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Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 109-114

The role of focused echocardiography in optimizing lactate clearance in the first 3 h of pediatric sepsis resuscitation

Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Airlangga – Dr Soetomo General Hospital, Surabaya, East Java, Indonesia

Date of Submission07-Apr-2020
Date of Decision02-May-2020
Date of Acceptance23-May-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Arie Utariani
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Airlangga – Dr Soetomo General Hospital, Mayjend Prof. Dr. Moestopo Street No. 6-8, Airlangga, Gubeng, Surabaya, East Java 60285
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_43_20

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Background: Sepsis causes high morbidity and mortality in pediatric patients globally. Early shock diagnosis and management are important to determine patient survival. Fluid boluses, early inotropic, and vasopressor usage are the keys to improve lactate clearance. Echocardiography helps both determining the type of shock and selecting the hemodynamic therapies. Patients and Methods: A quasi-experimental with one group posttest only design was conducted on 23 pediatric patients who were treated in the resuscitation room of Dr. Soetomo Hospital Surabaya. Patients who met the inclusion and exclusion criteria became the research sample and resuscitated, according to the 1-h sepsis bundle. Patients' hemodynamic status was assessed by echocardiography, and their early blood lactate was checked. Therapies such as fluid adequacy maintenance, cardiac contractility optimization, and vasopressor administration were given according to the type of shock. On the 3rd h, evaluation of clinical improvement, lactate level, and the posttherapy echocardiography were done. Results: As many as 39% of the patients suffered normotension cold shock, 26% with hypotension cold shock, 9% with normotension warm shock, and the rest 26% with hypotension warm shock. Echocardiographic-guided hemodynamic therapy statistically significantly improved the patient's volume status, contractility, and vascular resistance (P < 0.05). Reversal of shock within the first 3 h, which were derived from clinical improvement and echocardiography measurement, was statistically significantly correlated with >10% lactate clearance (P = 0.001; r = 0.558). Conclusion: Focused echocardiography was effective in evaluating the hemodynamics and lowering the clearance of lactate of pediatric patients with septic shock.

Keywords: Echocardiography, hemodynamic, lactate clearance, pediatric, septic shock

How to cite this article:
Kowara Y, Utariani A, Semedi BP, Hanindito E. The role of focused echocardiography in optimizing lactate clearance in the first 3 h of pediatric sepsis resuscitation. Bali J Anaesthesiol 2020;4:109-14

How to cite this URL:
Kowara Y, Utariani A, Semedi BP, Hanindito E. The role of focused echocardiography in optimizing lactate clearance in the first 3 h of pediatric sepsis resuscitation. Bali J Anaesthesiol [serial online] 2020 [cited 2021 Apr 18];4:109-14. Available from: https://www.bjoaonline.com/text.asp?2020/4/3/109/290094

  Introduction Top

Sepsis causes high morbidity and mortality rate in pediatric patients. The prevalence of septic shock and severe sepsis among hospitalized pediatric patients varies from 1% to 26%, with a 5% mortality rate in the developed countries, and up to 35% in the developing countries.[1] A global study that compared hospitals with adequate and limited resources showed no difference in mortality rate (25%).[2] Among them, 67% of sepsis patients experienced multi-organ dysfunction, and 17% of those who survived had moderate disabilities. In 2015, Cipto Mangunkusumo Hospital in Indonesia reported that as many as 19.3% of the 502 pediatric sepsis patients had a mortality rate of 54%, with the highest incidence at the 1st year of age.[3]

Early recognition, adequate fluid resuscitation, and administration of antibiotics are a series of actions that must be carried out within the 1st h of sepsis.[4],[5] The 2017 American College of Critical Care Medicine/Pediatric Advanced Life Support (ACCM/PALS) guidelines are still in line with the 2014 targets: Central venous oxygen saturation and Cardiac Index (CI) goals need to be achieved in this golden period.[6] Normalization of blood pressure and returning capillary refill time to <3 s in the early hours using vasoactive drugs have succeeded in reducing the mortality rate from 39% to 12%.[7]

Initial standard therapy in pediatric patients with sepsis is based on the data from adult studies. Patients in a state of shock receive 60 ml/kg of fluid in the first 15 min. The Fluid Expansion As Supportive Therapy (FEAST) study showed a higher mortality rate within 48 h of fluid administration in critically ill children with poor perfusion.[8] Gelbart et al.[9] showed the results of a systematic study in both randomized and nonrandomized studies and did not reveal reliable evidence to recommend aggressive fluid therapy. Some practitioners believe that the guidelines which have been used so far can be used in developed countries with strict and invasive monitoring.[10]

Additional hemodynamic examinations will certainly help to guide practitioners to be more precise in establishing the diagnosis and providing appropriate management. However, reports on the effectiveness of echocardiography are still minimal.[10],[11] Echocardiography, which is conducted simultaneously with resuscitation, is an important noninvasive tool to overcome the limitations of clinical examination in diagnosing the various categories of septic shock in pediatrics.

Through echocardiography-guided volume infusion, 96% of patients survived from shock condition, and 91% were discharged from the hospital.[12] In pediatric patients with sepsis, the focused bedside echocardiography usage provides crucial information that is not apparent by the clinical assessment. Focused echocardiography also helps the clinicians in determining the cause of low cardiac output in patients with intractable shock conditions despite rigorous fluid administration and inotropic support.

  Patients and Methods Top

This was a quasi-experimental with one group posttest only design, which evaluated all pediatric patients who were admitted to the resuscitation room of Dr. Soetomo General Hospital (Surabaya, Indonesia) from February to April 2019. All patients who were admitted in this unit were classified into blue triage tags according to Canadian triage criteria. The Hospital Ethics Commission of Dr. Soetomo General Hospital has approved this study.

The inclusion criteria include age 2 months to 18 years with sepsis suspicion who met 3 out of 8 clinical signs criteria of the 2017 ACCCM-PALS standard.[6] During the 1st h, the patient received standard oxygenation therapy, either with oxygen supplementation or endotracheal intubation with controlled ventilation for patients who were prone to have respiratory failure. They also had empiric antibiotic therapy and rapid crystalloid fluid infusion through intravenous or intraosseous route, with dosing based on their body weight. Complete blood count and lactate level (lactate1) were also measured within the 1st h. The patients would receive vasoactive agents when they show the signs of fluid-resistant shock to raise their blood pressure. The exclusion criteria include major congenital cardiac abnormalities, intracardiac shunt, pediatric logistic organ dysfunction score <10, initial lactate level <2 mmol/L, and history of other underlying diseases such as dengue shock syndrome, intoxication, malaria, or malignancy.

After the 1st h, a focused echocardiographic examination was performed to assess the patient's fluid adequacy, cardiac contractility, and systemic vascular resistance (SVR). Fluid adequacy was assessed based on the inferior vena cava (IVC) diameter and its collapsibility, which is useful to estimate the right atrial pressure (RAP). Contractility was measured by calculating CI through the diameter of the aorta and the velocity-time integral calculation of the aortic output. Systemic Vascular Resistant Index (SVRI) calculation was conducted with a formula: (80 × [MAP − RAP])/CI.

Based on the results of focused echocardiography and the patient's clinical condition, septic shock was divided into four categories: (1) cold shock with normotension, (2) cold shock with hypotension, (3) warm shock with normotension, or (4) warm shock with hypotension. This classification would determine whether the patient still needed more fluids, inotropic, or vasoconstrictor. Finally, lactate was taken again at the 3rd h (lactate3) to calculate the lactate clearance using this formula: ([Lactate1− Lactate3)/Lactate1) × 100%. This study outcome was the lactate clearance improvement, which was achieved when the lactate clearance was >10% of the initial lactate.

Statistical analysis was performed using the The IBM SPSS® software SPSS software version 20. Samples distribution was carried out by the Kolmogorov–Smirnov test. Continuous variables were written in the mean ± standard deviation, and categorical variables were expressed in absolute numbers and percentages (%). A comparison between improved lactate clearance group and not improved lactate clearance group was performed with the Mann–Whitney test or simple t-test for continuous variables, and Chi-square test or Fisher's exact test for categorical variables. Two-tailed P < 0.05 was set as a standard of significance.

  Results Top

[Table 1] described subjects based on shock classification (cold or warm) along with normal blood pressure or with low blood pressure. The highest frequency was found in cold shock with normal blood pressure, followed by cold shock with low blood pressure and warm shock with low blood pressure. The highest frequency based on the age group was in the range of 2 months to 1 year (52.2%), with the lowest frequency was on the age group of 12 years–18 years. The average volume of crystalloid given in the group with nonimproving lactate clearance was 18 ml/kg body weight, whereas in the improved lactate clearance group was 26 ml/kg body weight [Table 2].
Table 1. Profile of resuscitative efforts, echocardiography results and patient outcome based on shock profile

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Table 2: Patient demographics based on lactate clearance

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Echocardiographic utilization was important to measure whether there was an improvement in echocardiographic results between the initial examination at the 1st h and the final examination at the end of resuscitation hours. In this case, focused echocardiographic examination will observe three conditions: Volume adequacy [Table 3], cardiac contractility [Table 4], and SVR [Table 5]. The echocardiography analysis result of these three parameters was combined with the patient's clinical condition (the warmth of extremities, cardiac resynchronization therapy, pulse, systolic pressure, awareness, urine production according to age and weight) to conclude whether there was an overall improvement or not. The combined analysis results were then compared with lactate clearance improvement to analyze the impact of focused echocardiography utilization and the serum lactate clearance improvement [Table 6].
Table 3: Volume adequacy test based on echocardiography results

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Table 4: Contractility test based on echocardiography results

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Table 5: Vascular resistance test based on echocardiography results

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Table 6: Correlation between shock improvement and lactate clearance

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Shock improvement is defined as the improvement of clinical condition (warmth of extremities, CRT, pulse, systolic pressure, consciousness, urine production based on age and body weight) and echocardiographic improvement.

  Discussion Top

The incidence of cold shock was higher than the warm shock, which corresponds to the pathophysiological stages of sepsis in pediatrics.[13] The early stage of pediatric sepsis begins with impaired perfusion, which is caused by relative hypovolemia due to the reduction of the Stroke Volume Index and CI. The second stage of pediatric sepsis is marked with myocardial dysfunction, without any sign of decrease SVRI. At this stage, the condition may vary on the occurrence of peripheral vasodilation. However, a good cardiac contractility is capable of compensating for this condition. At the advanced stage, cardiac contractility disorders and severe peripheral vascular disorder occur.[14] This is in line with the survival rate in the first 48 h, which got worse (33.3%) at the stage of warm shock with hypotension. The 48-h survival rate in patients with cold shock was quite high (77.8%–83.3%) because they were still in the early stages of sepsis.

Exogenous administration of catecholamines was the lowest in cold-shock patients (20%) and highest in warm-shock patients (62.5%). This condition might happen because patients with warm shock and hypotension do not respond to a fluid bolus. Most crystalloid boluses were given at 20–40 ml/kg.[15] These were certainly different from the ACCM standard. ACCM recommends fluid administration of 60 ml/kg in the 1st h if there are neither rhonchi in the lungs nor enlarging liver.[16]

As many as 13%–25% of patients were not given fluid bolus due to the presence of fluid overload signs (frothy pink sputum and bilateral rhonchi). The fluid administration variation is basically caused by the “zero” point that varies for each patient.[15] This study was in line with the FEAST study that administered as much as 20–40 ml/kg, either using crystalloid boluses or albumin.[8]

Echocardiography results focused on four main signs: IVC diameter and collapsibility, systolic dysfunction on both left and right ventricles, diastolic dysfunction, and peripheral vascular dysfunction.[17] In cold shock, there were 66.7%–78.8% of patients with collapsed IVC. In contrast to patients with cold shock, there was no collapsed IVC in normotension patients with warm shock, and there were 50% collapsed IVC incidence in hypotension patients with warm shock.

The incidence of fluid overload was 16.7%–22.2%. Previous studies also revealed a very different variation in IVC collapsibility, namely 25% in cold shock with normotension and 83% in cold shock with hypotension, and 29% in warm shock with normotension and 80% in warm shock with hypotension.[16] The great variation shows how important it is to use echocardiography to decide on the administration of fluid bolus in the following hours. The IVC collapsibility rate found by previous studies varies between 21.1% and 41.4% with the assumption of giving crystalloid fluid in the 1st h as much as 50 ml/kg.[16] Therefore, the Surviving Sepsis Campaign (SSC) Pediatrics recommends giving a maximum of 40 ml/kg with bolus titration of 10–20 ml/kg, but the recommendation grade is still weak, and the level of evidence is low.[15]

In contractility disorders, the average of SI was 29.66 ± 9.85 ml/m2, which was slightly below the normal value (40–60 ml/m2). The average of CI was 4.27 ± 1.26 ml/m2/min, which was still within the normal range (3.3–6.0 ml/m2/min). This result showed that in pediatric patients, a low SI would be compensated with significant tachycardia to meet the need for CI.[18]

In our study, the SVRI results were within the normal limit (1102.76 ± 380.98 ds/cm5/m2). Therefore, inotropic (dobutamine) without any addition of vasopressor was enough to treat our patients. Kawasaki reported that in general, most of the children with community-acquired septic shock presented in cold shock conditions, whereas all the children with hospital-acquired septic shock manifested in warm shock conditions. However, some of the patients in cold shock who were initially commenced on adrenaline would require noradrenaline or milrinone later on. Meanwhile, some of the patients with warm shock who initially responded to noradrenaline would subsequently develop a decrease in the cardiac output.[19] This was in line with various studies in each group of sepsis.[20],[21] El-Nawawy used dobutamine and milrinone as an alternative inotropic and combined it with norepinephrine or epinephrine for vasopressors.[11]

Ranjit et al. used dobutamine in combination with norepinephrine for patients with cold shock and used dopamine in combination with adrenaline for the warm shock.[12] ACCCM/PALS standard used adrenaline or dopamine as an initial exogenous catecholamine for patients with unclassified and unconfirmed shock conditions.[22] By the use of focused echocardiography, clinicians could choose the most suitable and individualized inotropic or vasopressor for the patient.[23]

Echocardiographic assessment is conducted before and after the resuscitation process. In evaluating fluid adequacy, significant positive results were achieved with the use of echocardiographic guidance (P = 0.001). Measurement of IVC and collapsibility index was easy to do and very helpful in assessing whether the patients still needed to take more fluid boluses or even fluid restriction. This finding was in line with the previous study. A total of 12 of 22 patients had uncorrected hypovolemia despite the 60 ml/kg fluid resuscitation protocol, either accompanied by myocardial dysfunction or not.[16] Fluid overload also increased the patient's morbidity and mortality rate. The use of echocardiography will be very helpful in guiding the administration of fluid therapy of pediatric patients with sepsis. Studies conducted in 90% of pediatrics with sepsis showed fewer fluid overload events in echocardiographic-guided patients (11%) compared to the standard therapy group (44%).[11]

Significant contractility assessment using echocardiographic was very helpful in improving the patient's CI (P = 0.004). The CI results were also used to calculate the SVRI representing the patient's vascular system. Vascular comparisons of patients before and after the resuscitation process, with the help of echocardiography, showed significant results (P = 0.016). Classification of cold or warm shock based on the clinical course only causes bias results and errors in determining the most appropriate therapy. A study reported that echocardiography use led to an earlier administration of dobutamine, which in turn led to a better outcome compared to those whose echocardiography was not performed.[11]

Ranjit et al.[16] showed that 7 of 10 patients with cardiac dysfunction had significantly better cardiac function with echocardiography guided treatment. Raj et al.[20] found that 37% of pediatric patients with sepsis had systolic dysfunction, whereas 33% of them had diastolic dysfunction, and the other 17% of them had both.

This study showed clinical improvement of 91% patients based on the echocardiography evaluation, clinical improvement of the five sepsis signs, and urine production. The results were in line with what was done in the previous studies using echocardiography, which showed a high percentage of recovery patients (94.7%–96.6%).[16] Statistical analysis showed a significant correlation between the improvement of shock guided by echocardiography on lactate clearance >10% with a value of sufficient correlation. Of course, improvement in lactate clearance was not only caused by hemodynamic improvement, but also improvement in hypoxemia, administration of antibiotics, and actions to reduce oxygen consumption (reducing fever and sedation). Previous studies showed a survival rate of 73% in all 12 patients. With the use of focused echocardiography, it has been shown to produce a high survival rate and rapid recovery from shock (<3 h).[11] Focused echocardiography also provides objective data to determine detailed hemodynamic conditions that cannot be assessed only by physical examination (perfusion, pulsation, and peripheral blood pressure).

The study has some limitations. The pathophysiology of sepsis certainly develops based on the age groups. More specific age classification will correspond better with the pathophysiology of shock based on the pediatric category. Another limitation is the ethical problem, which makes it inappropriate to divide the sample population into two groups where echocardiography was not performed in one group. This study contributes as an initial study whether the use of focused echocardiography is useful for reducing lactate clearance.

  Conclusion Top

Focused echocardiography usage helps clinicians in analyzing hemodynamic parameters (IVC diameter and collapsibility, stroke index and CI, and calculation of SVRI) and determining the type of septic shock which could help in choosing the most appropriate therapeutic approach in pediatric sepsis patient. Effective usage of focused echocardiography also improved the patient's lactate clearance after the 3-h initial resuscitation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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