Low Cardiac Output in the Pediatric...

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 dr. Jeffrey Burns, Chillan 2009

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

• What is the low cardiac output syndrome (LCOS)?

• What about other etiologies of low cardiac output in the pediatric patient?

• Management strategies

Etiologies of Low Cardiac Output

• Sepsis • Chronic (cardiomyopathy) • Acute (myocarditis) • Weaning from CPB • Progressive postoperative failure • Pulmonary hypertension • Refractory arrhythmias • Post Cardiac arrest

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.

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

(n=75) (n=79) (n=73)

RRR=64% P =.007

RRR=34% p=.183

Is there a hormonal component to the LCOS?

Wessel DL. Managing low cardiac output syndrome after congenital heart surgery. Crit Care Med. 2001;29:S220-30.

Wessel DL. Managing low cardiac output syndrome after congenital

heart surgery. Crit Care Med. 2001;29:S220-30.

Arno Zaritsky, M.D.

Is there an alogorithm to treat LCOS in the patient without congenital heart disease?

Septic Shock

FLUIDS, FLUIDS!

Low SVR, Nl CVP Good SV,

SV02 > 70% (warm shock)

Low SVR, high CVP Poor SV,

SV02 < 70%

Nl to increased SVR; high CVP, Poor SV,

SVO2 <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

Establish CVL; measure venous O2 sat and lactate

Start Dopamine (DA)

Arno Zaritsky, M.D.

Is there an alogorithm to treat LCOS in the patient without congenital heart disease?

Rivers, E. et al. N Engl J Med 2001;345:1368-1377

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

Jeffrey.Burns@Childrens.Harvard.EDU

No conflicts or financial disclosures to convey

Low Cardiac Output in the Pediatric...

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