Abstract
Objective
To evaluate the frequency and diagnostic yield of transthoracic echocardiography (TTE) in a noncardiac pediatric intensive care unit (PICU).
Study design
This was a single-center retrospective observational study of a 48-bed quaternary-care PICU. Patients younger than 18 years who had a TTE performed during their PICU stay from February 3, 2015, to December 8, 2022, were included, and patients on extracorporeal membrane oxygenation support were excluded.
Results
We analyzed 2633 TTEs from 1445 patients, with only the first study included for patients with multiple TTEs. The median age of all patients was 4.4 years (IQR 1-12.4 years). Low ventricular function, defined as moderate or severe systolic dysfunction, was found in 6% of all TTEs, whereas 94% showed hyperdynamic, normal, or mildly diminished ventricular function. TTEs were classified into 25 categories on the basis of indications. Low ventricular function was present in 10% of shock cases, 17% of cardiac arrests, and 2% of respiratory failures. Among cases of respiratory failure, 88% showed no pulmonary hypertension. A low yield group, comprising 16% of total first TTEs, included acute respiratory failure, persistent tachycardia, abnormal electrocardiograms, and systemic hypertension. Among those evaluated for pulmonary hypertension, 62% showed no evidence of it, whereas 4% exhibited severe pulmonary hypertension, all with a pre-existing history. For pericardial effusion evaluation, 82% had no or trivial-small effusion.
Conclusions
TTE frequently is used in the noncardiac PICU, but its diagnostic yield varies widely on the basis of clinical indications. This study emphasizes the need for careful use of TTE in the PICU, with consideration of pretest probability and clinical context to enhance diagnostic effectiveness in critically ill pediatric patients.
Keywords: echocardiography, pediatrics, ventricular dysfunction, shock, cardiac arrest
Transthoracic echocardiography (TTE) plays a crucial role in the diagnosis and management of children, particularly those who are critically ill within the pediatric intensive care unit (PICU). It provides a comprehensive visualization of intracardiac and valvular anatomy, cardiac function, and hemodynamics.
The advantages of TTE stem from its accessibility, portability, and the absence of radiation risk.1,2 Existing studies examining the utility of TTE in PICUs often focus on combined medical and cardiac surgical units or involve limited sample sizes.3, 4, 5 Importantly, although appropriate use criteria for TTE have been established in the pediatric outpatient setting,6 applying similar criteria in the PICU can be challenging as a result of the dynamic and critical nature of conditions affecting critically ill children. Physicians may understandably hesitate to adopt strict criteria in this environment, where individualized clinical judgment is essential. Therefore, we aimed to study the use of echocardiography within a quaternary medical noncardiac PICU to gain a better understanding of common use indications and yield. Our objectives were to evaluate the frequency of echocardiographic studies conducted for various indications in critically ill, noncardiac patients and to identify specific considerations for their use.
Methods
Patient Selection and Study Design
We conducted a single-center, retrospective observational study of all patients less than 18 years of age who had a TTE performed during their stay in a 48-bed PICU within a quaternary care children's hospital from February 3, 2015, to December 8, 2022. The study received approval from the Cincinnati Children's Hospital Institutional Review Board on November 9, 2022; Institutional Review Board 2022-0309 titled “The utility of transthoracic echocardiography in the pediatric intensive care unit.”
The study met the criteria for a waiver of informed consent. Procedures were followed in accordance with the ethical standards of the responsible institutional committee on human experimentation and with the Helsinki Declaration of 1975. Eligible patients were identified by cross-referencing the institution's echocardiogram database, excluding those older than 18 years and those on extracorporeal membrane oxygenation support. It is important to note that patients with a primary cardiac diagnosis at our institution receive specialized care in a dedicated cardiac intensive care unit and are, therefore, not included in this study. For patients who had multiple TTE performed during the study period, we only included the results of the first eligible study.
Classification
Echocardiograms were classified on the basis of the presence of qualitative moderate or severe systolic dysfunction of either the left ventricular (LV) or right ventricle (RV), denoted as low ventricular function (LVF), whereas non-LVF described hyperdynamic, normal, low-normal, or mildly diminished systolic function in both ventricles. To avoid potential misclassification of low-normal or mild dysfunction as the result of variability in echocardiogram measurements, we classified LVF as moderate or severe systolic dysfunction.7,8 We systematically categorized the patient cohort by primary indications for obtaining TTE, on the basis of documentation in the medical records at the time of the order. In cases in which the indication was ambiguous, we conducted comprehensive chart reviews to ascertain the underlying rationale for the study. Indications for TTE were stratified into a total of 25 categories. For patients who experienced cardiac arrest, we further distinguished individuals who experienced in-hospital cardiac arrest (IHCA) from those who had out-of-hospital cardiac arrest (OHCA). For patients with respiratory failure, we subclassified those who were mechanically ventilated and those who exhibited evidence of pulmonary hypertension. The severity of pulmonary hypertension was distinguished by RV pressure exceeding one-half of the systemic pressure vs less than one-half of the systemic pressure estimated by tricuspid valve regurgitant jet peak velocity. However, when this measure is not available, RV hypertension is assessed using septal flattening, pulmonary artery doppler patterns as well as peak pulmonary regurgitation velocity. In TTE performed for the evaluation of pericardial effusion, effusion size was dichotomized into either moderate-large effusion vs no effusion or small-trivial effusion. Finally, a comprehensive evaluation led to the identification of a group for whom TTE was performed primarily to assess cardiac function. This "function" category served as a catch-all for patients whose indications did not align with the predefined categories.
Statistical Analyses
Statistical analysis was conducted using Microsoft Excel (Version 2312). Dichotomous variables were compared with the χ2 test. Nonparametric continuous variables were described as medians with IQRs and compared with the Wilcoxon rank-sum test. Statistical significance was defined as P < .05.
Results
There were 3320 TTEs during the study period. After excluding 687 for age or extracorporeal membrane oxygenation support, the remaining 2633 TTE met inclusion criteria, representing data from 1445 patients (Figure 1). The median age of all patients was 4.4 years (IQR 1-12.4 years). The annual number of TTEs performed and the number of patients who received a TTE over the study period are depicted in Figure 2. Ninety-four percent (n = 2465) of all TTEs were categorized as non-LVF. Only 168 TTEs (6%) exhibited LVF, defined as moderate or severe systolic dysfunction in either ventricle. Seventy-seven of 1445 patients (5%) had LVF on their initial TTE (Table I). Median age did not differ among those with and without LVF (5.0 years [2.0-13.6] vs 4.4 years [1.0-12.3 years]; P = .13). Indications for TTE for patients are summarized in Table II and stratified by the presence or absence of LVF. Of the 192 patients who underwent TTE for assessing cardiac function during shock, only 20 patients (10%) showed LVF. All 20 of these patients presented with LV dysfunction, whereas only 6 patients manifested RV dysfunction. Left ventricular ejection fraction (LVEF) data were accessible for 18 of these patients. Median LVEF among patients with shock and LVF was 36% (IQR 30.25%-39.75%). LVEF data were available for 140 of the 172 patients with shock and non-LVF. Median LVEF among those patients with shock and non-LVF was 61% (IQR 57%-68%). Among the 149 patients who had TTE within 24 hours of cardiac arrest, 25 patients (17%) demonstrated LVF, including 22 patients (15%) with LV systolic dysfunction and 12 patients (8%) with RV systolic dysfunction. Of these 22 patients with LV systolic dysfunction, LVEF data were available for 18 patients. Median LVEF among these patients with cardiac arrest and LVF was 31% (IQR 25.25%-38.75%). In comparison, LVEF data were available for 96 of the 124 patients with cardiac arrest and non-LVF. Median LVEF for cardiac arrest patients and non-LVF was 62% (IQR 56%-67%). Fifty-four (36%) of the cardiac arrest patients were IHCA, whereas the remaining 95 patients had OHCA. Nine of 54 patients (17%) with IHCA exhibited LVF.
Figure 1.
Flow diagram of TTE included in analysis.
Figure 2.
The number of TTEs and number of patients on the y-axis and the corresponding years on the x-axis.
Table I.
Total number of TTEs and the number of patients on the basis of their initial TTE
| Ventricular functions | Total number of TTE studies | Number of patients on the basis of the first TTE |
|---|---|---|
| Non-LVF | 2465 | 1368 |
| LVF | 168 | 77 |
| Total | 2633 | 1445 |
Table II.
Different indications for obtaining TTE
| Indications | Non- LVF | LVF | Total |
|---|---|---|---|
| Shock | 172 | 20 | 192 |
| Cardiac arrest | 124 | 25 | 149 |
| MIS-C | 35 | 4 | 39 |
| Pulmonary hypertension | 199 | 1 | 200 |
| Pericardial effusion | 72 | 1 | 73 |
| Function | 90 | 16 | 106 |
| Acute respiratory failure∗ | 119 | 2 | 121 |
| Abnormal electrocardiogram∗ | 45 | 0 | 45 |
| Systemic hypertension∗ | 30 | 0 | 30 |
| Persistent tachycardia∗ | 28 | 0 | 28 |
| Concern for congenital heart disease | 48 | 0 | 48 |
| Cardiomegaly on chest radiograph | 25 | 0 | 25 |
| Pulmonary edema on chest radiograph | 28 | 0 | 28 |
| Screening | 136 | 0 | 136 |
| Endocarditis | 58 | 3 | 61 |
| Bubble study/stroke evaluation | 42 | 0 | 42 |
| IVC stent | 21 | 0 | 21 |
| Thrombus | 19 | 1 | 20 |
| Chest mass | 20 | 0 | 20 |
| Organ donation | 11 | 2 | 13 |
| Kawasaki disease | 12 | 0 | 12 |
| Pulmonary hemorrhage | 8 | 1 | 9 |
| Trauma | 11 | 0 | 11 |
| Myocarditis | 5 | 1 | 6 |
| Other | 10 | 0 | 10 |
| Total | 1368 | 77 | 1445 |
IVC, inferior vena cava; MIS-C, multisystem inflammatory syndrome in children.
Low yield was defined as the absence of low ventricular function or significant anatomical lesions.
Similarly, in the OHCA group, 16 of 95 patients (17%) had LVF (P = .98). Twenty patients (13%) in the OHCA group were infants younger than 6 months old who had a cardiac arrest at home, with only 1 patient who had LVF (moderately diminished LV systolic dysfunction). During the coronavirus disease COVID-19 pandemic from 2020 to 2022, TTE studies were conducted in 39 patients to evaluate cardiac function in the context of suspected multisystem inflammatory syndrome in children, with only 4 patients (10%) exhibiting LVF. Abnormal coronary arteries were identified in 2 patients (5%). One hundred twenty-one patients underwent TTE in the setting of acute respiratory failure, and only 2 patients (2%) exhibited LVF. Besides ventricular evaluation, significant TTE findings were identified in 2 patients (2%) without LVF. One patient had subaortic stenosis and dynamic LV outflow tract obstruction, whereas the other had a large atrial septal defect (ASD). Among these 121 patients with respiratory failure, 77 (64%) were invasively mechanically ventilated, and the remaining 44 patients (36%) were on noninvasive positive-pressure ventilation or high-flow nasal cannula. TTE in 106 of these patients (88%) with respiratory failure showed no evidence of pulmonary hypertension, whereas in 15 patients (12%) there was evidence of pulmonary hypertension. Among those only 6 patients (5%) had severe pulmonary hypertension, defined as right ventricular pressure more than half systemic pressure. Ten of the 15 patients (67%) who showed evidence of pulmonary hypertension were invasively mechanically ventilated. Only 3 of the 6 patients who had severe pulmonary hypertension were invasively mechanically ventilated. Pre-existing pulmonary hypertension history was noted in 7 of the 15 patients, including 3 out of the 6 with severe disease. Of 200 individuals who underwent TTE to primarily assess for pulmonary hypertension, only 1 patient had LVF (moderate RV systolic dysfunction). In addition, 123 (62%) of these patients showed no evidence of pulmonary hypertension. Notably, only 8 (4%) patients exhibited severe pulmonary hypertension, all of whom had a pre-existing history of pulmonary hypertension (Table III). Of the 73 patients who underwent TTE for evaluation of pericardial effusion, only 1 patient exhibited LVF. Further analysis of these patients, categorized by the size of the effusion, is presented in Table IV. Sixty patients (82%) had either no or a trivial-small pericardial effusion. Among 48 patients who had TTE to rule out congenital heart disease, none had LVF. However, in 2 of these patients (4%) TTE revealed aortic coarctation required surgical intervention (end-to-end anastomosis). The rest had normal anatomy with no congenital lesions other than small ventricular septal defect in 2 patients and small ASD in 4 patients.
Table III.
Pulmonary hypertension data
| Pulmonary hypertension | RV pressure > 1/2 systemic (severe) | RV pressure less than 1/2 systemic (mild/Moderate) | Present but unable to estimate | No evidence of pulmonary hypertensin | Unable to assess |
|---|---|---|---|---|---|
| 200 | 8 | 36 | 25 | 123 | 8 |
| 100% | 4% | 18% | 12% | 62% | 4% |
Table IV.
Pericardial effusion data
| Pericardial effusion | Moderate-large | Trivial-small | No effusion |
|---|---|---|---|
| 73 | 13 | 33 | 27 |
| 100% | 18% | 45% | 37% |
In the group of 28 patients who underwent TTE because of pulmonary edema, none exhibited LVF. Significant findings were identified in 3 patients, which accounts for 10%: 1 patient had cor triatriatum with severely obstructed pulmonary venous return, another had severe mitral valve regurgitation, and the third had severe pulmonary hypertension. Of the 25 patients who underwent TTE as the result of cardiomegaly observed on radiograph of the chest, none exhibited LVF.
However, moderate-to-large pericardial effusion was identified in 2 patients (8%). A group of 106 patients who did not otherwise fit into other predefined categories underwent TTE for the listed indication to assess cardiac function, and their characteristics are detailed in Table V. None of the patients who underwent TTE studies because of abnormal electrocardiogram, systemic hypertension, and persistent tachycardia had LVF or significant anatomical lesions. The same is true for the 136 patients who underwent TTE for screening purposes. This subset comprised individuals who had undergone TTE as part of their preoperative assessment: complex airway surgeries in 22 patients (16%), liver transplant in 17 patients (13%), lung transplant evaluation in 3 patients (2%), and noncardiac surgery in the context of known congenital heart disease in 3 patients (2%). There were 24 bone marrow transplant recipient patients (18%) who underwent routine TTE for screening purposes per our institution's protocol, as well as 52 oncology patients (38%) scheduled for routine TTE examinations before the initiation of chemotherapy. The remaining 15 patients (11%) had TTE for follow-up purposes. None of these patients had LVF.
Table V.
Category function form Table II, which served as a catch-all for patients whose indications did not align with the predefined categories
| Indications | Non-LVF | LVF |
|---|---|---|
| Orthotopic heart transplant | 7 | 0 |
| Cardiomyopathy | 25 | 11 |
| Metabolic disease | 5 | 1 |
| Inflammatory process | 10 | 0 |
| Severe anemia | 8 | 2 |
| Acute liver failure | 11 | 0 |
| Postliver transplant | 6 | 1 |
| Ingestion | 6 | 0 |
| Altered mental status | 3 | 0 |
| Miscellaneous | 9 | 1 |
| Total | 90 | 16 |
Discussion
TTE was commonly used in a busy, quaternary, noncardiac PICU, averaging 0.9 echocardiograms per day over the study period, but the incidence of LVF varied widely by indication. Overall, LVF was evident in only 6% of total TTE. Subgroup analysis revealed that LVF occurred in 10% of septic shock, 17% of cardiac arrest, and 2% in respiratory failure. Among respiratory failure cases, 88% had no pulmonary hypertension. In patients primarily evaluated for pulmonary hypertension, 61% exhibited no evidence, and only 4% had severe disease. In patients evaluated for pericardial effusion, 82% had either no or small effusion. Notably, none of the patients undergoing TTE for conditions like persistent tachycardia, systemic hypertension, or abnormal electrocardiogram showed LVF or anatomical anomalies emphasizing the overall low diagnostic yield of TTE in these clinical scenarios (Table II).
Our study distinguishes itself from other investigations into the use of TTE in the PICU by focusing on a predominantly noncardiac medical patient population and due to the substantial volume of TTE studies examined.3, 4, 5 It is of significance to highlight that within our cohort, the prevalence of LVF in septic shock was observed to be 10%, a figure lower than what is commonly reported in the existing literature. In a preceding study focused on assessing the risk of mortality associated with sepsis-related myocardial dysfunction, 32 of 181 children with septic shock (18%) exhibited LVEF less than 45%, consistent with moderate or severely diminished LV systolic function.8 This percentage is consistent with findings from a retrospective study by Williams et al, where 15 of 78 patients (19%) with fluid- and catecholamine-refractory septic shock exhibited moderate or severe left ventricular dysfunction.9
In other studies, LV systolic dysfunction is reported to occur at a rate ranging from 37% to 40% in pediatric septic shock10,11 and 23%-60% in adults.12, 13, 14, 15, 16 In our study, patients categorized as in shock were determined on the basis of the indications noted in their medical records for undergoing TTE, which may have resulted in a more extensive range of inclusion. In contrast, other studies might use more stringent criteria for shock definition, potentially resulting in variations in patient selection and reported prevalence rates.
In the current study, we identified LVF in 17% of the 149 patients who underwent TTE after cardiac arrest. This prevalence is also lower than what has been reported in the existing literature. In a retrospective analysis focusing on pediatric patients who experienced in- and out-of-hospital cardiac arrest, Gardner et al found that 40% of the 63 children who underwent qualitative LV assessment exhibited moderate-to-severe LV systolic dysfunction.17 Conversely, another investigation by Conlon et al, which included 58 pediatric patients after OHCA, reported decreased LV systolic function in 41% of the cases,18 Although Gardner et al found that 40% of children postarrest exhibited moderate-to-severe LV dysfunction, it is notable that they reported qualitative LV function data for only 63 of the 170 subjects initially included.17
Conversely, Conlon et al reported LV dysfunction in 41% of cases, but they combined mild, moderate, and severe dysfunction. In our study, however, only moderate, and severe dysfunction were reported as LVF, without amalgamating with mild dysfunction. These differences in reporting and categorization could significantly affect the interpretation of LV dysfunction prevalence among patients postcardiac arrest across the studies. Within our dataset, 36% of patients experienced IHCA, whereas 64% had OHCA. Interestingly, 17% of patients with both IHCA and OHCA exhibited LVF. In the OHCA group, we identified 20 cases of cardiac arrest in infants occurring at home and only one patient exhibited LVF with moderate LV systolic dysfunction.
An intriguing subset of patients within our study encompasses those for whom TTE was acquired for general diagnostic purposes in the context of acute respiratory failure, with 64% of these individuals receiving invasive mechanical ventilation. The acquisition of TTE in the presence of respiratory failure appears to yield limited results, as only 2% of patients exhibited LVF, 2% had significant anatomical findings (subaortic stenosis, large ASD), and only 5% had severe pulmonary hypertension with at least one-half systemic RV pressures, and one-half of these patients with severe disease had a known history of pulmonary hypertension. These findings should prompt a re-evaluation of the indications for obtaining TTE in patients experiencing acute respiratory failure. The observed low yield in detecting LVF, severe pulmonary hypertension, and anatomical lesions in this clinical scenario raises questions about the utility of performing TTE in such cases. We suggest a more nuanced consideration of when TTE should be pursued in the context of respiratory failure, with a focus on optimizing diagnostic yield and clinical relevance in the management of these patients.
When evaluating pulmonary hypertension as the primary indication for TTE, 62% of patients had no pulmonary hypertension, whereas 34% exhibited some degree with only 4% demonstrating severe disease (Table III). For evaluation of pericardial effusion, the majority of patients (82%) had either no or a small effusion, with only 18% having a moderate-to-large effusion (Table IV).
In total, 224 TTE studies were conducted in the setting of respiratory failure, systemic hypertension, abnormal electrocardiogram, and persistent tachycardia, this accounted for 16% of the indications for the first TTE conducted, highlighting a notable proportion of TTEs with potentially low yield (Table II).
This study's strengths lie in its substantial sample size of TTE cases and its specific focus on a medical non-cardiac PICU setting. Furthermore, we meticulously categorized our patient cohort on the basis of the specific indications for which TTE was ordered. In instances in which systolic function was not the primary concern, such as in cases of pulmonary hypertension and pericardial effusion, we assessed disease severity in the former and effusion size in the latter. Our study has certain limitations. First, as a retrospective analysis, it relies on historical data, limiting our ability to assess how TTE results influenced patient care, particularly in excluding diagnoses, based on available electronic medical records. Despite this, the descriptive data on the prevalence of normal and abnormal findings for specific clinical indications can guide clinicians in estimating pre-test probabilities when considering TTE in critically ill pediatric patients. Second, the indications for TTE were primarily derived from documentation at the time of the order, which may sometimes lack precision. When indications were unclear, we performed detailed chart reviews to clarify the study's rationale.
Conclusions
In summary, TTE use was common in a noncardiac PICU, and although the overall prevalence of LVF was low, it varied by clinical indication for TTE. Specifically, TTE appeared to have a low diagnostic yield in acute respiratory failure as the primary indication to obtain the study, in addition to abnormal electrocardiogram, systemic hypertension, and persistent tachycardia. Although this study does not advocate for the development of rigid criteria in the PICU, it underscores the importance of considering pretest probability and clinical context when ordering echocardiograms to enhance their utility in critically ill pediatric patients.
CRediT authorship contribution statement
Shafee Salloum: Writing – original draft, Visualization, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Andrew J. Lautz: Writing – review & editing, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Christopher Statile: Writing – review & editing, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization.
Declaration of Competing Interest
A.L. received funding from the National Institutes of Health (K08GM148957, R21GM150093, and L40GM134527). S.S. and C.S. have no conflicts of interest to disclose.
References
- 1.Lai W.W., Geva T., Shirali G.S., Frommelt P.C., Humes R.A., Brook M.M., et al. Guidelines and standards for performance of a pediatric echocardiogram: a report from the Task Force of the Pediatric Council of the American Society of Echocardiography. J Am Soc Echocardiogr. 2006;19:1413–1430. doi: 10.1016/j.echo.2006.09.001. [DOI] [PubMed] [Google Scholar]
- 2.Opfer E., Shah S. Advances in pediatric cardiovascular imaging. Mo Med. 2018;115:354–360. [PMC free article] [PubMed] [Google Scholar]
- 3.Kutty S., Attebery J.E., Yeager E.M., Natarajan S., Li L., Peng Q., et al. Transthoracic echocardiography in pediatric intensive care: impact on medical and surgical management. Pediatr Crit Care Med. 2014;15:329–335. doi: 10.1097/PCC.0000000000000099. [DOI] [PubMed] [Google Scholar]
- 4.Şahin S., Uysal Yazıcı M., Ayar G., Köksal T., Çetin İ.İ., Ekici F., et al. Clinical impact and efficacy of bedside echocardiography on patient management in pediatric intensive care units (PICUs): a prospective study. Anatol J Cardiol. 2017;18:136–141. doi: 10.14744/AnatolJCardiol.2017.7659. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Stanko L.K., Jacobsohn E., Tam J.W., De Wet C.J., Avidan M. Transthoracic echocardiography: impact on diagnosis and management in tertiary care intensive care units. Anaesth Intensive Care. 2005;33:492–496. doi: 10.1177/0310057X0503300411. [DOI] [PubMed] [Google Scholar]
- 6.Campbell R.M., Douglas P.S., Eidem B.W., Eidem B.W., Lai W.W., Lopez L., et al. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology appropriate use Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol. 2014;64:2039–2060. doi: 10.1016/j.jacc.2014.08.003. [DOI] [PubMed] [Google Scholar]
- 7.Frommelt P.C., Minich L.L., Trachtenberg F.L., Altmann K., Camarda J., Cohen M.S., et al. Challenges with left ventricular functional parameters: the pediatric heart network normal echocardiogram database. J Am Soc Echocardiogr. 2019;32:1331–1338.e1. doi: 10.1016/j.echo.2019.05.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lautz A.J., Wong H.R., Ryan T.D., Statile C.J. Myocardial dysfunction is independently associated with mortality in pediatric septic shock. Crit Care Explor. 2020;2 doi: 10.1097/CCE.0000000000000231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Williams F.Z., Sachdeva R., Travers C.D., Walson K.H., Hebbar K.B. Characterization of myocardial dysfunction in fluid- and catecholamine-refractory pediatric septic shock and its clinical significance. J Intensive Care Med. 2019;34:17–25. doi: 10.1177/0885066616685247. [DOI] [PubMed] [Google Scholar]
- 10.Raj S., Killinger J.S., Gonzalez J.A., Lopez L. Myocardial dysfunction in pediatric septic shock. J Pediatr. 2014;164:72–77.e72. doi: 10.1016/j.jpeds.2013.09.027. [DOI] [PubMed] [Google Scholar]
- 11.Ranjit S., Aram G., Kissoon N., Ali M.K., Natraj R., Shresti S., et al. Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study∗. Pediatr Crit Care Med. 2014;15:e17–e26. doi: 10.1097/PCC.0b013e3182a5589c. [DOI] [PubMed] [Google Scholar]
- 12.Landesberg G., Gilon D., Meroz Y., Georgieva M., Levin P.D., Goodman S., et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012;33:895–903. doi: 10.1093/eurheartj/ehr351. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Endo T., Kushimoto S., Yamanouchi S., Sakamoto T., Ishikura H., Kitazawa Y., et al. Limitations of global end-diastolic volume index as a parameter of cardiac preload in the early phase of severe sepsis: a subgroup analysis of a multicenter, prospective observational study. J Intensive Care. 2013;1:11. doi: 10.1186/2052-0492-1-11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Pulido J.N., Afessa B., Masaki M., Yuasa T., Gillespie S., Herasevich V., et al. Clinical spectrum, frequency, and significance of myocardial dysfunction in severe sepsis and septic shock. Mayo Clin Proc. 2012;87:620–628. doi: 10.1016/j.mayocp.2012.01.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Vieillard-Baron A., Caille V., Charron C., Belliard G., Page B., Jardin F. Actual incidence of global left ventricular hypokinesia in adult septic shock. Crit Care Med. 2008;36:1701–1706. doi: 10.1097/CCM.0b013e318174db05. [DOI] [PubMed] [Google Scholar]
- 16.Beesley S.J., Weber G., Sarge T., Nikravan S., Grissom C.K., Lanspa M.J., et al. Septic cardiomyopathy. Crit Care Med. 2018;46:625–634. doi: 10.1097/CCM.0000000000002851. [DOI] [PubMed] [Google Scholar]
- 17.Gardner M.M., Wang Y., Himebauch A.S., Conlon T.W., Graham K., Morgan R.W., et al. Impaired echocardiographic left ventricular global longitudinal strain after pediatric cardiac arrest children is associated with mortality. Resuscitation. 2023;191 doi: 10.1016/j.resuscitation.2023.109936. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Conlon T.W., Falkensammer C.B., Hammond R.S., Nadkarni V.M., Berg R.A., Topjian A.A. Association of left ventricular systolic function and vasopressor support with survival following pediatric out-of-hospital cardiac arrest. Pediatr Crit Care Med. 2015;16:146–154. doi: 10.1097/PCC.0000000000000305. [DOI] [PMC free article] [PubMed] [Google Scholar]