• Suchitra Ranjit, Gnanam Aram, Niranjan Kissoon, Mhd Kashif Ali, Rajeshwari Natraj, Sharad Shresti, Indira Jayakumar, and Deepika Gandhi.
• 1Pediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, Tamil Nadu, India. 2Pediatric Intensive Care Unit, Manipal Hospital, Bangalore, Karnataka, India. 3Emergency Department and Intensive Care Unit, British Columbia Children's Hospital and the University of British Columbia, Vancouver, BC, Canada. 4Pediatric Intensive Care Unit, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India.
• Pediatr Crit Care Me. 2014 Jan 1;15(1):e17-26.

ObjectivesTo evaluate the cardiovascular aberrations using multimodal monitoring in fluid refractory pediatric septic shock and describe the clinical characteristics of septic myocardial dysfunction.DesignProspective observational study of patients with unresolved septic shock after infusion of 40 mL/kg fluid in the first hour.SettingTwo tertiary care referral Indian PICUs.PatientsPatients aged 1 month to 16 years who had fluid refractory septic shock.InterventionsChanges in therapy were based on findings of clinical assessment, bedside echocardiography, and invasive blood pressure monitoring within 6 hours of recognition of septic shock.Measurements And Main ResultsOver a 4-year period, 48 patients remained in septic shock despite at least 40 mL/kg fluid infusion. On clinical examination, 21 patients had cold shock and 27 had warm shock. Forty-one patients (85.5%) had vasodilatory shock on invasive blood pressure; these included 14 patients who initially presented with cold shock. The commonest echocardiography findings were impaired left ± right ventricular function in 19 patients (39.6%) and hypovolemia in 16 patients (33%). Three patients who had normal myocardial function on day 1 developed secondary septic myocardial dysfunction on day 3. Echocardio graphy, along with invasive arterial pressure monitoring, allowed fluid, inotropy, and pressors to be titrated more precisely in 87.5% of patients. Shock resolved in 46 of 48 patients (96%) and 44 patients (91.6%) survived to discharge.ConclusionBedside echocardiography provided crucial information leading to the recognition of septic myocardial dysfunction and uncorrected hypovolemia that was not apparent on clinical assessment. With invasive blood pressure monitoring, echocardiography affords a simple noninvasive tool to determine the cause of low cardiac output and the physiological basis for adjustment of therapy in patients who remain in shock despite 40 mL/kg fluid.

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