paediatric decision tree



To know:

  • If the child is in a high, optimal or low cardiac output state
  • If the flow is adequate to meet the metabolic needs of the child
  • Whether therapy changes flow status (Tibby et al. 2000. 28:2045-2050)

This paediatric decision tree has been created with the help of Dr Davandra Patel, Consultant in Paediatric Anaesthesia & Pain Management at The Royal Manchester Children’s Hospital, UK. Acknowledgement is also given to Royal Manchester Children’s Hospital for use of their MANCHEWS scoring chart, which was used to create the trigger points.

It uses a rational approach to using Doppler flow based measurements to guide therapy and is applicable to sedated or anaesthetised paediatric patients both perioperatively and in critical care.

It is applicable for those paediatric patients already being monitored with the ODM+, or for those where further haemodynamic monitoring is indicated. See trigger points.

The decision tree can be used as seen here, or it could be a foundation for the development of other protocols. Any normal values are a guide only.


Navigation is by a series of Yes/No lemon-coloured boxes with actions in blue boxes and questions in pink boxes.


Note: These trigger points:

  • Should not be assessed in isolation
  • Are not the same as physiological targets
  • Are indicative and not absolute
  • Are not prioritised

Basic considerations:

  • Respiratory rate: Under 4 months: <30 or >39, 4 months-2 years: <25 or >34, 2-5 years <20 or >29, 5-12 years: <20 or >29, Over 12 years: <15 or >24.
  • Oxygen requirements: Below 95% in air (all ages).
  • Heart rate: Under 4 months: <110 or >160, 4 months-2 years: <100 or >149, 2-5 years <80 or >119, 5-12 years: <70 or >119, Over 12 years: <65 or >99.
  • Systolic blood pressure: Under 4 months: <60 or >80mmHg 4 months-2 years: <70 or >90, 2-5 years <90 or >129, 5-12 years: <90 or >129, Over 12 years: <90 or >129.
  • Capillary refill time: <2 seconds (all ages).
  • Conscious level: <alert (all ages).

Cardiac output: Is the child in a high, low or acceptable cardiac output state? (see CO table for age appropriateness).

Other trigger points that can be considered:

  • ScVO2: <65-70% (all ages).
  • Central/peripheral temperature gradient: >2°C (all ages).
  • Low urine output: <2-3ml/kg/hr (neonate), 2ml/kg/hr (infant), 1-2ml/kg/hr (child), 0.5-1ml/kg/hr (adolescent) (From Hazinski 1992).
  • ECG abnormalities (all ages).
  • Glucose levels: high or low (all ages).
  • Lactate: >2 mmol/L (all ages).

Base excess: -3 or +3 mEq/L (all ages).



November 2017

Note: The items in Italics are papers where the ODM was used or reviewed. Items in black either mention the ODM or are documents Deltex Medical are working with to refine the system and develop an understanding of its place in the clinical setting.

  1. Krovetz LJ, McLoughlin TG, Mitchell MB and Schiebler GL. Hemodynamic Findings in Normal Children. Pediat. Res. 1967. 1: 122-130.
  2. Grenadier E, Oliveira C, Allen HD, Sahn DJ, Barron JV, Vales-Cruz LM and Goldberg SJ. Normal Intracardiac and Great Vessel Doppler Flow Velocities in Infants and Children. JACC. 1984. 4(2): 343-350​.
  3. Hanseus K, Björkhem G and Lundrtöm NR. Cardiac Function in Healthy Infants and Children: Doppler Echocardiographic Evaluation. Pediatr Cardiol. 1994. 15:211-218.
  4. Murdoch IA, Marsh MJ, Tibby SM, McLuckie A. Continuous haemodynamic monitoring in children: use of transoesophageal Doppler. Acta Paediatr. 1995. 84: 761-764.
  5. Tibby S, Hatherill M, Marsh MJ and Murdoch IA. Clinicians’ ability to estimate cardiac index in ventilated children and infants. Archives of Disease in Childhood. 1997. 77:516-518.
  6. Childs C, Goldring S, Tann W and Hillier VF. Suprasternal Doppler ultrasound for assessment of stroke distance. Arch Dis Child. 1998. 79:251-255.
  7. Tibby SM, Hatherill M, Murdoch IA. Use of transoesophageal Doppler ultrasonography in ventilated pediatric patients: Derivation of cardiac output. Crit Care Med. 2000. 28:2045-2050.
  8. Wodey E, Carre F, Beneux X, Schaffuser A and Ecoffey C. Limits of Corrected Flow Time to Monitor Hemodynamic status in Children. Journal of Clinical Monitoring and Computing. 2000. 16: 223-228.
  9. Sohn S and Kim HS. Doppler Aortic Flow velocity Measurement in Healthy Children. J Korean Med. 2001. 16: 140-4.
  10. Tibby SM, Hatherill M, Durward A, Murdoch IA. Are transoesophageal Doppler parameters a reliable guide to paediatric haemodynamic status and fluid management? Intensive Care Med.
  11. Carcillo JA and Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Jornal de Pediatria. 2002. 78(6): 449-466.
  12. Larousse E, Asehnoune K, Datayet B, Albaladejo P, Dubousset AM, Gauthier F and Benhamou D. The hemodynamic effects of pediatric caudal anesthesia assessed by esophageal Doppler. Anesth Analg. 2002 May; 94(5): 1165-8.
  13. Mohan UR, Britto J, Habibi P, Munter C, Nadel S. Noninvasive Measurement of Cardiac Output in Critically Ill Children. Journal Pediatric Cardiology. 2002. 23(1): 58-61.
  14. Tibby SM and Murdoch IA. Measurement of cardiac output and tissue perfusion. Curr Opin Pediatr 2002, 14:303-309.
  15. Chew MS and Poelaert J. Accuracy and repeatability of pediatric cardiac output measurement using Doppler: 20-year review of the literature. Intensive Care Medicine. 2003. 29(11): 1889-894.
  16. Tibby SM, Murdoch IA. Monitoring cardiac function in intensive care. Arch Dis Child. 2003. 88:46-52.
  17. King SL and Lim MS. The Use of the Oesophageal Doppler Monitor in the Intensive Care Unit. Critical Care and Resuscitation. 2004. 6: 113-122.
  18. Raux O, Rochette A, Morau E, Dadure C, Vergnes C and Capdevila X. The effects of spread of block and adrenaline on cardiac output after epidural anesthesia in young children: a randomized, double-blind, prospective study. Anesth Analg. 2004. 98(4): 948-55.
  19. Almenrader N and Patel D. Spinal fusion surgery in children with non-idiopathic scoliosis: is there a need for routine postoperative ventilation? BJA. 2006. 97(6): 851-857
  20. Hack H. Case report. Use of the Esophageal Doppler Machine to help guide the intraoperative management of two children with pheochromocytoma. Pediatric Anesthesia. 2006. 16:867-87.
  21. Monsel A, Salvat-Toussaint A, Durand P, Haas V, Baujard C, Rouleau P, El Aouadi S, Benhamou D and Asehnoune K. The Transesophageal Doppler and Hemodynamic Effects of Epidural Anesthesia in Infants Anesthetized with Sevoflurane and Sufentanil. International Anesthesia Research Society. 2007. 105(7): 46-50.
  22. Rowlands H, Bagshaw O and Duncan H. Does Trans-Oesophageal Doppler Cardiac Output Measurement Change Clinical Management Strategy? 2007 Poster.
  23. Knirsch W, Kretschmar O, Tomaske M, Stutz K, Nagdyman N, Balmer C, Schmitz A, Bettex D, Berger F, Bauersfeld U and Weiss M. Cardiac output measurement in children: comparison of the Ultrasound Cardiac Output Monitor with thermodilution cardiac output measurement. Intensive Care Med. 2008. 34(6): 1060-4.
  24. Mukhtar AM and Obayah G. Esophageal Doppler Monitor: A New Tool in Monitoring Video Assisted Thorascopic Surgery for Ligation of Patent Ductus Arteriosus. Anesthesia & Analgesia. 2008. 107(1) 346-347.
  25. Schubert S, Schmitz T, Weiss M, Nagdyman N, Huebler M, Alexi-Meskishvili V, Berger F and Stiller B. Continuous, non-invasive techniques to determine cardiac output in children after cardiac surgery: evaluation of transesophageal Doppler and electric velocimetry. J Clin Monit Comput. 2008. 22(4): 299-307.
  26. Brierley J et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009. 37(2) 666-688.
  27. Fleck T, Schubert S, Stiller B, Redlin M, Ewert P, Nagdyman N, and Berger F, Capability of a new paediatric oesophageal Doppler monitor to detect changes in cardiac output during testing of external pacemakers after cardiac surgery. J Clin Monit Comput. 2011. 25(6): 419-25.
  28. Absi MA, Lutterman J and Wetzel GT. Noninvasive cardiac output monitoring in the pediatric intensive care unit. Current Opinion in Cardiology. 2010. 25: 77-79.
  29. Lemson J, Nusmeier A and van de Hoeven JG. Advanced Hemodynamic Monitoring in Critically Ill Children. Pediatrics. 2011. 128: 560-571.
  30. Lechner E, Hofer A, Leitner-Peneder G, Freynschlag R, Mair R, Weinzettel R, Rehak P and Gombotz H. Levosimendan versus milrinone in neonates and infants after corrective open-heart surgery: a pilot study. Pediatr Crit Care Med. 2012 Sep;13(5):542-8.
  31. Brown Z, Görges M, Cooke E, Malberbe S, Dumont G and Ansermino J. Changes in cardiac index and blood pressure on positioning children prone for scoliosis surgery. Anaesthesia. 2013. 68: 742- 746.
  32. Galante D and Melchionda M. Transesophageal Doppler ultrasound and hemodynamic monitoring using regional anesthesia in pediatrics. Ultrasounds Anesthesia Journal. 2013. 1: 1-5
  33. Gan H, Cannesson M, Chandler JR and Ansermino JM. Predicting Fluid Responsiveness in Children: A Systematic Review. Anesthesia & Analgesia. 2013. 117(6): 1380- 1392.
  34. Dubost C, Bouglé A, Hallynck C, Le Dorze M, Roulleau P, Baujard C and Benhamou D. Comparison of monitoring performance of bioreactance versus esophageal Doppler in pediatric patients. Indian Journal of Crit Care Med. 2015 19(1): 3-8.
  35. Weber T, Wagner T, Neuman K and Deusch E. Low Predictability of Three Different Noninvasive Methods to determine Fluid responsiveness in Critically Ill Children. Pediatric Critical Care. 2015. 16(3): 89-94.