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Early norepinephrine can reverse shock and limit positive fluid balance in pediatric septic shock

S. Ranjit, R. Natraj, S. Kandath

Presented: WFPICCS 2016 Abstract PICC-0582


Objectives: We previously reported on the prominent role that vasodilatation plays in pediatric septic shock. Thus, norepinephrine(NE) may be a useful first-line vaso-active agent in these cases since it can reverse underlying pathophysiology by venoconstriction thus improving venous return(VR), improve myocardial function via mild inotropy and increase SVRI.
We primarily aimed to study the effect of early NE after the initial 20-30ml/kg fluid on resolution of shock, VR and fluid balance as compared to a historical cohort of 41 patients managed as per ACCM-PALS septic shock algorithm where early epinephrine was employed. We also aimed to study the effect of NE on myocardial performance including the diagnosis, treatment and outcomes of severe septic myocardial dysfunction(SMD).

Methods: This is an observational study where we closely monitored hemodynamics and myocardial performance using extended multimodal-monitoring(physical examination[PEx], ECHO, USCOM) before and after NE. Historical cohort were consecutive patients from our previous study. We also followed lactate trends, fluid balance, response to therapy and outcomes. Hospital Ethics Committee approved the study and waived need for informed consent.

Results: (Figure1,2) 27 patients received early NE after 20-30ml/kg fluid. As compared to our historical cohort, the 6- and 24-hour fluid requirement and ventilated days were significantly reduced, however, no difference in mortality was seen. Low SVRI confirmed in most patients using USCOM was improved by NE administration as was VR [significantly decreased stroke-volume-variation(SVV)]. The hyperdynamic shock associated elevated CI decreased towards normal while lactate trends were favorable. Severe SMD unmasked in 5/27 during NE administration improved with additional inotropy(dobutamine/epinephrine).

Conclusions: Early NE offers important benefits in pediatric vasodilatory septic shock by limiting positive fluid balance and ventilation time. Cardiac function may improve in most, however severe SMD may be unmasked with NE, which may be reliably detected by physical examination and responds well to additional inotropy.