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

Suchitra Ranjit, Rajeswari Yousefzadeh Natraj, Sathish Kumar Kandath, Niranjan Kissoon, Balasubramaniam Kazemnezhad Ramakrishnan, Paul E Marik

Published: Indian J Crit Care Med. 2016 Oct;20(10):561-569

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.