May the Flow Be with You: Practical Hemodynamics in the PICU

Oct 12, 2025

Explore the intricacies of blood pressure management in pediatric intensive care. The hosts break down the pros and cons of invasive arterial lines versus non-invasive cuffs. They delve into blood pressure targets during critical illnesses like sepsis and traumatic brain injuries. Discover practical strategies for weaning vasoactive medications and the importance of accurate measurements. All this, backed by the latest guidelines and research, offers actionable insights for treating the most vulnerable patients.

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INSIGHT

Invasive Monitoring Is The Gold Standard

Arterial lines provide continuous, direct pressure and are the gold standard in the PICU.
Automated cuffs are intermittent and less reliable in unstable or special-population patients.

ADVICE

Interpret Cuff Readings Correctly

Treat the MAP from an oscillometric cuff as the true measured value and systolic/diastolic as calculated estimates.
Expect arterial line systolic and diastolic to be true measurements while cuff-derived systolic/diastolic are estimated.

INSIGHT

Cuff Biases Vary With Patient State

Oscillometric devices often underestimate systolic and overestimate diastolic compared to arterial lines.
These biases widen in hypertensive, obese, infant, or rapidly changing hemodynamic states.

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Ever wondered how PICU teams make those critical calls about blood pressure and vasoactive meds? On this episode, Dr. Monica Gray and Dr. Pradip Kamat dive into the real-world questions that come up during pediatric intensive care rounds. They break down the pros and cons of arterial line versus non-invasive cuff measurements, talk through blood pressure targets for tough cases like sepsis and brain injury, and share practical tips for weaning kids off vasoactive drugs. With a focus on the latest guidelines and research, Monica and Pradip offer actionable advice to help you fine-tune hemodynamic management for your sickest patients. Tune in!

Show Highlights:

Relationship between blood pressure and cardiac output in pediatric patients
Comparison of arterial line (invasive) versus non-invasive cuff measurements for blood pressure monitoring in the PICU
Blood pressure targets for critical illnesses such as sepsis, traumatic brain injury, and respiratory failure in children
Strategies for weaning vasoactive medications in critically ill pediatric patients
Importance of accurate blood pressure measurement and monitoring in the PICU
Discussion of organ autoregulation and its impact on blood pressure management
Clinical assessment and individualized care in setting blood pressure goals
Recommendations for initial vasoactive agents in pediatric septic shock
Challenges and considerations in vasoactive medication selection and weaning
Need for further research on pediatric vasoactive medication management strategies

References:

Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 110. Alder M et al. Pediatric Sepsis. Pages 1293-1309.
Rogers Textbook of Pediatric Critical Care Medicine. Chapter 88. Fitzgerald J et al. Bacterial Sepsis.Pages 1469-1485.
Reference 1 Weiss S. Vasoactive Selection for Pediatric Septic Shock-Where to begin. JAMA Network Open, 2025;8(4):e254726.
Reference 2 Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):665-674.