Hemodynamic monitoring can be lifesaving in pediatric septic shock

Background

Pediatric septic shock is usually associated with multiple factors, including hypovolemia, myocardial depression, vascular failure, endocrine and metabolic disturbances. Eighty percent of the children with fluid refractory septic shock present with a low cardiac index. We emphasize the role of invasive and non-invasive monitoring for children with septic shock, leading to changes in treatment and prognosis.

Case

A 5-year-old boy presenting with pneumonia, respiratory failure and severe sepsis. At admission, he was tachypneic and tachycardic, with inaudible blood pressure, prolonged capillary refill time and weak pulses. The patient received 60 ml/kg normal saline in 60 min, without recovery. After placement of a central venous catheter, he was started on continuous dopamine, reaching 15 μg/kg/min. Again without significant improvement in arterial blood pressure and perfusion, epinephrine infusion was associated, starting with 0.1 μg/kg/min and increasing until 1.5 μg/kg/min. At this moment, he had low blood pressure, tachycardia, superior vena cava saturation (SVO₂) of 65%, oliguria and prolonged capillary refill time and, 2 hours later, presented with desaturation, hepatomegaly and acute pulmonary edema. An echocardiogram revealed a cardiac index of 1 l/min/m². Changing treatment strategy, he was started on milrinone infusion and monitoring with continuous SVO₂ and pulmonary artery catheter. Two hours later, he had normal urinary output, normal blood pressure, SVO₂ of 74% and cardiac index of 3 l/min/m². Treated with milrinone and low-dose epinephrine, he progressively improved arterial blood pressure, perfusion, pulse and mental status. The patient was weaned off vasoactive drugs and mechanical ventilation after 6 days.

Discussion

Myocardial dysfunction is frequent in children with septic shock, and it persists even after correction of hypovolemia, acidosis and electrolyte disturbances. Most of the children with septic shock have a low cardiac index and increased systemic vascular resistance.

Conclusion

Monitoring cardiac function, combining an echocardiogram with invasive methods, such as SVO₂ or pulmonary artery catheter, can be lifesaving in pediatric refractory septic shock.