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Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock
Joseph A Carcillo1, Alan I Fields,
1Children's Hospital of Pittsburgh, Division of Critical Care Medicine, 15213, USA. carcilloj@anes.upmc.edu
Insights
Developing clinical guidelines for pediatric septic shock is crucial. Current adult guidelines are not applicable to neonates and children, necessitating age-specific research for improved outcomes.
Area of Science:
- Critical Care Medicine
- Pediatric Critical Care
- Neonatal Critical Care
Background:
- The Institute of Medicine advocates for clinical guidelines to establish best practices and enhance patient outcomes.
- Existing guidelines for hemodynamic support in septic shock primarily focus on adults.
Purpose of the Study:
- To develop American College of Critical Care Medicine (ACCM) clinical guidelines for hemodynamic support in neonates and children with septic shock.
- To address the need for age-specific management strategies in pediatric and neonatal septic shock.
Main Methods:
- A literature review and solicitation of experts in neonatal and pediatric septic shock were conducted.
- A modified Delphi method was used, involving multiple rounds of expert review and consensus-building.
- MEDLINE database searches utilized age-specific keywords related to sepsis and its complications.
Main Results:
- Limited randomized controlled trials (RCTs) exist for pediatric septic shock, with no prior RCTs influencing practice.
- Clinical practice relies heavily on physiological experiments, case series, and cohort studies.
- Despite limited evidence, pediatric septic shock mortality has significantly decreased, with better survival rates than adults.
- Pathophysiology and treatment responses differ significantly with age; cardiac failure is key in children, while vascular failure dominates in adults.
Conclusions:
- American College of Critical Care Medicine (ACCM) adult guidelines for septic shock are not suitable for pediatric or neonatal populations.
- Further studies are needed to evaluate the implementation and effectiveness of pediatric and neonatal septic shock guidelines.
Background:
The Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome.
Objective:
To provide American College of Critical Care Medicine clinical guidelines for hemodynamic support of neonates and children with septic shock.
Setting:
Individual members of the Society of Critical Care Medicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001).
Methods:
The MEDLINE literature database was searched with the following age-specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task-force chairman modified the document until <10% of experts disagreed with the recommendations.
Results:
Only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicine-graded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three-fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival.
Conclusion:
American College of Critical Care Medicine adult guidelines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome.