Early norepinephrine decreases fluid and ventilatory requirements in pediatric vasodilatory septic shock

Suchitra Ranjit; Rajeswari Natraj; Sathish Kumar Kandath; Niranjan Kissoon; Balasubramaniam Ramakrishnan; Paul E Marik

doi:10.4103/0972-5229.192036

Early norepinephrine decreases fluid and ventilatory requirements in pediatric vasodilatory septic shock

Indian J Crit Care Med. 2016 Oct;20(10):561-569. doi: 10.4103/0972-5229.192036.

Authors

Suchitra Ranjit¹, Rajeswari Natraj¹, Sathish Kumar Kandath¹, Niranjan Kissoon², Balasubramaniam Ramakrishnan³, Paul E Marik⁴

Affiliations

¹ Pediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, Tamil Nadu, India.
² Department of Pediatrics and Emergency Medicine, BC Children's Hospital, Sunny Hill Health Centre for Children, University of British Columbia, BC V6H 3V4, Canada.
³ Department of Medical Education, Apollo Hospitals, Chennai, Tamil Nadu, India.
⁴ Department of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, VA 23507, USA.

Abstract

Aims: We previously reported that vasodilatation was common in pediatric septic shock, regardless of whether they were warm or cold, providing a rationale for early norepinephrine (NE) to increase venous return (VR) and arterial tone. Our primary aim was to evaluate the effect of smaller fluid bolus plus early-NE versus the American College of Critical Care Medicine (ACCM) approach to more liberal fluid boluses and vasoactive-inotropic agents on fluid balance, shock resolution, ventilator support and mortality in children with septic shock. Secondly, the impact of early NE on hemodynamic parameters, urine output and lactate levels was assessed using multimodality-monitoring.

Methods: In keeping with the primary aim, the early NE group (N-27) received NE after 30ml/kg fluid, while the ACCM group (N-41) were a historical cohort managed as per the ACCM Guidelines, where after 40-60ml/kg fluid, patients received first line vasoactive-inotropic agents. The effect of early-NE was characterized by measuring stroke volume variation(SVV), systemic vascular resistance index (SVRI) and cardiac function before and after NE, which were monitored using ECHO + Ultrasound-Cardiac-Output-Monitor (USCOM) and lactates.

Results: The 6-hr fluid requirement in the early-NE group (88.9+31.3 to 37.4+15.1ml/kg), and ventilated days [median 4 days (IQR 2.5-5.25) to 1day (IQR 1-1.7)] were significantly less as compared to the ACCM group. However, shock resolution and mortality rates were similar. In the early NE group, the overall SVRI was low (mean 679.7dynes/sec/cm5/m2, SD 204.5), and SVV decreased from 23.8±8.2 to 18.5±9.7, p=0.005 with NE infusion suggesting improved preload even without further fluid loading. Furthermore, lactate levels decreased and urine-output improved.

Conclusion: Early-NE and fluid restriction may be of benefit in resolving shock with less fluid and ventilator support as compared to the ACCM approach.

Keywords: Critical illness; fluid infusion; morbidity; mortality; norepinephrine; pediatrics; sepsis; septic shock; vasodilatory; venous return.