Low Cardiac Output in the Pediatric Patient Jeffrey Burns, M.D., M.P.H. Chief, Division of Critical Care Medicine Children s Hospital Boston Associate Professor of Anesthesia and Pediatrics Harvard Medical School
Jeffrey.Burns@Childrens.Harvard.EDU No conflicts or financial disclosures to convey 2
Low Cardiac Output in the Pediatric Patient: Should Dr. Bohn give this talk? Bohn DJ, Poirer CS, Demonds JF: Efficacy of dopamine, dobutamine and epinephrine during emergence from cardiopulmonary bypass in children. Crit Care Med 1980; 8:367 3
Low Cardiac Output in the Pediatric Patient What is the low cardiac output syndrome (LCOS)? What about other etiologies of low cardiac output in the pediatric patient? Management strategies 4
Etiologies of Low Cardiac Output Sepsis Chronic (cardiomyopathy) Acute (myocarditis) Weaning from CPB Progressive postoperative failure Pulmonary hypertension Refractory arrhythmias Post Cardiac arrest 5
Low Cardiac Output in the Pediatric Patient What is the low cardiac output syndrome (LCOS)? What about other etiologies of low cardiac output in the pediatric patient? Management strategies 6
LCOS: Landmark reports Parr GVS, Blackstone EH, Kirklin JW. Cardiac performance and mortality early after intracardiac surgery in infants and young children. Circulation. 1975;51:867 874. Wernovsky G, Wypij D, Jonas RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants: a comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation. 1995;92:2226 2235. 7
Wernovsky G, Wypij D, Jonas RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants: a comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation. 1995;92:2226 2235 8
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RRR=64% P =.007 26.7% RRR=34% p=.183 % of Patients 17.7% 9.6% (n=75) (n=79) (n=73) 11
Is there a hormonal component to the LCOS? 12
Is there a hormonal component to the LCOS? 13
Is there a hormonal component to the LCOS?
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Wessel DL. Managing low cardiac output syndrome after congenital heart surgery. Crit Care Med. 2001;29:S220-30. 18
Wessel DL. Managing low cardiac output syndrome after congenital heart surgery. Crit Care Med. 2001;29:S220-30. 19
Wessel DL. Managing low cardiac output syndrome after congenital heart surgery. Crit Care Med. 2001;29:S220-30. 20
Wessel DL. Managing low cardiac output syndrome after congenital heart surgery. Crit Care Med. 2001;29:S220-30. 21
Low Cardiac Output in the Pediatric Patient What is the low cardiac output syndrome (LCOS)? What about other etiologies of low cardiac output in the pediatric patient? Management strategies 22
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Low Cardiac Output in the Pediatric Patient What is the low cardiac output syndrome (LCOS)? What about other etiologies of low cardiac output in the pediatric patient? Management strategies 28
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Is there an alogorithm to treat LCOS in the patient without congenital heart disease? Arno Zaritsky, M.D. 30
Is there an alogorithm to treat LCOS in the patient without congenital heart disease? Septic Shock FLUIDS, FLUIDS! Establish CVL; measure venous O 2 sat and lactate Start Dopamine (DA) Low SVR, Nl CVP Good SV, SV0 2 > 70% (warm shock) Low SVR, high CVP Poor SV, SV02 < 70% Nl to increased SVR; high CVP, Poor SV, SVO 2 <70% (cold shock) NE ± DA Vasopressin Stress steroids Dopamine, NE+Dob Vasopressin Milrinone Stress steroids Titrate Epi? SNP, NTG+Dob Milrinone BNP, DA Stress steroids Arno Zaritsky, M.D. 31
Rivers, E. et al. N Engl J Med 2001;345:1368-1377 32
Low Cardiac Output in the Pediatric Patient Management strategies 1. Most important monitor: a good intensivist doing frequent physical exams. 2. Proactive NOT reactive approach to the patient; continual re-assessment of the clinical trajectory and the management plan. 3. Biomarkers: serial lactate and ScVO2, trends more important than absolute values 33
Jeffrey.Burns@Childrens.Harvard.EDU No conflicts or financial disclosures to convey 34