Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial

EL-Nawawy, Ahmed A.; Abdelmohsen, Aly M.; Hassouna, Hadir M.

doi:10.1016/j.jped.2017.02.005

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Original articles • J. Pediatr. (Rio J.) 94 (1) • Jan-Feb 2018 • https://doi.org/10.1016/j.jped.2017.02.005 copy

Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial^☆ ☆ Please cite this article as: EL-Nawawy AA, Abdelmohsen AM, Hassouna HM. Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial. J Pediatr (Rio J). 2018;94:31-9.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To evaluate the role of echocardiography in reducing shock reversal time in pediatric septic shock.

Methods:

A prospective study conducted in the pediatric intensive care unit of a tertiary care teaching hospital from September 2013 to May 2016. Ninety septic shock patients were randomized in a 1:1 ratio for comparing the serial echocardiography-guided therapy in the study group with the standard therapy in the control group regarding clinical course, timely treatment, and outcomes.

Results:

Shock reversal was significantly higher in the study group (89% vs. 67%), with significantly reduced shock reversal time (3.3 vs. 4.5 days). Pediatric intensive care unit stay in the study group was significantly shorter (8 ± 3 vs. 14 ± 10 days). Mortality due to unresolved shock was significantly lower in the study group. Fluid overload was significantly lower in the study group (11% vs. 44%). In the study group, inotropes were used more frequently (89% vs. 67%) and initiated earlier (12[0.5-24] vs. 24[6-72] h) with lower maximum vasopressor inotrope score (120[30-325] vs. 170[80-395]), revealing predominant use of milrinone (62% vs. 22%).

Conclusion:

Serial echocardiography provided crucial data for early recognition of septic myocardial dysfunction and hypovolemia that was not apparent on clinical assessment, allowing a timely management and resulting in shock reversal time reduction among children with septic shock.

KEYWORDS
Echocardiography; Pediatric septic shock; Shock reversal time; Inotropes

	Control (n = 45)	Study (n = 45)	p
Age ^a a Median (range). (months)	7 (1-132)	4 (1-60)	^Up = 0.305
Weight ^a a Median (range). (kg)	7.5 (1.5-29)	5.6 (2.1-15)	^Up = 0.214
Height ^b b Mean ± SD. (cm)	75.02 ± 22.5	63.6 ± 12.7	^tp = 0.746
Sex n (%)
Male	27 (60.0%)	26 (57.8%)	^FEp = 0.830
Female	18 (40.0%)	19 (42.2%)	^FEp = 0.830
PIM2 ^b b Mean ± SD.	52.67 ± 21.68	58.04 ± 21.54	^tp = 0.242
Type of infection n (%)
Community-acquired	35 (77.8%)	35 (77.8%)	^FEp = 1.000
Hospital-acquired	10 (22.2%)	10 (22.2%)	^FEp = 1.000
Patient immunity n (%)
Immune deficient^c c Recent/current long-term steroid use or leukemia.	6 (13.3%)	5 (11.1%)	^FEp = 0.748
Immune competent	39 (86.7%)	40 (88.9%)	^FEp = 0.748
Source of infection n (%)
Pneumonia	20 (44.4%)	13 (28.9%)	^FEp = 0.126
Abdominal infection	22 (48.9%)	20 (44.4%)	^FEp = 0.673
Urosepsis	4 (8.9%)	2 (4.4%)	^FEp = 0.677
Skin and soft tissue infection	1 (2.2%)	1 (2.2%)	^FEp = 1.000
Meningitis	19 (42.2%)	23 (51.1%)	^FEp = 0.398
Blood stream infection	24 (53.3%)	30 (66.7%)	^FEp = 0.197
Baseline laboratory findings
Hemoglobin^b b Mean ± SD. (gm/dL)	10.24 ± 2.3	9.94 ± 2.15	^tp = 0.514
White cell count^a a Median (range). (per mm³)	11,400 (200-82,400)	10,000 (1900-91,600)	^Up = 0.744
C-reactive protein^a a Median (range). (mg/dL)	72 (2.5-317)	43 (1.9-262)	^Up = 0.093
Troponine I^a a Median (range). (ng/mL)	0.63 (0.01-6.2)	0.8 (0.01-2.8)	^Up = 0.671
DIC score^a a Median (range).	6 (0-8)	6 (0-8)	^Up = 1.00
Type of shock n (%)
Warm shock	19 (42.2%)	19 (42.2%)	^MCp = 0.895
Cold shock	23 (51.1%)	24 (53.3%)
Cold with wide pulse pressure	3 (6.7%)	2 (4.4%)
Shock index ^b b Mean ± SD. ^, ^d d Shock index = heart rate/systolic blood pressure.	1.96 ± 0.56	2.04 ± 0.43	^tp = 0.429
Steroid use n (%)	31 (68.9%)	31 (68.9%)	^FEp = 1.00
Intubation n (%)	42 (93.3%)	45 (100.0%)	^FEp = 0.242

	Initial	1 h	6 h	24 h	p+
Systolic blood pressure (mmHg)
Control	82.31 ± 14.03	91.04 ± 15.48	102.87 ± 16.12	107.73 ± 13.67	0.001^a a Statistically significant at p ≤ 0.05.
Study	85.73 ± 14.22	95.64 ± 14.80	98.40 ± 16.94	105.27 ± 16.32	0.001^a a Statistically significant at p ≤ 0.05.
p	0.254	0.153	0.203	0.439
Mean arterial pressure (mmHg)
Control	54.44 ± 14.10	54.33 ± 13.52	65.51 ± 14.07	71.02 ± 11.19	0.001^a a Statistically significant at p ≤ 0.05.
Study	54.43 ± 8.33	64.62 ± 8.82	67.29 ± 12.12	76.73 ± 10.19	0.001^a a Statistically significant at p ≤ 0.05.
p	0.994	<0.001^a a Statistically significant at p ≤ 0.05.	0.522	0.013^a a Statistically significant at p ≤ 0.05.
Heart rate (beats/min)
Control	169.87 ± 22.42	167.78 ± 24.43	163.42 ± 23.26	155.51 ± 24.04	0.01^a a Statistically significant at p ≤ 0.05.
Study	184.09 ± 14.95	168.0 ± 15.44	175.18 ± 15.26	158.96 ± 21.77	0.001^a a Statistically significant at p ≤ 0.05.
p	0.001^a a Statistically significant at p ≤ 0.05.	0.959	0.006^a a Statistically significant at p ≤ 0.05.	0.478
Central oxygen venous saturation ^b b Initial time for central venous pressure and central venous oxygen saturation is at the time of insertion of the central venous catheter within the first hour of admission. (%)
Control	43.43 ± 18.14	53.14 ± 19.35	59.13 ± 20.79	61.69 ± 15.55	0.001^a a Statistically significant at p ≤ 0.05.
Study	45.23 ± 13.34	56.43 ± 15.03	65.42 ± 15.44	63.98 ± 10.97	0.001^a a Statistically significant at p ≤ 0.05.
p	0.601	0.371	0.107	0.422
Central venous pressure ^b b Initial time for central venous pressure and central venous oxygen saturation is at the time of insertion of the central venous catheter within the first hour of admission. (cmH ₂ O)
Control	7.09 ± 2.45	10.49 ± 3.61	13.40 ± 3.04	16.33 ± 3.38	0.001^a a Statistically significant at p ≤ 0.05.
Study	5.25 ± 4.54	10.87 ± 2.74	13.60 ± 4.72	14.67 ± 3.19	0.001^a a Statistically significant at p ≤ 0.05.
p	0.078	0.586	0.818	0.020^a a Statistically significant at p ≤ 0.05.
MAP-CVP (mmHg)
Control	51.78 ± 13.54	47.65 ± 13.4	56.3 ± 14.5	60.50 ± 11.82	0.001^a a Statistically significant at p ≤ 0.05.
Study	50.99 ± 6.73	56.63 ± 8.65	57.29 ± 10.8	65.95 ± 10.51	0.001^a a Statistically significant at p ≤ 0.05.
p	0.728	< 0.001^a a Statistically significant at p ≤ 0.05.	0.718	0.023^a a Statistically significant at p ≤ 0.05.
Lactate (mmol/L)
Control	4.27 ± 2.88	3.0 ± 2.17	3.1 ± 3.07	2.46 ± 1.87	0.001^a a Statistically significant at p ≤ 0.05.
Study	3.70 ± 2.06	2.89 ± 1.55	1.96 ± 0.75	1.72 ± 0.8	0.001^a a Statistically significant at p ≤ 0.05.
p	0.809	0.783	0.353	0.050^a a Statistically significant at p ≤ 0.05.
Urine output (mL/kg/h)
Control	-	0.75 ± 0.64	1.68 ± 1.12	2.4 ± 1.76	0.001^a a Statistically significant at p ≤ 0.05.
Study	-	0.68 ± 0.54	1.82 ± 1.39	2.5 ± 1.11	0.001^a a Statistically significant at p ≤ 0.05.
p	-	0.582	0.594	0.738
Cumulative fluid (mL/kg)
Control	-	61.33 ± 10.79	75.11 ± 15.47	98.2 ± 26.2	0.001^a a Statistically significant at p ≤ 0.05.
Study	-	70.2 ± 16.0	77.2 ± 19.3	86.0 ± 24.5	0.125
p	-	0.003^a a Statistically significant at p ≤ 0.05.	0.574	0.027^a a Statistically significant at p ≤ 0.05.
Features of fluid overload ^c c New/worsening respiratory signs, increased oxygen requirement, or hepatomegaly. n(%)
Control				20(44.4%)
Study				5(11.1%)
^FE p				0.001^a a Statistically significant at p ≤ 0.05.

	Control	Study	p
Initial therapy n (%)
Adrenaline	26 (57.8%)	26 (57.8%)	^FEp = 1.000
Noradrenaline	19 (42.2%)	19 (42.2%)
Add-on therapy n (%)
No	23 (51.1%)	26 (57.8%)	^MCp = 0.735
Adrenaline	4 (8.9%)	5 (11.1%)
Noradrenaline	18 (40.0%)	14 (31.1%)
Intropes^a a Inotropes included both dobutamine and milrinone. n (%)	30 (66.7%)	40 (88.9%)	^FEp = 0.011^e e Statistically significant at p ≤ 0.05.
Start of intropes^b b Median (range). (hours from admission)	24 (6-72)	12 (0.5-24)	^Up = 0.001^e e Statistically significant at p ≤ 0.05.
Dobutamine n (%)	28 (62.2%)	19 (42.2%)	^FEp = 0.050^e e Statistically significant at p ≤ 0.05.
Start of dobutamine^c c Mean ± SD. (hours from admission)	24.1 ± 14.8	12.5 ± 10.3	^tp = 0.005^e e Statistically significant at p ≤ 0.05.
Milrinone n (%)	10 (22.2%)	28 (62.2%)	^FEp ≤ 0.001^e e Statistically significant at p ≤ 0.05.
Start of milrinone^c c Mean ± SD. (hours from admission)	44.4 ± 17.9	11.9 ± 7.8	^tp ≤ 0.001^e e Statistically significant at p ≤ 0.05.
Maximum VIS ^b b Median (range).	170 (80-395)	120 (30-325)	^Up = 0.047^e e Statistically significant at p ≤ 0.05.
Withdrawal time^b b Median (range). ^, ^d d Time at which vasopressors/inotropes were initially withdrawn. (hours from admission)	48 (8-144)	24 (8-96)	^Up ≤ 0.001^e e Statistically significant at p ≤ 0.05.

	Control (n = 45)	Study (n = 45)	p
Shock reversed n (%)	30 (66.7%)	40 (88.9%)	^FEp = 0.011^e e Statistically significant at p ≤ 0.05.
Shock reversal time^a a Median (range). (hours from admission)	108 (30-240)	78 (24-192)	^Up = 0.010^e e Statistically significant at p ≤ 0.05.
Resuscitation time^a a Median (range). ^, ^b b When the patient met the therapeutic outcomes of septic shock resuscitation while on inotropes/vasopressors. (hours from admission)	24(6-72)	6 (6-32)	^Up ≤ 0.001^e e Statistically significant at p ≤ 0.05.
PELOD day 1^c c Mean ± SD.	22.8 ± 12.9	25.0 ± 16.0	^tp = 0.488
PELOD day 2^c c Mean ± SD.	22.5 ± 15.8	20.2 ± 15.4^d d Statistically significant from baseline by repeated measures ANOVA.	^tp = 0.497
PELOD day 3^c c Mean ± SD.	21.9 ± 17.7	14.8 ± 17.9 ^d d Statistically significant from baseline by repeated measures ANOVA.	^tp = 0.050^e e Statistically significant at p ≤ 0.05.
PICU duration among survivors^b b When the patient met the therapeutic outcomes of septic shock resuscitation while on inotropes/vasopressors. (days)	14.2 ± 10.4	8.1 ± 2.8	^tp = 0.005^e e Statistically significant at p ≤ 0.05.
Fate n (%)
Survived	28 (62.2%)	32 (71.1%)	^FEp = 0.371
Deceased	17 (37.8%)	13 (28.9%)
Due to unresolved shock	15 (88.2%)	5 (38.5%)	^FEp = 0.006^e e Statistically significant at p ≤ 0.05.
Others causes	2 (11.8%)	8 (61.5%)	^FEp = 0.006^e e Statistically significant at p ≤ 0.05.

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[1] * Corresponding author. E-mail:hadirelrouby@yahoo.com (H.M. Hassouna).