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Role of early fluid resuscitation in pediatric septic shock
J A Carcillo1, A L Davis, A Zaritsky
1Department of Anesthesiology, Children's Hospital National Medical Center, George Washington University, Washington, DC.
Insights
Rapid fluid resuscitation exceeding 40 mL/kg in the first hour of pediatric septic shock improved survival and reduced hypovolemia without increasing risks of ARDS or pulmonary edema.
Area of Science:
- Pediatric Critical Care Medicine
- Septic Shock Management
- Fluid Resuscitation Strategies
Background:
- Septic shock in children requires timely and effective fluid resuscitation.
- The optimal volume of fluid administration in the initial hours remains a critical question.
- Understanding fluid's impact on outcomes like ARDS and hypovolemia is essential.
Purpose of the Study:
- To investigate the association between fluid resuscitation volume at 1 and 6 hours post-presentation and patient outcomes.
- To determine the impact of fluid administration on survival, adult respiratory distress syndrome (ARDS), cardiogenic pulmonary edema, and persistent hypovolemia in pediatric septic shock.
- To compare outcomes across different fluid resuscitation volumes in the first hour.
Main Methods:
- Retrospective analysis of pediatric septic shock patients over a 6-year period with pulmonary artery catheterization.
- Patients categorized into three groups based on first-hour fluid volume: <20 mL/kg, 20-40 mL/kg, and >40 mL/kg.
- Diagnosis of ARDS, cardiogenic pulmonary edema, and hypovolemia based on established clinical and hemodynamic criteria.
Main Results:
- Survival was significantly higher in the group receiving >40 mL/kg (8/9) compared to <20 mL/kg (6/14) or 20-40 mL/kg (4/11).
- Higher fluid volumes were not associated with an increased incidence of ARDS or cardiogenic pulmonary edema.
- Persistent hypovolemia occurred in 6 patients in the <20 mL/kg group and 2 in the 20-40 mL/kg group, all of whom died.
Conclusions:
- Administering rapid fluid resuscitation exceeding 40 mL/kg in the first hour is associated with improved survival in pediatric septic shock.
- This aggressive fluid approach did not elevate the risk of adult respiratory distress syndrome or cardiogenic pulmonary edema.
- Early and adequate fluid resuscitation appears crucial for preventing persistent hypovolemia and improving outcomes.
Objective:
To examine the association of the volume of fluid administered at 1 and 6 hours after presentation, with survival and the occurrence of the adult respiratory distress syndrome, cardiogenic pulmonary edema, and persistent hypovolemia during the resuscitation of children with septic shock.
Setting And Patients:
All pediatric patients with septic shock presenting to the emergency department over a 6-year period and having a pulmonary artery catheter inserted by 6 hours after presentation were identified.
Methods:
Patients were analyzed together and in three groups based on fluid volume in the first hour: group 1, less than 20 mL/kg; group 2, 20 to 40 mL/kg; and group 3, more than 40 mL/kg. Adult respiratory distress syndrome was diagnosed by the presence of alveolar infiltrates, hypoxemia, and a pulmonary capillary wedge pressure of 15 mm Hg or less. Cardiogenic pulmonary edema was diagnosed similarly, except the pulmonary capillary wedge pressure was greater than 15 mm Hg. Hypovolemia was diagnosed by the presence of oliguria, hypotension, and a pulmonary capillary wedge pressure of 8 mm Hg or less 6 hours after presentation.
Results:
We identified 34 patients (median age, 13.5 months). At 1 and 6 hours, respectively, group 1 (n = 14) received 11 +/- 6 and 71 +/- 29 mL/kg (mean +/- SD) of fluid; group 2 received 32 +/- 5 and 108 +/- 54 mL/kg of fluid; and group 3 received 69 +/- 19 and 117 +/- 29 mL/kg of fluid. Survival in group 3 (eight of nine patients) was significantly better than in group 1 (six of 14 patients) or group 2 (four of 11 patients). Adult respiratory distress syndrome developed in 11 patients (32%) and cardiogenic pulmonary edema developed in five patients (15%). Having adult respiratory distress syndrome was associated with increased mortality, but adult respiratory distress syndrome was not increased in any group. Similarly, cardiogenic pulmonary edema was not associated with the fluid volume received or with decreased survival. Hypovolemia occurred in six patients in group 1 and two patients in group 2; all eight subsequently died.
Conclusion:
Rapid fluid resuscitation in excess of 40 mL/kg in the first hour following emergency department presentation was associated with improved survival, decreased occurrence of persistent hypovolemia, and no increase in the risk of cardiogenic pulmonary edema or adult respiratory distress syndrome in this group of pediatric patients with septic shock.