Background Over-zealous fluid resuscitation in septic shock can lead to fluid overload and its associated poor outcomes. Hence we need dynamic markers of fluid responsiveness to better guide fluid therapy in children with septic shock. Ultrasound parameters are an option available to PICU physicians for the same.

Objectives To evaluate the role of Ultrasound in reducing the incidence of fluid overload in children with septic shock. Fluid overload was defined as Cumulative fluid balance percentage (CFB%) >10%. The primary outcome was a reduction in the number of patients with fluid overload on day 3 of admission. Secondary outcomes were resuscitation and shock reversal time, total fluid bolus, fluid overload on day 1, use of Furosemide and inotropes, the occurrence of AKI, the requirement of mechanical ventilation, length of stay, and mortality.

Methods This is a prospective randomized controlled superiority trial, conducted in the PICU of a government-aided tertiary care hospital in Eastern India. The sample size was 56, calculated on the basis of a similar pediatric RCT. Patient enrolment occurred between May 2019 and July 2020. Children aged between 1 month and 12 years with suspected septic shock were randomized to receive either ultrasound or clinically guided fluid boluses (in a 1:1 ratio) and subsequently followed up for primary and secondary outcomes. Exclusion criteria were Dengue, Anaphylaxis, Ascites, and patients with pre-existing chronic kidney disease, interstitial lung disease, heart disease, and adrenal insufficiency. Ultrasound was used in the treatment group whenever there was clinical suspicion of inadequate perfusion.

Results 68 children were enrolled in the study. 4 patients of Dengue and 4 patients who died within 24 hours were excluded. The number (%) of patients with fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs. 62%, p=0.012) as was the CFB% on day 3 (6.8±6.6% vs. 13.4±10.7%, p=0.019). Total fluid bolus was significantly lower {median of 40(30–50) ml/kg vs. 50 (40–80) ml/kg, p=0.003}. Resuscitation time was significantly lower in the ultrasound group (13.4 ± 5.6h vs. 20.5 ± 8h, p=0.002) and so was the requirement of Furosemide (39.3% vs. 71.4%, p=0.016). None of the deaths in the ultrasound group were due to unresolved shock (p=0.101). There was no significant benefit derived from ultrasound in terms of ventilator duration, inotrope/vasopressor requirement, length of PICU/hospital stay, and mortality.

Conclusions Due to a lack of comparative studies on this topic, our study adds insight into the utility of ultrasound in improving outcomes in septic shock. Ultrasound made the PICU physician exercise restraint in administering fluid boluses and allowed earlier initiation of inotropes. Ultrasound was found to be significantly better than clinically guided therapy, in preventing fluid overload as well as being quicker in achieving initial hemodynamic stabilization. Hence ultrasound is a potentially useful tool for fluid resuscitation in children with septic shock.