Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study

Swathi S Rao; A V Lalitha; Mounika Reddy; Santu Ghosh

doi:10.5005/jp-journals-10071-23730

Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study

Indian J Crit Care Med. 2021 Feb;25(2):185-192. doi: 10.5005/jp-journals-10071-23730.

Authors

Swathi S Rao¹, A V Lalitha², Mounika Reddy², Santu Ghosh³

Affiliations

¹ Department of Pediatrics, KS Hegde Medical College, Mangaluru, Karnataka, India.
² Department of Pediatric Intensive Care, St. John' s Medical College and Hospital, Bangaluru, Karnataka, India.
³ Department of Biostatistics, St. John' s Medical College and Hospital, Bangaluru, Karnataka, India.

Abstract

Aim: To evaluate the utility of noninvasive electrocardiometry (ICON®) for hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock.

Materials and methods: 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/m² and systemic vascular resistance index (SVRI) >1600 dyn sec/cm⁵/m² were classified as vasoconstrictive shock-electrocardiometry (VCEC) and those with CI >5.5 L/min/m² and SVRI <1000 dyn sec/cm⁵/m² 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.

Results: 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%, p < 0.001) and a higher reduction in SVV after fluid bolus (10.0 ± 2.8% vs. 6.0 ± 4.5%, p = 0.006), higher lactate clearance (p = 0.03) and lower vasoactive-inotropic score (p = 0.04) at 6 hours, higher percentage of clinical shock resolution at 6 (p = 0.01) and 12 hours (p = 0.01), and lesser mortality (p = 0.002). Five (16.6%) children with VCEC had SMD and were less fluid responsive (p = 0.04) with higher mortality (p = 0.01) compared to those without SMD.

Conclusions and clinical significance: 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.

How to cite this article: 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.

Keywords: Cardiac output; Fluid bolus; Myocardial dysfunction; Noninvasive; Sepsis.