Recommendations for hemodynamic monitoring for critically ill children—expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Abstract

Background Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. Methods Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature—a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. Results Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached “strong agreement,” 20 “weak agreement,” and 2 had “no agreement.” Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. Conclusions These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.

Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations

“…Only recently investigators have reported on the mathematical conversions to allow comparison of NIRS data between devices ( 74 , 75 ). Due to these limitations, the European Society of Paediatric and Neonatal Intensive Care recommends against routine clinical use of NIRS in all children with hemodynamic instability and there is no agreement from the group on the significance of a decline in ScO 2 from baseline or a lower limit of normal ( 76 ).…”

Current Practice of Fluid Maintenance and Replacement Therapy in Mechanically Ventilated Critically Ill Children: A European Survey

“…This is in conjunction with current guidelines and studies ( 11 , 21 ) although 20 ml/kg is still used by some. Fluid therapy was guided most frequently by clinical signs and symptoms, although research has shown that these do not always predict fluid responsiveness in a reliably way ( 22 , 23 ). Fluid responsiveness, defined as an increase in cardiac output as a result of fluid loading, was sometimes determined using various methods.…”

“…This can be a result of the sparse use of invasive tools for hemodynamic monitoring, such as central venous pressure or pulmonary artery catheters, in children as compared to adults. Therefore, in contrast to the adult ICU, fluid resuscitation is not always performed based upon valid parameters and might contribute to fluid overload ( 23 , 24 ). Future research needs to identify more accurate parameters for guiding fluid resuscitation in critically ill children in order to prevent fluid overload.…”

“…55/86 (63.9%) of the respondents reported that they use the Holiday-Segar formula (4 ml/kg/h for the first 10 kg + 2 ml/kg/u for the second 10 kg + 1 ml/kg/u>20 kg) to determine the normal daily total fluid volume requirement in healthy children (non-critically ill, non-mechanically ventilated patients). For PICU patients at the start of invasive mechanical ventilation, 64/86 (74.4%) of the respondents reported to give less fluids (median (IQR) 20% (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)] based on the calculated normal daily total fluid volume. The remainder of the respondents 21/86 (24.4 %) stated to give the full 100% of calculated normal maintenance fluid.…”

Early restrictive fluid resuscitation has no clinical advantage in experimental severe pediatric acute respiratory distress syndrome

“…CVP is dependent on several factors, such as venous return, right heart function, and mechanical ventilator settings, and thus does not reliably reflect either preload of the heart or volume status. A lower intravascular volume, as reflected by a lower GEDVi and SV, may thus be accompanied by a lower, equal, or even raised CVP (40). To compensate for reduced intravascular volume, the animals with the restrictive regimen had higher heart rates, suggesting they were slightly lower positioned on the Starling curve than animals receiving liberal fluid.…”