Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome
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Published on: April 7, 2023
Yong Y Han1, Joseph A Carcillo, Michelle A Dragotta
1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Insights
Early septic shock reversal in children significantly improves survival. Adhering to American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines for fluid and inotropic therapies by community physicians is crucial for better outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Neonatal Septic Shock Management
- Hemodynamic Resuscitation Strategies
Background:
- Septic shock in neonates and children requires timely intervention.
- Early fluid and inotropic therapies are associated with improved survival in septic shock.
- The American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines provide a framework for hemodynamic support.
Purpose of the Study:
- To evaluate the association between early septic shock reversal and patient outcomes.
- To assess community physicians' adherence to ACCM-PALS Guidelines in pediatric septic shock resuscitation.
- To determine the impact of guideline-concordant care on mortality in pediatric septic shock.
Main Methods:
- Retrospective cohort study of 91 infants and children with septic shock.
- Data collected on shock reversal, resuscitation practices, and hospital mortality.
- Analysis of time to shock reversal and concordance with ACCM-PALS Guidelines.
Main Results:
- Overall mortality was 29%. Early shock reversal (median 75 minutes) was associated with 96% survival.
- Each hour of persistent shock increased mortality risk by over twofold.
- Guideline-consistent resuscitation was associated with significantly lower mortality (8% vs. 38%).
Conclusions:
- Prompt recognition and aggressive resuscitation of pediatric septic shock by community physicians can be life-saving.
- Educational initiatives promoting ACCM-PALS guideline adherence for fluid and inotropic therapies are recommended.
- Improved adherence to guidelines may enhance survival rates in pediatric septic shock.
Objective:
Experimental and clinical studies of septic shock support the concept that early resuscitation with fluid and inotropic therapies improves survival in a time-dependent manner. The new American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines for hemodynamic support of newborns and children in septic shock recommend this therapeutic approach. The objective of this study was to determine whether early septic shock reversal and use of resuscitation practice consistent with the new ACCM-PALS Guidelines by community physicians is associated with improved outcome.
Methods:
A 9-year (January 1993-December 2001) retrospective cohort study was conducted of 91 infants and children who presented to local community hospitals with septic shock and required transport to Children's Hospital of Pittsburgh. Shock reversal (defined by return of normal systolic blood pressure and capillary refill time), resuscitation practice concurrence with ACCM-PALS Guidelines, and hospital mortality were measured.
Results:
Overall, 26 (29%) patients died. Community physicians successfully achieved shock reversal in 24 (26%) patients at a median time of 75 minutes (when the transport team arrived at the patient's bedside), which was associated with 96% survival and >9-fold increased odds of survival (9.49 [1.07-83.89]). Each additional hour of persistent shock was associated with >2-fold increased odds of mortality (2.29 [1.19-4.44]). Nonsurvivors, compared with survivors, were treated with more inotropic therapies (dopamine/dobutamine [42% vs 20%] and epinephrine/norepinephrine [42% vs 6%]) but not increased fluid therapy (median volume; 32.9 mL/kg vs 20.0 mL/kg). Resuscitation practice was consistent with ACCM-PALS Guidelines in only 27 (30%) patients; however, when practice was in agreement with guideline recommendations, a lower mortality was observed (8% vs 38%).
Conclusions:
Early recognition and aggressive resuscitation of pediatric-neonatal septic shock by community physicians can save lives. Educational programs that promote ACCM-PALS recommended rapid, stepwise escalations in fluid as well as inotropic therapies may have value in improving outcomes in these children.