1. Clinical signs |
CS1 | We recommend to perform a clinical assessment as the initial evaluation in all patients for the detection of hemodynamic alterations and thereupon decide on the subsequent monitoring, diagnostic tests and initial treatment | Strong agreement |
CS2 | There is no single clinical parameter that allows to evaluate the global hemodynamic status in children and, therefore, we recommend to analyze several parameters and make frequent assessments | Strong agreement |
CS3 | We recommend to interpret heart rate and respiratory rate with respect to the age or height of patient, sex, temperature and other influencing factors | Strong agreement |
CS4 | We recommend to measure thermal gradient and capillary refill time to evaluate peripheral perfusion | Strong agreement |
CS5 | In unstable patients we recommend to evaluate clinical signs periodically together with hemodynamic monitoring parameters | Strong agreement |
CS6 | We do not recommend to titrate hemodynamic therapy based upon clinical signs alone in unstable patients | Strong agreement |
CS7 | We do not recommend fluid loading solely based upon clinical signs with exception of the initial resuscitation phase | Strong agreement |
CS8 | We do not recommend fluid loading solely based upon a reduced urinary output | Strong agreement |
2. Arterial blood Pressure |
BP1 | We recommend the use of intra-arterial blood pressure (IBP) over oscillometric blood pressure (OBP) measurement when a reliable blood pressure (BP) measurement is of importance | Strong agreement |
BP2 | We recommend the use of IBP over OBP when fast and accurate changes in blood pressure need to be detected | Strong agreement |
BP3 | In children under 12 years of age we recommend a target blood pressure (preferably mean arterial pressure (MAP)) during shock and after return of spontaneous circulation from cardiac arrest higher than P5 for the age and sex, and if possible, around the P50, unless uncontrolled hemorrhage due to trauma is present. We advise to take blood flow parameters into account and avoid the overuse of vasoconstrictors when guiding hemodynamic therapy using BP | Weak agreement |
BP4 | In children under 12 years of age we do not recommend a target MAP > 65 mmHg unless under very specific conditions (e.g. intracranial hypertension) | Strong agreement |
BP5 | In children over 12 years of age we recommend a target blood pressure of > = 65 mmHg MAP (according to adults surviving sepsis guidelines) unless in children known to have prior hypertension | Strong agreement |
BP6 | We recommend not to use BP as the only therapeutic target in unstable children. The hemodynamic state should be evaluated integrating several clinical and hemodynamic parameters | Strong agreement |
BP7 | We recommend to measure IBP in children after major surgery that could produce hemodynamic, respiratory or neurologic alterations or risk of bleeding | Strong agreement |
BP8 | We recommend IBP monitoring in children in shock not responsive to initial fluid therapy or requiring vasopressor treatment | Strong agreement |
BP9 | We recommend to use IBP in malignant hypertension or other hypertensive emergencies to control the effect of continuous invasive hypotensive drugs. Oral or intermittent intravenous drugs can be monitored using OBP | Strong agreement |
BP10 | We recommend to use IBP in patients with intracranial hypertension to measure cerebral perfusion pressure and control the effects of the therapy | Strong agreement |
BP11 | We recommend to use IBP in patients on extracorporeal membrane oxygenation (ECMO) | Strong agreement |
3. Serum lactate measurement |
LAC1 | We recommend prompt point of care measurement of lactate or analysis in the laboratory according to local laboratory instructions | Strong agreement |
LAC2 | We recommend to obtain a repeat blood sample from a reliable site (central venous, arterial or peripheral venous with a time of tourniquet use shorter than 60 secs) when the lactate value of a capillary sample is higher than 3.0 mmol/L | Strong agreement |
LAC3 | We recommend to closely follow up patients with increased lactate levels until lactate values at least drop below 3.0 mmol/L, especially if other signs of tissue hypoxia are present | Strong agreement |
LAC4 | We recommend to interpret lactate levels always in conjunction with clinical indicators of poor systemic perfusion and monitoring parameters | Strong agreement |
LAC5 | We recommend to closely follow up and eventually intensify medical treatment in unstable patients with concerns regarding tissue hypoxia and lactate levels (> 3.0 mmol/L) | Strong agreement |
LAC6 | We recommend to use goal-directed medical therapy in patients admitted after open heart surgery based on serial blood lactate values obtained in short periods of time (4 hours in children, contemplate 1 hour in neonates), considering 5 mmol/L as a cut-off value | No agreement |
LAC7 | In children with septic shock and persistently high levels of lactate we recommend to intensify medical treatment (when possible) | Weak agreement |
LAC8 | In children treated with extracorporeal life support with persistently high levels of lactate, we recommend to intensify medical or mechanical treatment | Weak agreement |
4. Central venous pressure |
CVP1 | We recommend to place the tip of a central venous catheter at the junction of the superior caval vein (SCV) and the right atrium to obtain an optimal central venous pressure (CVP) measurement | Strong agreement |
CVP2 | We recommend the use of a short catheter with a semi-rigid wall connected with a transducer and electronic monitor to record CVP continuously | Strong agreement |
CVP3 | We recommend to measure CVP in all unstable patients refractory to initial hemodynamic treatment | Strong agreement |
CVP4 | We recommend against the use of CVP to predict fluid responsiveness. Therefore, fluid loading should not be started solely based upon a low CVP | Strong agreement |
CVP5 | An abrupt elevation in CVP upon fluid administration should raise suspicion of significant cardiac dysfunction | Strong agreement |
CVP6 | An isolated CVP measurement is of limited value in clinical practice. However, trends in CVP may provide important information regarding changes in cardiovascular pathophysiology such as evolving right heart failure | Strong agreement |
CVP7 | CVP is not a reliable parameter to assess right ventricular function | Weak agreement |
5. Central venous oxygen saturation measurement |
ScvO2 1 | We recommend to measure central venous oxygen saturation (ScvO2) in unstable patients not responding to the initial treatment | Strong agreement |
ScvO2 2 | ScvO2 > 65%* (and arterial to venous difference less than 30%) is acceptable in children, and a sustained drop in ScvO2 (or increase in arterio-venous difference) may reflect inability of the cardiovascular system to respond to an increased demand or decreased supply | Weak agreement |
ScvO2 3 | ScvO2 values may differ depending upon the site of catheter tip: we recommend placing the central catheter tip at the junction of SVC and right atrium | Strong agreement |
ScvO2 4 | ScvO2 is not an adequate marker of cardiac index (CI) | Strong agreement |
ScvO2 5 | When ScvO2 is < 65% there is a possible hemodynamic alteration. However, in sepsis a normal or high ScvO2 may reflect mitochondrial dysfunction and mask hemodynamic alterations | Strong agreement |
ScvO2 6 | We recommend against targeting hemodynamic therapy solely based upon ScvO2 | Strong agreement |
*This only applies for normal arterial saturation |
6. Echocardiography / Ultrasonography |
US1 | We recommend against using cardiac ultrasound for routine hemodynamic monitoring in intensive care setting but in infants and children with hemodynamic instability it should be used as an adjunct to gain additional information required for making accurate clinical decisions | Strong agreement |
US2 | Cardiac ultrasound can be reliably used in neonates and children with cardiac tamponade | Strong agreement |
US3 | Cardiac ultrasound can help in diagnosing pulmonary hypertension and assessing severity of pulmonary hypertension | Strong agreement |
US4 | Cardiac ultrasound may help in identifying underlying pathophysiology of shock and choosing the right intervention based upon deranged hemodynamic physiology (preload, afterload or cardiac function) | Strong agreement |
US5 | Cardiac ultrasound performed by adequately trained intensivists can help in assessing global cardiac function qualitatively on visual inspection and also semi-quantitatively | Weak agreement |
US6 | Cardiac ultrasound may help in assessing fluid responsiveness: we recommend using velocity time integral (VTI) across aortic valve for assessing fluid responsiveness rather than inferior vena cava collapsibility in mechanically ventilated infants and children | Strong agreement |
US7 | We recommend serial longitudinal assessment to assess response to therapy in patients with significant hemodynamic instability | Strong agreement |
7. Cardiac output measurement and transpulmonary thermodilution |
CO1 | We recommend against the use of PAC for measuring CO in children as the first-choice method | Strong agreement |
CO2 | In patients with a refractory shock when an accurate measurement of CO is needed, we recommend to use transpulmonary thermodilution (TPTD) or semi-invasive transpulmonary ultrasound dilution (TPUD) | Weak agreement |
CO3 | We recommend to use ultrasound/doppler based methods of estimating CO if TPTD or TPUD are not available or do not match the conditions to be used | Strong agreement |
CO4 | We recommend to use ultrasound/doppler based methods of estimating CO for the initial assessment of unstable patients, to decide if a more invasive method is needed or in stable patients | Strong agreement |
CO5 | We cannot give any recommendations regarding other non-invasive methods due to the limited experiences in critically-ill children | Strong agreement |
CO6 | We recommend that cardiac index (CI) should be maintained above 3.5 L/min/m2, otherwise titrated to ensure adequate end organ support | Strong agreement |
CO7 | In young children the use of uncalibrated continuous arterial pressure-based CO monitoring is not recommended | Strong agreement |
CO8 | We recommend to use invasive (and if possible continuous) CO monitoring in unstable post-operative patients after major (cardiothoracic) surgery, multiple trauma injuries or burns or patients with complex cardiopulmonary interactions | Strong agreement |
CO9 | We recommend to use invasive and or calibrated continuous CO monitoring in patients with high intrathoracic pressure that “threatens” the hemodynamic status (like severe PARDS) for titrating hemodynamic and ventilatory therapy | Weak agreement |
TPD1 | We recommend against the routine use of transpulmonary dilution (TPD) in children | Strong agreement |
TPD2 | Blood volumes measured with TPD reflect volume status in children, however we recommend against targeting fluid therapy based upon these parameters | Strong agreement |
TPD3 | Lung water measurement may provide a physiological insight into the amount of pulmonary edema in critically ill children. However, we recommend against targeting hemodynamic therapy based upon this parameter | Strong agreement |
TPD4 | TPD methods can be useful for indicating cardiac or non-cardiac shunts | Weak agreement |
TPD5 | TPD methods are the most accurate methods available at the bedside for measuring CO in children | Weak agreement |
TPD6 | When reliable absolute measurements of CO are deemed necessary TPD is the method of first choice | Strong agreement |
TPD7 | Because of their intermittent measurement technique, TPD methods are not suitable for the detection of fast changes in CO unless used in conjunction with continuous trend monitoring using pulse contour analysis, calibrated by transpulmonary indicator dilution technology | Strong agreement |
TPD8 | In unstable children TPD measurements may be advantageous. However, the risk of femoral arterial access when using transpulmonary thermodilution (TPTD) method and complicated measurements must be weighed against the potential benefit | Strong agreement |
8. Pulmonary artery pressure |
PAC1 | Transthoracic echocardiography is reliable enough to estimate systolic pulmonary artery pressure (SPAP) at the bedside in most patients when tricuspid valve regurgitation is present and in absence of severe right ventricle (RV) failure | Weak agreement |
PAC2 | We recommend using pulmonary artery catheters (PAC) for measurement of (gold standard) pulmonary arterial pressure (PAP) only during cardiac catheterization or, in selected cardiac surgery patients, using surgically inserted catheters | Strong agreement |
PAC3 | We do not recommend to use a PAC for the measurement of cardiac output (CO) | Strong agreement |
PAC4 | We do not recommend to use a PAC for the measurement of pulmonary artery wedge pressure | Strong agreement |
PAC5 | We recommend the monitoring of left atrial pressure only in selected cardiac surgery patients or patients after lung transplant using a surgically inserted catheter | Strong agreement |
PAC6 | We do not recommend non-invasive techniques using cardiac ultrasound to estimate left atrial pressure | Strong agreement |
PAC7 | We recommend monitoring of PAP using ultrasound in young patients with refractory shock states to exclude pulmonary hypertension | Strong agreement |
PAC8 | Transthoracic echocardiography can be a useful tool to estimate SPAP in patients on VV or VA ECMO | Weak agreement |
9. Volume resuscitation and fluid responsiveness |
FR1 | We recommend to observe the patient’s clinical situation, physical exam and various perfusion indicators suggesting an inadequate CO (or oxygen transport) caused by hypovolemia before considering fluid loading | Strong agreement |
FR2 | We recommend, when possible or available, to confirm fluid responsiveness before commencing fluid loading when hypovolemia is suspected | Strong agreement |
FR3 | In delivering a bolus of fluid we recommend to administer a small bolus of fluid in a short time period while tracking changes in cardiac output, blood pressure and CVP | Strong agreement |
FR4 | We recommend alternative therapeutic strategies for hypotension management in fluid non-responders** | Strong agreement |
FR5 | We recommend against delivering a fluid bolus based on static measures, particularly CVP | Strong agreement |
FR6 | We recommend to withhold fluid therapy in patients with an increasing CVP and no significant increase in blood pressure or cardiac output as a result of previous fluid therapy | Strong agreement |
FR7 | We recommend fluid therapy (with boluses 5–10 ml/kg) as part of early resuscitation in unstable patients guided by the effect on blood pressure and / or cardiac output | Strong agreement |
FR8 | No specific recommendations regarding estimating fluid responsiveness can be made in patients with raised intracranial pressure or extracorporeal life support (ECLS) | Weak agreement |
**Non-responders defined cases who had no rise in cardiac output (or stroke volume) as a result of volume resuscitation. |
8. Near infrared spectroscopy |
NIRS1 | The mean baseline cerebral capillary-venous hemoglobin saturation (rSO2) is > 70% in healthy children and those with an acyanotic heart disease (similar to the adult population). Infants and children with cyanotic heart disease have a mean cerebral rSO2 between 46–57%* | Weak agreement |
NIRS2 | Cerebral rSO2 less than 40% or a significant drop from the baseline may be associated with hypoxic-ischemic neural injury | No agreement |
NIRS3 | It is recommended that the cerebral probe should be placed on the right and or left side of the forehead | Weak agreement |
NIRS4 | Near infrared spectroscopy (NIRS) can be useful during the peri-operative period after surgery for congenital heart defects | Weak agreement |
NIRS5 | We recommend against the routine use of NIRS during non-cardiac surgery | Weak agreement |
NIRS6 | We cannot make recommendations regarding the use of NIRS while treating children in shock, post-cardiac arrest, post traumatic brain injury and infants with hypoxic-ischemic encephalopathy | Weak agreement |
NIRS7 | Trend in NIRS values may provide valuable physiological information in children with hemodynamic instability but routine use in all children with hemodynamic instability is not recommended | Strong agreement |
*Normal range described is while using INVOS NIRS monitor and practitioners should be mindful that different devices and sensors provide different values – we recommend checking normal values for the device being used in clinical practice |
11. Microcirculation |
MICRO1 | In addition to monitoring blood pressure and cardiac output assessment of microcirculation should be considered in children with shock | Weak agreement |
MICRO2 | Many routinely used parameters like capillary refill, peripheral temperature, lactate, NIRS etc. reflect aspects of the hemodynamic condition but do not adequately reflect the microcirculation and cannot be used as such | Strong agreement |
MICRO3 | We recommend against routine microcirculation evaluation by video microscopy in stable children except those in clinical studies | Strong agreement |
MICRO4 | We recommend to evaluate the microcirculation by video microscopy in various types of patients with hemodynamic compromise or complicated clinical course only for research purposes | Strong agreement |
MICRO5 | We recommend the use of microcirculation measurement technologies such as sidestream dark field (SDF) or incident dark field (IDF) in sublingual area in critically ill children that are deeply sedated to evaluate microcirculation | Strong agreement |
MICRO6 | We recommend to use the recommendations of 2017 adult consensus to the acquisition and analysis of video microscopy (SDF or IDF cameras) | Strong agreement |
MICRO7 | Although central venous to arterial CO2 difference could provide additional insight into the microcirculatory condition, we recommend against its use to guide resuscitation in critically ill children | Strong agreement |