Dobutamine Versus Milrinone in Management of Critically Ill Low Cardiac Output Pediatric Patients at Cairo University Children's Hospital

Inclusion Criteria: * 1-Patients from age of 1 month to 14 years old of both sexes. 2-Patients presenting with fluid refractory shock with low cardiac output state, evidenced by sustained hypotension (systolic blood pressure below 5th percentile for age) and end organ dysfunction (altered level of consciousness, renal or hepatic dysfunction) 3-Clinical evidence of systemic and/or pulmonary congestion despite use of vasodilators and/or diuretics 4-Refractory heart failure requiring admission for inotropic support. Exclusion Criteria: 1-All other causes of pediatric shock not in need for inotropic support (eg.isolated hypovolemic shock, anaphylaxis,….) 2 - patients not fit for randomization needing specific line of management (eg. Sever hypotension patients with good filling pressure unfit for milrinone , patients previously known having sever pulmonary hypertension not fit for dobutamine ,…) 3-post cardiac surgery patients with low cardiac output manifestation.