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Background: Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys. Primary objective: To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion. Methods and results: This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD. Conclusion: VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI. [ABSTRACT FROM AUTHOR]

The three main pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses (FBs), vasopressors ± inotropic agents. The three goals of hemodynamic resuscitation include an adequate cardiac output (CO)/clinical perfusion markers, pressure parameters (adequate mean arterial pressure [MAP] and diastolic blood pressure [DBP]) for organ perfusion, and avoiding congestion (worse filling) parameters. Fluid bolus-induced CO improvements are variable (33%–50%) and ill-sustained on account of sepsis-mediated glycocalyx injury. A pragmatic approach is to administer a small bolus (10 mL/kg over 20–30 min) as a test and judge the response based on clinical perfusion markers, pressure parameters, and congestive features. Vasoplegia is characterized by low DBP, which is a major contributor to hypotension in septic shock; furthermore, FBs may exacerbate vasoplegia. A strategy of restricted FB with early low-dose norepinephrine (NE) (0.05–0.1 μg/kg/min) can be helpful. NE has press or effects and also mild inotropy and can be a useful first-line vasoactive even in patients with mild-moderate septic myocardial dysfunction (SMD) to maintain adequate coronary perfusion and DBP while minimizing tachycardia. Severe SMD may benefit from additional inotropy (epinephrine/dobutamine). Except vasopressin, most vasoactive drugs may safely be administered via a peripheral route. The lowest MAP (5th centile for age) may be an acceptable target, provided that end-organ perfusion and organ function (mentation and urine output) are satisfactory. An individualized rather than protocolized approach combining the history, physical examination, laboratory analyses, available monitoring tools, and re-assessments can improve outcomes. [ABSTRACT FROM AUTHOR]

Objective: Persistent shock (PS) or recurrent shock (RS) after initial fluids and vasoactives can be secondary to myriad complex mechanisms, and these patients can have a high mortality. We developed a noninvasive tiered hemodynamic monitoring approach which included, in addition to basic echocardiography, cardiac output monitoring and advanced Doppler studies to determine the etiology and provide targeted therapy of PS/RS. Design: Prospective observational study. Setting: Tertiary Care Pediatric Intensive Care Unit, India. Methods: A pilot conceptual report describing the clinical presentation of 10 children with PS/RS using advanced ultrasound and noninvasive cardiac output monitoring. Children with PS/RS after initial fluids and vasoactive agents despite basic echocardiography underwent BESTFIT + T3 (Basic Echocardiography in Shock Therapy for Fluid and Inotrope Titration) with lung ultrasound and advanced 3-tiered monitoring (T1-3). Results: Among 10/53 children with septic shock and PS/RS over a 24-month study period, BESTFIT + T3 revealed combinations of right ventricular dysfunction, diastolic dysfunction (DD), altered vascular tone, and venous congestion (VC). By integrating information obtained by BESTFIT + T1-3 and the clinical context, we were able to modify the therapeutic regimen and successfully reverse shock in 8/10 patients. Conclusion: We present our pilot results with BESTFIT + T3, a novel approach that can noninvasively interrogate major cardiac, arterial, and venous systems that may be particularly useful in regions where expensive rescue therapies are out of reach. We suggest that, with practice, intensivists already experienced in bedside POCUS can use the information obtained by BESTFIT + T3 to direct time-sensitive precision cardiovascular therapy in persistent/recurrent pediatric septic shock. [ABSTRACT FROM AUTHOR]

Byline: Suchitra. Ranjit, Rajeswari. Natraj, Sathish. Kandath, Niranjan. Kissoon, Balasubramaniam. Ramakrishnan, Paul. Marik Aims: We previously reported that vasodilatation was common in pediatric septic shock, regardless of whether they were [...]

Acute kidney injury (AKI) is a neglected and least studied complication of dengue. AKI secondary to thrombotic thrombocytopenic purpura (TTP) in dengue is extremely rare and there are few case reports. A 2.5-year-old boy with dengue who developed TTP in the critical phase of illness is described. He presented with microangiopathic haemolysis, thrombocytopenia and AKI. Haemolytic uraemic syndrome (HUS)/TTP was suspected and he underwent seven cycles of plasma exchange along with renal replacement therapy, following which he made a complete recovery. Prompt recognition of renal complications in dengue fever and early initiation of appropriate renal replacement therapy along with plasma exchange are essential for a good outcome. Abbreviations: AKI, acute kidney injury; GCS, Glasgow coma scale; HUS, haemolytic uraemic syndrome; LDH, lactate dehydrogenase; NS1, non-structural protein 1; pRIFLE, paediatric risk, injury, failure, loss, end-stage renal disease; SLED, sustained low-efficiency dialysis; TMA, thrombotic microangiopathy; TTP, thrombotic thrombocytopenic purpura. [ABSTRACT FROM AUTHOR]