Hemodynamic monitoring for critically ill children: ESPNIC guidelines

Written By : Dr Satabdi Saha |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2020-11-02T16:15:07+05:30 | Updated On 3 Nov 2020 12:09 PM IST

The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section has recently provided expert consensus recommendations on hemodynamic monitoring in critically ill children.the recommendations have been published in Critical Care.

Cardiovascular instability is common in children admitted to pediatric intensive care. Multiple-organ dysfunction is commonly associated with cardiovascular derangements in patients with shock and carries high mortality. Effective hemodynamic monitoring can help in identifying cardiovascular instability early and choosing the appropriate targeted therapy timely. Currently, with the exception of management of shock, there are no published HD monitoring guidelines for critically ill children, and the published evidence remains scarce.

These are therefore the first expert consensus recommendations for HD monitoring in critically ill children with hemodynamic instability. The recommendations as put forth in their own language has been elaborated below.

Recommendations on use of clinical examination and blood pressure measurement in hemodynamic monitoring in critically ill children

There is no single clinical parameter that allows to evaluate the global hemodynamic status in children and, therefore, we recommend to analyze several parameters and make frequent assessments.	Strong agreement
2. We recommend to perform a clinical assessment as the initial evaluation in all patients for the detection of hemodynamic alterations and to evaluate clinical signs periodically together with hemodynamic monitoring parameters in unstable patients	. Strong agreement
3. We do not recommend to titrate hemodynamic therapy or fluid loading solely based upon clinical signs or a reduced urine output alone in unstable patients with the exception of the initial resuscitation phase.	Strong agreement
Arterial blood pressure
4. We recommend the use of intra-arterial blood pressure (IBP) over oscillometric blood pressure (OBP) measurement when a reliable blood pressure (BP) measurement is of importance or when fast changes in blood pressure need to be detected.	Strong agreement
5. In children over 12 years of age we recommend a target blood pressure of ≥ 65 mmHg MAP (according to adults surviving sepsis guidelines) unless in children known to have prior hypertension	Strong agreement
6. We recommend not to use BP as the only therapeutic target in unstable children. The hemodynamic state should be evaluated integrating several clinical and hemodynamic parameters .	Strong agreement
7. We recommend IBP monitoring in children in shock not responsive to initial fluid therapy or requiring vasopressor treatment, and hypertensive emergencies to control the effect of continuous invasive hypotensive drugs.	Strong agreement

Recommendations on use of measurement of CVP, SCVO2, and prediction of fluid responsiveness in hemodynamic monitoring in critically ill children

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 ScvO_2.	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

1. **Non-responders defined cases who had no rise in cardiac output (or stroke volume) as a result of volume resuscitation

Recommendations on the use of cardiac ultrasound and other methods to estimate cardiac output for hemodynamic monitoring in critically ill children

Echocardiography/cardiac ultrasound

1. We recommend to use cardiac ultrasound as an adjunct to gain additional information required for making accurate clinical decisions in infants and children with hemodynamic instability but not as a tool for routine hemodynamic monitoring in intensive care setting.Strong agreement

2. Cardiac ultrasound can help in diagnosing pulmonary hypertension and assessing severity of pulmonary hypertension, and in detecting cardiac tamponade.Strong agreement

3. We recommend monitoring of pulmonary artery pressure (PAP) using ultrasound with refractory shock states to exclude pulmonary hypertension. Cardiac ultrasound may help in identifying underlying pathophysiology of shock and choosing the right intervention based upon deranged hemodynamic physiology (preload, afterload, or cardiac function).Strong agreement

4. Cardiac ultrasound may help in assessing fluid responsiveness and we recommend using velocity time integral (VTI) across aortic valve for assessing fluid responsiveness rather than inferior vena cava collapsibility in mechanically ventilated infants and children.Strong agreement

5. We recommend using serial longitudinal assessments to assess response to therapy in patients with significant hemodynamic instability.Strong agreement

Cardiac output measurement and transpulmonary indicator dilution

6. We recommend to use ultrasound/Doppler-based methods of estimating CO in stable patients, for the initial assessment of unstable patients and to decide if a more invasive method is required. When reliable absolute measurements of CO are deemed necessary, thermodilution (TPD) is the method of first choice.Strong agreement

7. In patients with a refractory shock when an accurate measurement of CO is needed, we recommend to use transpulmonary thermodilution (TPTD) or semi-invasive transpulmonary ultrasound dilution (TPUD).Weak agreement

8. We recommend to use invasive (and if possible continuous) CO monitoring in unstable post-operative patients after major (cardiothoracic) surgery, multiple trauma injuries or burns or patients with complex cardiopulmonary interactions.Strong agreement

9. We recommend against targeting fluid therapy based upon blood volumes measured with TPD or targeting hemodynamic therapy based upon lung water measurement to assess pulmonary edema in critically ill children.Strong agreement

10. Because of their intermittent measurement technique, TPD methods are not suitable for the detection of fast changes in CO unless used in conjunction with continuous trend monitoring using pulse contour analysis, calibrated by transpulmonary indicator dilution technology.Strong agreement

Pulmonary artery pressure

11. We do not recommend to use pulmonary artery catheter (PAC) to measure CO in children. However, monitoring of left atrial pressure only in selected cardiac surgery patients or patients after lung transplant using a surgically inserted catheter can be helpfulStrong agreement

Recommendations on use of serum lactate, near infrared spectroscopy (NIRS), and microcirculation assessment for hemodynamic monitoring in critically ill children

Serum lactate measurement
1.	We recommend to obtain a repeat blood sample from a reliable site when the lactate value of a capillary sample is higher than 3.0 mmol/L and to closely follow-up patients and intensify treatment until lactate values at least drop below 3.0 mmol/L, especially if other concerns regarding tissue hypoxia are present.	Strong agreement
2.	We recommend to interpret lactate levels always in conjunction with clinical indicators of poor systemic perfusion and monitoring parameters.	Strong agreement
Near infrared spectroscopy
3.	Trend in NIRS values may provide valuable physiological information in children with hemodynamic instability but routine use in all children with hemodynamic instability is not recommended.	Strong agreement
4.	Near infrared spectroscopy (NIRS) can be useful during the peri-operative period after surgery for congenital heart defects; however, we recommend against the routine use of NIRS during non-cardiac surgery.	Weak agreement
Microcirculation
5.	Many routinely used parameters like capillary refill, peripheral temperature, lactate, NIRS etc., reflect aspects of the hemodynamic condition, but they do not adequately reflect the microcirculation. Although central venous to arterial CO₂ difference could provide additional insight into the microcirculatory condition, we recommend against its use to guide resuscitation in critically ill children	Strong agreement
6.	We recommend against routine microcirculation evaluation by video microscopy in stable children except those in clinical studies	Strong agreement

For the full article follow the link : https://doi.org/10.1186/s13054-020-03326-2

Primary source: Critical Care

Source : Critical Care

Dr Satabdi Saha

Dr Satabdi Saha (BDS, MDS) is a practicing pediatric dentist with a keen interest in new medical researches and updates. She has completed her BDS from North Bengal Dental College ,Darjeeling. Then she went on to secure an ALL INDIA NEET PG rank and completed her MDS from the first dental college in the country – Dr R. Ahmed Dental College and Hospital. She is currently attached to The Marwari Relief Society Hospital as a consultant along with private practice of 2 years. She has published scientific papers in national and international journals. Her strong passion of sharing knowledge with the medical fraternity has motivated her to be a part of Medical Dialogues.

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751