Objectives:

n
Review available hemodynamic monitoring
technologies for critically ill children
n
Refresh knowledge of artifacts and technical
limitations inherent in clinical physiologic
measurements
n
Identify pitfalls in interpretation and
application of hemodynamic data in the
clinical setting
Key words: hemodynamic monitoring, venous
oxygen saturation, lactate, pulmonary artery
occlusion pressure, thermodilution, capnography
iNtRODUctiON
Heisenbergs uncertainty principle, which was
proposed in the early days of atomic and subatomic
particle physics research, has applicability in
pediatric critical care hemodynamics. In essence,
the very act of measuring a physiologic variable
may affect the value of that variable. It is therefore
appropriate to approach the discussion and the use
in practice, of imperfect measures of the status
of our patients with humility and with constant
vigilance for potentially misleading information.
Pediatric critical care is a discipline driven
by a steady stream of data which is acquired,
analyzed, and synthesized to allow a rational and
effective approach to care of critically ill and
injured children. Algorithms and guidelines have
evolved through efforts to improve outcomes
by standardizing the approach to certain major
pathophysiologic states. Accuracy and validity of
the data measurements are essential elements of
any critical care plan, and algorithms and pathways
do not allow one to assume that data are correct.
The practitioner must be aware of potential sources
of error in measurement and interpretation, and be
able to interpret data in context, considering the
COMMON PITFALLS AND ARTIFACTS
IN HEMODYNAMIC MONITORING
Stephen R. Keller, MD, MHSA
entire picture of the patient rather than viewing
the data as a collection of independent variables.
In addition, complications associated with invasive
monitoring must be clearly understood in order to
rationally progress to goal-directed therapy based
on measurements acquired in this way.
bLOOD PRessURe MONitORiNG
Blood pressure measurement is integral to support
of the critically ill patient. Forward fow to vital
organs, necessary for delivery of oxygen and
substrate, and removal of waste, depends on the
presence of a pressure gradient, or perfusion
pressure. In the absence of such a gradient, no
fow occurs. Establishment of an adequate pressure
gradient is therefore paramount in support of the
ICU patient.
invasive blood Pressure Monitoring
Arterial cannulation and transduction of pressure
waveforms is considered the gold standard for
monitoring of arterial pressure in the intensive
care unit. Numerous technical issues can affect the
accuracy of the measurement. These inaccuracies
may become clinically signifcant, especially in the
context of goal-directed therapy, in which control
loop algorithms are used to titrate vasoactive
therapy or intravascular volume manipulation.
Also, it is not uncommon for discrepancies to occur
between invasive and noninvasive measurements
of blood pressure, resulting in confusion at the
bedside over which number to use in directing
therapy. A good understanding of the reasons for
such discrepancies and for the potential sources of
error in invasive measurements of blood pressure
will allow rational resolution of these issues and
application of appropriate interventions. Finally,
the importance and limitations of blood pressure
measurement as a representation of overall
circulatory status in the critically ill child must be
appreciated.

Current Concepts in Pediatric Critical Care Refresher Course

technical sources Of error
Physical properties of the system being measured
have signifcant infuence on the potential errors. The
vascular system is complex, with periodic variations
in pressure following each heart beat over a wide
range of frequency. The high heart rate of infants was
an issue in terms of responsiveness and fdelity of
the transduced waveforms early in development of
monitoring devices, but this has been addressed and
generally is not a concern in modern PICU settings.
A more diffcult problem in accurate monitoring
relates to the transmission of the pressure waveform
down a progressively smaller, branching vascular
tree with variable elastance and resistance depending
on humoral and neural regulation of vascular tone.
In clinical situations associated with increased
resistance (e.g., hypovolemia, early compensated
shock), refection of kinetic energy back from the
vascular tree to the end-hole vascular cannula can
result in a higher measured systolic pressure which
does not contribute to forward fow via a pressure
gradient. An understanding of the physical concepts
which follow can allow one to assess the accuracy of
the data by analyzing the pulse waveform displayed
on the monitor, prior to including it in goal-directed
therapy.
Damping of the pulse waveform is associated
with falsely low systolic pressures and falsely
high diastolic pressures. The most common cause
of this fattening of the waveform is vasospasm
of the vessel in which the cannula lies. Technical
problems, such as an air bubble in the fuid-flled
tubing leading from the vascular cannula to the
electronic transducer, or a loose connection in the
tubing, may also cause this problem. The problem
can be addressed by checking the tubing carefully
for bubbles or loose connections. Once these have
been eliminated, adding papaverine to the arterial
line infusate is often helpful in reducing vasospasm
at the site of the line insertion, which may result
in a better waveform and more reliable pressure
measurement. Finally, use of the mean arterial
blood pressure (MABP) as a guide to therapy may
be most appropriate. It is a function of the area
under the arterial pulse waveform curve and is less
affected by damping of the signal.
Resonance refers to the interaction between the
natural frequency of a physical monitoring system
and the frequency of the physiologic parameter
being measured, such that erroneous waveforms and
pressures are displayed. This waveform interaction
is very similar to the interference displayed in
the illuminated wave pool often performed in
high school physics. The natural frequency of a
tubing/transducer system is not dissimilar to that
of a xylophone, so that the monitoring system itself
may, with its intrinsic physical properties, infuence
the data generated. The modern ICU monitoring
system is engineered to minimize these sources
of error primarily by using stiff, noncompliant,
narrow gauge, and short tubing. However, it is
fairly common to see fling elevation of the
systolic blood pressure, visible as a needle point
projection at the peak of the pulse waveform,
because the systems are set up to reduce damping
of the signal. Once again, the mean arterial blood
pressure is less affected by this phenomenon, so use
of MABP in algorithms for goal-directed therapy
may be more appropriate.
Finally, catheter whip due to movement within the
vessel in a hyperdynamic circulatory state may
impart kinetic energy to the end hole of the cannula,
resulting in a higher pressure measurement. While
this is not evident in small peripheral arteries, it
may be a factor in catheters placed in larger central
arteries or the aorta or pulmonary artery.
Noninvasive blood Pressure Monitoring
Measurement of blood pressure by noninvasive
methods is commonly performed in the PICU
setting. Because of the need for frequent
repetitive measurement of blood pressure in
critically ill children, the standard method using
a sphygmomanometer and a stethoscope with
auscultation of Korotkoff sounds has been largely
supplanted by oscillometric automated devices
integrated into the bedside monitor. Because either
method depends on flow being present in the
extremity being subjected to assessment, reliable
data may be diffcult to obtain in low-fow states.
Less accurate measurement in alternate sites such
as the leg, and by inferior methods such as the fush

Current Concepts in Pediatric Critical Care Refresher Course

technique or Doppler detection of fow with manual
decompression of the blood pressure cuff, are
sometimes used until more accurate intravascular
monitoring can be established.
It is important for the clinician to understand
the differences between pressures measured
by invasive versus noninvasive techniques. In
each of these noninvasive methods, pressure is
externally applied until fow ceases, and the blood
pressure is then extrapolated from gradual release
of that pressure until distension of compressed
vessel walls occurs and fow is re-established and
detected by various indicators. Conversely, with an
invasive arterial line one is measuring a pressure
head in a fuid medium with a static pressure and
a kinetic energy component. The effect of the
kinetic energy component is to make the measured
intra-arterial systolic pressure 8-16 torr higher
than the noninvasive measurement in the normal
hemodynamic state, and up to 25-30 torr higher in
patients with dramatically reduced vasomotor tone
and hyperdynamic cardiac contractions such as are
seen in sepsis (1).
Pitfalls in noninvasive blood pressure monitoring
relate to 3 problems:
1) Data acquisition is intermittent rather than
continuous, making it more diffcult to assess
response to therapy with titration.
2) Severe vasoconstriction may make
noninvasive blood pressure measurements
unobtainable.
3) Cuff size must be appropriate to acquire
accurate measurements. Since children vary
widely in size, cuff selection is important.
A cuff that is too small will result in blood
pressures that are falsely high. Conversely,
too large a cuff will underestimate
blood pressure.The American Academy
of Pediatrics (2) has recently revised
recommendations for sizing of the cuff, such
that the cuff length should approximate 40%
of the circumference of the upper arm. A
PICU study (3) comparing direct and indirect
blood pressure measurements demonstrated
that utilization of this recommendation
results in good correlation of systolic blood
pressure (SBP) but consistent overestimation
of diastolic blood pressure (DBP). These
investigators also studied the comparison
of direct intra-arterial measurement with
the commonly used but obsolete upper arm
length method (cuff width is two-thirds of
upper arm length), and found consistent
underestimation of both systolic and diastolic
blood pressure, by means of 14.7 and 5.6 mm
Hg, respectively.
Pressure Does Not equal Flow
While establishment of adequate systemic blood
pressure is central to the therapeutic plan, it does
not guarantee that the primary goal is met, i.e.,
establishment of adequate oxygen delivery to
the tissues. Flow, or cardiac output, is sometimes
poorly refected by blood pressure measurements
because high systemic vascular resistance may
maintain blood pressure in the normal range
even in a low cardiac output state. Therefore, the
clinician must not be reassured by the presence of
a normal blood pressure. Measurement of fow is
more complex, invasive, and subject to error, but is
sometimes helpful in the clinical setting, and will
be discussed in detail below.
DeteRMiNANts OF cARDiAc OUtPUt
Cardiac output is the product of stroke volume
and heart rate. Determinants of stroke volume
include preload, contractility, and afterload.
Assuring adequate ventricular preload is the
primary therapeutic intervention in pediatric shock,
so accurate and reliable assessment of preload
is highly desirable. Unfortunately, measurement
of fber length in the sarcomere at end-diastole,
the most direct physiologic measure of preload,
is not clinically feasible. Extrapolation from
measurements that are clinically available is
necessary. With each step away from direct
measurement there is more potential error in
measurement and interpretation. Contractility is
also an extrapolated assessment in clinical practice,
either derived from hemodynamic calculations
or echocardiographic visual evidence involving

Current Concepts in Pediatric Critical Care Refresher Course

measurements themselves subject to error.
Afterload status may be clinically recognized
by physical examination, qualitatively assessed
if anatomic abnormalities or abnormal flow
patterns are present by echocardiography or can
be quantitatively calculated if pulmonary artery
catheterization is performed. All methods are
subject to errors in interpretation. Despite the
diffculties in measurement and interpretation,
such data can be successfully incorporated into
goal-directed therapeutic algorithms with a holistic
clinical approach leavened by knowledge of the
pitfalls.
Preload Assessment
The most commonly used measure of preload in
pediatric critical care is the central venous pressure
(CVP). As a right-sided pressure measurement
being utilized to assess a remote left-sided volume
parameter, left ventricular end diastolic volume
(LVEDV), numerous factors may result in a
misleading value. In pediatric patients, isolated
left ventricular dysfunction not refected in a high
CVP measurement is unusual but must be kept in
mind. Common conditions which might result in
this picture include myocardial infarction related
to anomalous left coronary artery arising from
the pulmonary (ALCAPA) or Kawasaki disease
with coronary aneurysms. Acute myocarditis
or cardiomyopathy related to various metabolic
disorders may also present with signifcant left
ventricular (LV) dysfunction not necessarily
refected by a high CVP if right ventricular (RV)
compliance is normal.
Anot her maj or fact or affect i ng pressure
measurements is ventricular compliance. A stiff
ventricle, either on the right or the left side, may
result in a high pressure even if the left ventricle
is underflled. Similarly, pericardial effusion with
tamponade, constrictive pericarditis, or high
pericardial pressure secondary to high ventilatory
pressures may produce high flling pressures with
low end-diastolic volume (4). Obstructions to
left ventricular emptying such as aortic valvular
stenosis produce a high end-diastolic pressure.
Furthermore, any anatomic or pathophysiologic
cause of increased resistance to left ventricular
flling situated between the tip of the catheter
and the left ventricular chamber may result in
misleading high pressure readings suggesting
adequate preload is present. On the left side,
these include mitral valve disease and pulmonary
venous obstruction. On the right side, pulmonary
hypertension, pulmonary embolus, pulmonic valve
disease, right ventricular dysfunction, intracardiac
leftto-right shunt, tricuspid valve disease, or
thrombus in the vein in which the catheter is
placed all may obfuscate the true volume status
of the left ventricle by producing high pressure
measurements.
Despite all these potential pitfalls the CVP remains
a useful measurement in pediatric critical care
because in many cases the value is low, prompting
the correct initial intervention of intravascular
volume expansion. Observation of the response to
volume expansion with continuous monitoring of
the CVP can help identify adequate volume loading
and prompt addition of inotropic support. An initial
high value, on the other hand, should prompt
further thought and evaluation. Echocardiography
can be very helpful in this situation, to look for
anatomic or fow abnormalities explaining the
high pressure, to assess intracardiac chamber size
for adequate flling, and to obtain an assessment
of contractility.
In addition, knowledge of normal and abnormal
waveform patterns can be helpful and often
diagnostic of problems leading to high venous
pressure with low cardiac output. Examples include:
1) cannon waves seen in a-v dissociation resulting
in atrial contraction against a closed cardiac valve;
2) late cannon waves of tricuspid insuffciency;
and 3) narrow pulse pressure waveform seen in
pericardial tamponade.
Pulmonary artery occlusion pressure (PAOP)
measurement via placement of a pulmonary
artery catheter (PAC) may allow more accurate
assessment of left ventricular preload because
the appropriately measured value correlates
well with left atrial pressure and eliminates

Current Concepts in Pediatric Critical Care Refresher Course

some of the confounding variables involved in
CVP interpretation. Although pulmonary artery
catheterization is rarely performed in pediatric
critical care in 2005, it is important for pediatric
intensivists to become familiar with the risks
and pitfalls in interpretation associated with this
monitoring modality. For the occasional patient
subjected to this procedure, there is more risk of
misinterpretation and incorrect interventions due
to lack of experience.
Risks of PAC placement include ventricular
arrhythmias triggered by the catheter as it passes
through the right ventricle, perforation of the heart
resulting in tamponade, pulmonary infarction due
to inadvertent wedging of the catheter in a branch
of the pulmonary artery, formation of thrombus on
the catheter, and infection including endocarditis.
The assumption may be made that pulmonary
artery occlusion pressure accurately reflects
intravascular volume status and left ventricular
preload. However, PAOP may be high if there
is mitral valve disease or LV dysfunction with
decreased compliance, prompting the potentially
incorrect conclusion that fuid resuscitation has
been adequate or excessive.
Airway pressure is another very important
factor in interpretation of the PAOP in patients
receiving positive pressure ventilatory support.
Proper placement of the catheter in West Zone III
(posterior segments of lower lobes for the supine
patient, with higher levels of blood fow) to achieve
a continuous fuid column between the catheter
tip and the LV, is important in obtaining reliable
PAOP measurements as an indirect reflection
of left ventricular preload. Placement in upper
lobes or anterior segments with relatively more
infation of alveoli than pulmonary blood fow,
West Zone I, will exaggerate the effect of positive
pressure ventilation on the measurement, creating
a misleading high value. This effect results from
high levels of positive pressure ventilatory support,
which may increase pulmonary vascular resistance
due to compression of the pulmonary vascular bed
or refex vasoconstriction. In addition, if during
the respiratory cycle alveolar airway pressure
exceeds pulmonary venous pressure, thereby
interrupting pulmonary blood fow through vascular
compression, high levels of positive ventilatory
pressure may convert the monitored lung site from
optimal West Zone III to Zone II (lower fow to
ventilation ratio) despite proper initial placement
of the catheter tip in a dependent lower lobe. This
pitfall may be avoided by careful measurement of
PAOP at end-expiration as judged by observation
of respiratory variation in the pressure tracing
printout. Another non-intuitive source of error is
that, paradoxically, aggressive diuresis resulting
in hypovolemia may cause the conversion of Zone
III lung physiology to that of Zone II, causing
misleadingly high PAOP in volume-depleted
patients on high levels of PEEP. Finally, surgically
placed transthoracic left atrial catheters are used to
measure left atrial pressure (LAP) in postoperative
pediatric cardiac surgery patients to allow a more
direct assessment of LV function and preload in
the setting of pulmonary hypertension, selective
LV dysfunction, or other factors which might
create falsely high CVP readings in the setting of
an underflled left ventricle.

With all the clinical bedside measures of
intravascular volume status, it is important
to recognize the optimal value that supports
adequate cardiac output for the individual patient,
considering all confounding variables, rather than
aiming for a generic standard value. For example,
for a postoperative patient following complete
repair of Tetralogy of Fallot, the CVP may need to
be in the mid-teens (well above the normal range)
in order to support cardiac output, because of the
effect of longstanding right ventricular hypertrophy
resulting in decreased RV compliance. Another
common scenario for inadequate cardiac flling
despite high central venous pressure measurement
involves a patient with high mean airway pressure
(MAP), either with conventional mechanical
ventilation or with high-frequency oscillatory
ventilation. This may occur because systemic
venous return is inhibited by the high intrathoracic
pressure. Also, increased RV afterload produced by
increased pulmonary vascular resistance secondary

Current Concepts in Pediatric Critical Care Refresher Course

to high levels of ventilatory support may result
in RV dilatation causing interventricular septal
shift to the left compromising LVEDV and stroke
volume.
contractility Assessment
Contractility is defned as the velocity of myocardial
fber shortening, a measurement impossible to
achieve in the clinical setting. Therefore, evaluation
of contractility is intermittent, indirect, and subject
to interpretive error. The most common assessment
in the PICU is by 2-D echocardiography. Estimation
of shortening fraction or ejection fraction is
inherently inaccurate because the measurement is
made 2-dimensionally, while accurate estimation
of stroke volume would require a 3-dimensional
measurement. In addition, any of the measurements
approximating stroke volume as a marker of
contractility are subject to the infuence of afterload
and valvular regurgitation. High afterload secondary
to valvular stenosis or increased systemic vascular
resistance will decrease stroke volume even
with normal contractility, while pharmacologic
vasodilation can increase stroke volume even
with poor contractility. Valvular regurgitation may
effectively reduce afterload allowing a large stroke
volume, partially in the wrong direction with a net
result of inadequate systemic fow.
Estimations of contractility via nuclear medicine
scans or calculations based on data derived from
thermodilution pulmonary artery catheters are
subject to the same confounding factors and are
less available in the PICU setting, so they are
rarely used.
Afterload Assessment
Ventricular afterload is diffcult to assess in a
precise or continuous fashion, so it tends to be
followed clinically via physical examination of
pulses, surface temperature and color, and capillary
refll. Systemic and pulmonary vascular resistance
can be calculated from pulmonary artery catheter
thermodilution and hemodynamic data, but these are
rarely available. Measurement of pulmonary artery
pressures (PAP) can be carried out continuously
with a transthoracic catheter placed in surgery for
congenital cardiac repair, allowing recognition of
pulmonary hypertensive crises and evaluation of
response to therapy with inhaled nitric oxide or
other interventions. One pitfall in interpretation
of a high PAP is that high fow due to left-to-right
shunt may produce a high pressure even in the
presence of normal pulmonary vascular resistance.
Echocardiographic data estimating resistance via
fow patterns is available only intermittently and is
subject to error, so it is not a practical component of
goal-directed therapy. However, anatomic defects
causing increased afterload, such as valvular aortic
stenosis, can be appreciated by echocardiography,
which allows judicious application of therapeutic
interventions.
cardiac Output Assessment
Assessment of cardiac output in the PICU setting
is challenging and subject to a variety of potential
errors. Invasive measurement by green-dye
dilution, a mainstay of assessment in the early
days of open heart surgery, has been supplanted
by thermodilution utilizing a pulmonary artery
catheter. Both techniques actually measure venous
return rather than systemic output. Thermodilution
is not subject to the recirculation issue intrinsic to
green dye dilution, since the room-temperature
saline is fully normalized to body temperature in
the frst pass through the lungs. The technique can
be fairly accurate and reproducible in experienced
hands, but is subject to operator variation,
computational errors, and is based on the assumption
that there is no intracardiac shunt through septal
defects. Other confounding conditions which
may invalidate the measurement include tricuspid
regurgitation, atrial arrhythmias, and variation
in timing of the respiratory cycle with indicator
injection. Operator variation can be addressed by
performing 3 separate injections and measurements
to demonstrate concordance of the results. The
variation can be so signifcant that the clinician
often averages the best 2 out of 3 results. Frequent
injection of large volumes of saline is problematic
in small children due to potential fuid overload.
Finally, the measurement is only intermittent at
best, so that moment-to-moment changes in patient
status or responses to titration of therapy may not

Current Concepts in Pediatric Critical Care Refresher Course

be appreciated. Femoral artery thermodilution has
been compared to clinical assessment in infants and
children following open-heart surgery in a small
study, which showed superiority of the method to
clinical assessment by nurses and physicians in
recognition of hypovolemia and increased systemic
vascular resistance (5). This method eliminates
many of the risks associated with pulmonary artery
catheterization, but has not been studied suffciently
to document improvement in outcomes justifying
the cost and risk of limb ischemia in placement of
the catheter, so has not been widely adopted.
Direct measurement of oxygen consumption,
arterial oxygen content, and mixed venous
oxygen content can be utilized to calculate cardiac
output via the Fick principle (Cardiac output=O
2
consumption/CaO
2
-CmvO
2
); however, accurate
bedside measurement of O
2
consumption is
diffcult, and small errors in measurement can
produce large errors in computed cardiac output,
rendering this method impractical.
Echocardiography provides a noninvasive, indirect
approach to assessment of cardiac output, but is
subject to signifcant errors as well. For example,
fow estimation depends on the cross-sectional
area of the vessel being evaluated; a high fow
across a narrow vessel may not represent adequate
output. Also, measurements of ejection fraction and
shortening fraction may suggest a higher systemic
output than exists due to mitral valve regurgitation
or aortic insuffciency. Continuous transesophageal
echocardiography has been adopted for monitoring
adults in some venues (6), but has not gained
acceptance in pediatric centers. New technology
exists that offers continuous assessment of cardiac
output via measurements of beat-to-beat variations
in thoracic bioimpedance (7) or by analysis of the
arterial pulse waveform (8), but these have not
yet gained wide acceptance and application in the
pediatric intensive care setting.
Continuous or intermittent sampling of mixed
venous oxygen saturation provides an indirect
measure of the adequacy of tissue oxygen delivery,
which with normal oxygen consumption should
result in a venous saturation of around 75%. Low
venous saturations coupled with high arterial
saturations signify inadequate delivery of O
2
to
meet the metabolic demand. This may correlate
to low cardiac output, inadequate arterial oxygen
content, or excessive oxygen demand due to
a hypermetabolic state. Therefore, pitfalls in
interpretation of this data include the possibility
of anemia, abnormally high oxygen consumption,
or abnormal hemoglobin, which can present the
same pattern as low cardiac output. High venous
O
2
saturation may be seen if intracardiac shunting
is present, rendering venous oximetry useless as
an indirect monitor of cardiac output. Extracardiac
a-v shunting (seen in sepsis) or metabolic blockade
of electron transport, such as with cyanide, may
cause poor oxygen uptake and utilization in the
tissue beds not related to the adequacy of oxygen
delivery.
Measurement of oxygen delivery and consumption
has been studied as a guide to therapeutic
interventions in adult patients (9). In pediatrics, the
risk-beneft ratio of pulmonary artery catheterization
has not been established with respect to optimization
of oxygen delivery as a therapeutic goal, nor have
specifc optimal goals been established. Pitfalls
in interpretation include a-v shunting, uncoupling
of oxygen transport and energy generation, and
use of derived variables with inherent potential
inaccuracy in measurements and assumptions.
capnography
Monitoring of end-tidal CO
2
(ETCO
2
) has potential
utility as an early warning system for decreasing
cardiac output, since alveolar CO
2
depends on
delivery by adequate pulmonary blood fow. As
cardiac output decreases to a critical level, exhaled
CO
2
also falls. Adequacy of resuscitative efforts
will be refected in the rise of ETCO
2
in exhaled
gases. Pitfalls in interpretation are revealed when
arterial blood gases are performed showing a
gap between paCO2 and ETCO
2
, and include:
1) severe airway or parenchymal lung disease
causing signifcant ventilation-perfusion mismatch,
resulting in dead-space ventilation and a false low
ETCO
2
value; 2) false low value because of failure

Current Concepts in Pediatric Critical Care Refresher Course

to obtain a true alveolar sample due to expiratory
obstruction. Airway obstruction can be recognized
by evaluation of the capnograph waveform, which
does not achieve a plateau, but instead continuously
rises until end expiration.
Metabolic Parameters As indications Of
Adequate tissue Perfusion And O

Delivery
Many investigators have studied indicators of
end-organ function or tissue metabolism as
hemodynamic monitoring parameters. While these
indicators have some theoretical appeal, each
is limited by confounding variables, technical
unavailability, or lack of pediatric studies or
experience. Most prominent and widely used of
these is the serum lactate. It has been shown to
correlate to mortality risk in certain groups such
as postoperative cardiac surgery patients (10), and
in children with shock (11). Goal-directed therapy
using serial lactate determinations in postoperative
pediatric cardiac surgery patients has been reported
to be improve outcome, especially in younger, more
high-risk patients (12). The use of serum lactate as
an indicator for goal-directed therapy has not been
widely adopted to date, partly because modifcation
of therapy based on the lactate level requires rapid
turnaround probably best achieved, as in this study,
by point-of-care testing at the bedside. Base defcit
has been clinically used for many years as an
indicator of ongoing tissue acidosis, but as shown
by Murray et al (13) there is a poor correlation of
this calculated value with presence of unmeasured
organic acids and tissue lactate. Similar lack of
rapid expression of inadequate perfusion and tissue
hypoxemia, as well as lack of specifcity, underlie
the lack of utility of serum creatinine and liver
function parameters as monitors of hemodynamic
status.
Gastric tonometry has been studied extensively in
adults as an indicator of adequacy of splanchnic tissue
oxygen delivery as a proxy for hemodynamic status
(14). Unfortunately there are technical limitations
and confounding results in the limited studies on
children utilizing this technology (15), so it has not
been widely adopted in the PICU setting.
ReFeReNces
1. Swedlow DB, Cohen DE. Invasive
assessment of the failing circulation.
In: Swedlow DB, Raphaely RC (eds).
Cardiovascular Problems in Pediatric
Critical Care; Clinics in Critical Care
Medicine. New York, Edinburgh, London,
Melbourne: Churchill Livingstone; 1986:
129-168.
2. National High Blood Pressure Education
Program Working Group on Hypertension
Control in Children and Adolescents. Update
on the 1987 Task Force Report on High
Blood Pressure in Children and Adolescents:
A Working Group Report from the National
High Blood Pressure Education Program.
Pediatrics. 1996;98(4):649-658.
3. Clark JA, Lieh-Lai MW, Sarnaik A, Mattoo
TK. Discrepancies between direct and
indirect blood pressure measurements using
various recommendations for arm cuff
selection. Pediatrics. 2002;110(5):920-923.
4. Pinsky MR. Clinical signifcance of
pulmonary artery occlusion pressure.
Intensive Care Med. 2003;29:175-178.
5. Egan JR, Festa M, Cole AD, et al. Clinical
assessment of cardiac performance in infants
and children following cardiac surgery.
Intensive Care Med. 2005;31:568-573.
6. Poelaert JI, Schupfe G. Hemodynamic
monitoring utilizing transesophageal
echocardiography: the relationships
among pressure, fow, and function. Chest.
2005;127(1):379-390.
7. Tibby SM, Murdoch IA. Monitoring cardiac
function in intensive care. Arch Dis Child.
2003;88:46-52.
8. Piehl, MD, Manning J, McCurdy SL, et
al. Comparison of pulse contour analysis
with pulmonary artery thermodilution in
a pediatric model of hemorrhagic shock.
[Abstract]. 2004 Pediatric Critical Care
Colloquium, New York, NY. Available at:
http://pedsccm.wustl.edu/ORG-MEET/
PCCC2004/PCCC_2004_abstracts.htm.

Current Concepts in Pediatric Critical Care Refresher Course

9. Shoemaker WC, Appel PL, Kram HB,
Waxman K, Lee TS. Prospective trial
of supernormal values of survivors as
therapeutic goals in high-risk surgical
patients. Chest. 1988;94:1176-1186.
10. Siegel LB, Dalton HJ, Hertzog JH, et
al. Initial postoperative serum lactate
levels predict survival in children after
open heart surgery. Intensive Care Med.
1996;22(12):1418-1423.
11. Hatherhill M, Waggie Z, Purves L, Reynolds
L, Argent A. Mortality and the nature of
metabolic acidosis in children with shock.
Intensive Care Med. 2003;29:286-291.
12. Rossi AF, Khan DM, Hannan R, et al.
Goal-directed medical therapy and point-
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