Implementing ACCM critical care guidelines for septic shock management in a Cuban pediatric intensive care unit

INTRODUCTION Sepsis is the most common direct cause of death worldwide and septic shock the syndrome's most serious complication. In 2002, the pediatric intensive care unit of the José Luis Miranda Pediatric University Hospital in Santa Clara (Villa Clara Province), Cuba, began implementing the recently published guidelines of the American College of Critical Care Medicine (ACCM) for management of pediatric and neonatal septic shock, observing a drop in case fatality from 34.6% to 19% between the years 2003 and 2007. ACCM updated these Guidelines in 2007. OBJECTIVE Describe experiences with the use of the 2007 ACCM updated Guidelines and discuss their possible impact in reducing case fatality. METHODS Between 2008 and 2010, a study was conducted of 280 children and adolescents, from newborns through 18 years, admitted to the pediatric intensive care unit with a diagnosis of septic shock. The diagnostic and therapeutic criteria used were those recommended in the ACCM's 2007 updated Guidelines. The dependent variable was case fatality. Independent variables were age, sex, comorbidity or prior chronic disease, origin and course of sepsis, hemodynamic state, blood glucose level, hyperglycemia, organ dysfunction, volume of fluid therapy administered, use of mechanical ventilation and therapeutic response. RESULTS In the 3-year period, 28-day case fatality was 11.1% (31/280). A total of 45 patients had comorbidities, with 14 deaths and a case fatality rate of 31.1% vs. 7.2% (17/235) in previously healthy patients. Cold shock with a hemodynamic state of low cardiac output and high systemic vascular resistance predominated (68.9%), with low cardiac output and low systemic vascular resistance the least common type (12.5%), but the one with highest case fatality (34.4%). Hyperglycemia was present in 39.6% of patients, with 15.3% case fatality; case fatality was higher (25.6%) when hyperglycemia was in the 10-15.9 mmol/L range. Fluid therapy of 40-100 mL/kg was administered in the first hour to 90% of patients, increasing to >96% in the first 3-6 hours. The most common therapeutic response was fluid refractory, dobutamine responsive (39.3%). Mechanical ventilation was used in 33.9% of patients, with a case fatality of 30.5%. Cardiovascular, respiratory and hematologic dysfunctions were common. Failure of ≥4 organs raised case fatality to 77.8%. CONCLUSIONS Implementation of ACCM Guidelines facilitates timely, appropriate care for septic shock patients and contributes to lower case fatality. Early aggressive fluid therapy with support of vasoactive drugs, either singly or in combination, has a positive impact on patient outcomes. Similar studies with a larger number of patients are needed to corroborate these conclusions.