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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
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 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
Etiologies of Low Cardiac Output
• Sepsis • Chronic (cardiomyopathy) • Acute (myocarditis) • Weaning from CPB • Progressive postoperative failure • Pulmonary hypertension • Refractory arrhythmias • Post Cardiac arrest
5 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
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10 dr. Jeffrey Burns, Chillan 2009
% o
f Pat
ient
s
26.7%
17.7%
9.6%
(n=75) (n=79) (n=73)
RRR=64% P =.007
RRR=34% p=.183
11 dr. Jeffrey Burns, Chillan 2009
Is there a hormonal component to the LCOS?
12 dr. Jeffrey Burns, Chillan 2009
Is there a hormonal component to the LCOS?
13 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
Wessel DL. Managing low cardiac output syndrome after congenital
heart surgery. Crit Care Med. 2001;29:S220-30.
19 dr. Jeffrey Burns, Chillan 2009
Wessel DL. Managing low cardiac output syndrome after congenital
heart surgery. Crit Care Med. 2001;29:S220-30.
20 dr. Jeffrey Burns, Chillan 2009
Wessel DL. Managing low cardiac output syndrome after congenital
heart surgery. Crit Care Med. 2001;29:S220-30.
21 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
23 dr. Jeffrey Burns, Chillan 2009
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27 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
29 dr. Jeffrey Burns, Chillan 2009
Arno Zaritsky, M.D.
Is there an alogorithm to treat LCOS in the patient without congenital heart disease?
30 dr. Jeffrey Burns, Chillan 2009
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?
31 dr. Jeffrey Burns, Chillan 2009
Rivers, E. et al. N Engl J Med 2001;345:1368-1377
32 dr. Jeffrey Burns, Chillan 2009
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 dr. Jeffrey Burns, Chillan 2009
No conflicts or financial disclosures to convey
34 dr. Jeffrey Burns, Chillan 2009
