الفهرس 
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Abstract
Severe sepsis and septic shock are major health care problems, affecting millions of people around the world each year killing one in four (and often more), and increasing in incidence.
”Reversal of shock” is the first task that should be fulfilled whenever pediatric septic shock patients are seen. Each additional hour of persistent shock was associated with >2 folds increased odds of mortality. The primary aim of the study was to evaluate the role of echocardiography in reducing ”shock reversal time” among pediatric septic shock patients. Patients were managed using echocardiography to assess their hemodynamic state and guide changes in therapy compared to the common assessment on a clinical basis alone. The clinical uses of the echocardiographic findings in children with septic shock and their potential implications for choosing and optimizing vasoactive/inotropic medications have not yet been evaluated properly. Various studies assessed the use of echocardiography in adult intensive care units patients, yet few dealt with the pediatric population. Moreover, previous studies of echocardiographic evaluation of septic myocardial dysfunction (SMD) used to provide only a ”snapshot” assessment at the time of the study. However, serial echocardiographic monitoring ”over time” performed in the present study overcame this limitation.
Ninety enrolled children aged 1month to 11 years were randomly assigned in the control group (received standard therapy) or in the study group (received echocardiography guided therapy) as 45 children in each.
The proportion of children succeeded in shock reversal was significantly higher in the study group with a median of 1.2 days earlier than that in the control group. ”Resuscitation time” was significantly earlier in the study group (p=<0.001)
Although the proportion of children deceased was lower, but not statistically significant in the study group, yet deaths due to unresolved shock was significantly lower in the study group fulfilling the aim of the study. Early shock reversal in the study group was associated with a significant reduction in PICU stay (p=0.005)
Optimizing fluid and vasopressor/inotrope therapy among the study group by performing echocardiography resulted in significant higher MAP and MAP-CVP at 1 and 24 hours. At the end of 24 hours, CVP was significantly greater in the control group coinciding with the fluid overload clinical features revealed in this group which is four folds more than in the study group. Inotropes were used more frequently in the study group with earlier starting time dobutamine use predominated in the control group while milrinone use predominated in the study group guided by echocardiography. Maximum VIS was markedly lower in the study group.
Among the study group; the proportion of patients who developed SMD was 89%. The majority of patients developed SMD in day 1. Patients were categorized into 3groups according to type SMD; in which Category I had systolic dysfunction, Category II had diastolic dysfunction and Category III had both. The worst outcomes were revealed among Category III in which times of shock reversal, resuscitation and vasopressor/ inotropes withdrawal were significantly protracted.
The current study suggests that after suitable training qualitative bedside echocardiography could be a simple and accurate way to assess volume status and LV systolic function. It is recommended that early and serial echocardiography should be performed to all cases of septic shock admitted to PICUs for accurate fluid therapy and vasoactive inotropic medications optimization for reduction of shock reversal time.