Measurement-Informed and Fluid-Sparing Cardiovascular Resuscitation Strategies in Pediatric Septic Shock: A Systematic Review and Exploratory Meta-Analysis

BackgroundPediatric septic shock resuscitation requires restoration of tissue perfusion while avoiding unnecessary fluid accumulation. The available comparative evidence includes both measurement-informed cardiovascular strategies and protocolized early vasoactive/fluid-sparing strategies, which differ substantially in mechanism and implementation.MethodsWe conducted a prospectively registered systematic review and exploratory meta-analysis of pediatric septic shock. To address clinical heterogeneity, interventions were classified post hoc, without changing eligibility criteria or outcomes, as measurement-informed technology-enabled strategies, structured early vasoactive/fluid-sparing strategies, or a hybrid phenotype-informed strategy. Randomized and nonrandomized evidence were analyzed separately. Random-effects models used restricted maximum likelihood; Wald 95% confidence intervals were primary and Hartung-Knapp intervals were examined for every pooled outcome. Risk of bias was assessed using RoB 2 and ROBINS-I, and certainty using GRADE.ResultsSix comparative studies involving 422 children met eligibility criteria, including five randomized controlled trials and one prospective comparative study. The exploratory mortality synthesis across randomized strategies showed no statistically detectable difference (RR 0.88, 95% CI 0.60-1.28; very-low-certainty evidence); the measurement-informed subgroup yielded RR 0.77 (95% CI 0.46-1.27). Two small randomized trials of measurement-informed resuscitation suggested lower total fluid administration during the first 24 h (MD -11.47 mL/kg, 95% CI -16.88 to -6.05; moderate-certainty evidence). Evidence for acute kidney injury was very uncertain (RR 0.48, 95% CI 0.15-1.57). Other outcomes were synthesized narratively because definitions, time points, or estimands were not sufficiently comparable.ConclusionsThe pediatric evidence base comprises mechanistically distinct cardiovascular resuscitation strategies rather than a single uniform intervention. Exploratory mortality pooling does not establish benefit or equivalence. Two small measurement-informed trials suggest lower 24-h fluid administration, but whether this process-level effect improves patient-centered outcomes remains uncertain. Future trials should prospectively link measured physiological variables or protocolized treatment rules to standardized clinical outcomes.