Rao Swathi S, Lalitha A V, Reddy Mounika, Ghosh Santu
Department of Pediatrics, KS Hegde Medical College, Mangaluru, Karnataka, India.
Department of Pediatric Intensive Care, St. John' s Medical College and Hospital, Bangaluru, Karnataka, India.
Indian J Crit Care Med. 2021 Feb;25(2):185-192. doi: 10.5005/jp-journals-10071-23730.
To evaluate the utility of noninvasive electrocardiometry (ICON®) for hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock.
Pilot prospective observational study in a 12-bedded tertiary pediatric intensive care unit (PICU) in children aged between 2 months and 16 years with unresolved septic shock after a 20 mL/kg fluid bolus. Those with cardiac index (CI) <3.3 L/min/m and systemic vascular resistance index (SVRI) >1600 dyn sec/cm/m were classified as vasoconstrictive shock-electrocardiometry (VCEC) and those with CI >5.5 L/min/m and SVRI <1000 dyn sec/cm/m as vasodilated shock-electrocardiometry (VDEC). Fluid responsiveness was defined as a 10% increase in CI with a 20 mL/kg fluid bolus. Sepsis-induced myocardial dysfunction (SMD) was diagnosed on echocardiography. Outcomes studied included clinical shock resolution, length of PICU stay, and mortality.
Thirty children were enrolled over 6 months with a median (interquartile range) age and pediatric risk of mortality (PRISM) III score of 87(21,108) months and 6.75(1.5,8.25), respectively; 14(46.6%) were boys and 4(13.3%) died. Clinically, 19(63.3%) children had cold shock and 11(36.7%) had warm shock; however, 16(53.3%) children had VDEC (including five with clinical cold shock) and 14(46.7%) had VCEC using electrocardiometry. Fluid responsiveness was seen in 16(53.3%) children, 10 in the VCEC group and 6 in the VDEC group. In the VCEC group, the responders had a significant rise in CI and a fall in SVRI, while the responders in the VDEC group had a significant rise in CI and SVRI. Fluid responders, compared to nonresponders, had a significantly higher stroke volume variation (SVV) before fluid bolus (24.1 ± 5.2% vs. 18.2 ± 3.5%, < 0.001) and a higher reduction in SVV after fluid bolus (10.0 ± 2.8% vs. 6.0 ± 4.5%, = 0.006), higher lactate clearance ( = 0.03) and lower vasoactive-inotropic score ( = 0.04) at 6 hours, higher percentage of clinical shock resolution at 6 ( = 0.01) and 12 hours ( = 0.01), and lesser mortality ( = 0.002). Five (16.6%) children with VCEC had SMD and were less fluid responsive ( = 0.04) with higher mortality ( = 0.01) compared to those without SMD.
Continuous, noninvasive hemodynamic monitoring using electrocardiometry permits hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. This may provide real-time guidance for optimal interventions, and thus, improve the outcomes.
Rao SS, Reddy M, Lalitha AV, Ghosh S. Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study. Indian J Crit Care Med 2021;25(2):185-192.
评估无创心电监测（ICON®）在小儿感染性休克血流动力学分类及液体反应性评估中的应用价值。
在一家拥有12张床位的三级小儿重症监护病房（PICU）进行前瞻性观察性试验研究，研究对象为年龄在2个月至16岁之间、经20 mL/kg液体冲击后仍存在未缓解感染性休克的患儿。心脏指数（CI）<3.3 L/min/m²且全身血管阻力指数（SVRI）>1600 dyn sec/cm⁵/m²的患儿被分类为血管收缩性休克 - 心电监测（VCEC）组，CI>5.5 L/min/m²且SVRI<1000 dyn sec/cm⁵/m²的患儿被分类为血管舒张性休克 - 心电监测（VDEC）组。液体反应性定义为经20 mL/kg液体冲击后CI增加10%。通过超声心动图诊断脓毒症诱导的心肌功能障碍（SMD）。研究的结局指标包括临床休克缓解情况、PICU住院时间及死亡率。
6个月内共纳入30例患儿，年龄中位数（四分位间距）为87（21,108）个月，小儿死亡风险（PRISM）III评分为6.75（1.5,8.25）；其中14例（46.6%）为男性，4例（13.3%）死亡。临床上，19例（63.3%）患儿为冷休克，11例（36.7%）为暖休克；然而，通过心电监测，16例（53.3%）患儿为VDEC（包括5例临床冷休克患儿），14例（46.7%）患儿为VCEC。16例（53.3%）患儿存在液体反应性，VCEC组10例，VDEC组6例。在VCEC组中，有反应者CI显著升高，SVRI降低，而VDEC组有反应者CI和SVRI均显著升高。与无反应者相比，有反应者在液体冲击前每搏输出量变异度（SVV）显著更高（24.1±5.2% 对 18.2±3.5%，P<0.001），液体冲击后SVV降低幅度更大（10.0±2.8% 对 6.0±4.5%，P = 0.006），6小时时乳酸清除率更高（P = 0.03），血管活性药物 - 正性肌力药物评分更低（P = 0.04），6小时（P = 0.01）和12小时（P = 0.01）时临床休克缓解百分比更高，死亡率更低（P = 0.002）。5例（16.6%）VCEC组患儿存在SMD，与无SMD患儿相比，其液体反应性更低（P = 0.04），死亡率更高（P = 0.01）。
使用心电监测进行连续、无创的血流动力学监测可对小儿感染性休克进行血流动力学分类及评估液体反应性。这可为优化干预措施提供实时指导，从而改善结局。
Rao SS, Reddy M, Lalitha AV, Ghosh S. Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study. Indian J Crit Care Med 2021;25(2):185 - 192.
