在进行心脏超声重点评估后 4 小时内进行了与算法特征相符的管理。与管理不相符的患者相比（14/52，27%），管理相符的患者更不可能出现复杂的病程（8/19，42%；p=0.25）。
将心脏超声重点评估纳入疑似感染性休克患者的评估中，常常会改变临床医生对血流动力学特征的描述。专家开发的算法与临床医生在进行心脏超声重点评估后的血流动力学特征具有高度一致性。与算法特征相符的管理可能会改善疑似感染性休克患儿的结局。
