BESTFIT-T3: A Tiered Monitoring Approach to Persistent/Recurrent Paediatric Septic Shock – A Pilot Conceptual Report

Abstract

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.