Table 2 Recommendations on use of measurement of CVP, SCVO2, and prediction of fluid responsiveness in hemodynamic monitoring in critically ill children
Sr No | Recommendation | Level of agreement |
|---|---|---|
Central venous pressure | ||
1. | We recommend to place the tip of a central venous catheter at the junction of the superior caval vein (SCV) and the right atrium to obtain an optimal central venous pressure (CVP) measurement or ScvO2 sample. | Strong agreement |
2. | We recommend to measure CVP in all unstable patients refractory to initial hemodynamic treatment. | Strong agreement |
3. | We recommend against the use of CVP to predict fluid responsiveness; Fluid loading should not be started solely based upon a low CVP. | Strong agreement |
4. | An isolated CVP measurement is of limited value in clinical practice. However, trends in CVP may provide important information regarding changes in cardiovascular pathophysiology such as evolving right heart failure and an abrupt elevation in CVP upon fluid administration should raise suspicion of significant cardiac dysfunction. | Strong agreement |
Central venous oxygen saturation measurement | ||
5. | We recommend to measure central venous oxygen saturation (ScvO2) in unstable patients not responding to the initial treatment. ScvO2 < 65% suggest a possible hemodynamic alteration; however, in sepsis, a normal or high ScvO2 may reflect mitochondrial dysfunction and mask hemodynamic alterations. | Strong agreement |
6. | ScvO2 is not an adequate marker of cardiac index (CI). | Strong agreement |
7. | We recommend against targeting hemodynamic therapy solely based upon ScvO2. | Strong agreement |
Volume resuscitation and fluid responsiveness | ||
8. | We recommend to observe the patient’s clinical situation, physical exam, and various perfusion indicators suggesting an inadequate CO (or oxygen transport) caused by hypovolemia before considering fluid loading. | Strong agreement |
9. | In delivering a bolus of fluid, we recommend to administer a small bolus of fluid in a short time period while tracking changes in cardiac output, blood pressure and CVP, and when possible or available, to confirm fluid responsiveness before commencing fluid loading therapy. | Strong agreement |
10. | We recommend alternative therapeutic strategies for hypotension management in fluid non-responders.** | Strong agreement |
11. | We recommend to withhold fluid therapy in patients with an increasing CVP and no significant increase in blood pressure or cardiac output as a result of previous fluid therapy. | Strong agreement |
12. | We recommend fluid therapy (with boluses 5–10 ml/kg) as part of early resuscitation in unstable patients guided by the effect on blood pressure and/or cardiac output. | Strong agreement |