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Early Goal-Directed Therapy With and Without Intermittent Superior Vena Cava Oxygen Saturation Monitoring in
Puneet Jain1, Ramachandran Rameshkumar2, Ponnarmeni Satheesh1
1Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry.
Insights
Early goal-directed therapy (EGDT) with superior vena cava oxygen saturation (ScvO2) monitoring significantly reduced mortality in pediatric septic shock. This approach also improved organ dysfunction compared to EGDT without ScvO2 monitoring.
Area of Science:
- Pediatric Critical Care Medicine
- Septic Shock Management
- Hemodynamic Monitoring
Background:
- Pediatric septic shock requires timely and effective resuscitation.
- Early goal-directed therapy (EGDT) is a cornerstone of treatment.
- The role of continuous or intermittent monitoring of central venous oxygen saturation (ScvO2) in guiding EGDT for pediatric septic shock remains an area of investigation.
Purpose of the Study:
- To compare the efficacy of EGDT with and without intermittent superior vena cava oxygen saturation (ScvO2) monitoring in children with septic shock.
- To evaluate the impact of ScvO2-guided EGDT on mortality and secondary outcomes.
Main Methods:
- An open-label randomized controlled trial was conducted in a pediatric intensive care unit.
- Children aged 1 month to 12 years with septic shock, not responding to initial fluid resuscitation, were randomized.
- Intervention groups received EGDT with (n=59) or without (n=61) intermittent ScvO2 monitoring.
Main Results:
- The trial was stopped early due to significantly lower 28-day all-cause mortality in the EGDT with ScvO2 group (37.3% vs. 57.5%).
- Therapeutic endpoints were achieved earlier in the ScvO2-guided group (3.6 vs. 4.2 hours).
- Lower rates of organ dysfunction during the pediatric intensive care unit (PICU) stay were observed in the ScvO2 group.
Conclusions:
- EGDT guided by intermittent ScvO2 monitoring is associated with reduced mortality in pediatric septic shock.
- This monitoring strategy also improves the achievement of therapeutic goals and reduces organ dysfunction.
- Intermittent ScvO2 monitoring represents a valuable adjunct to EGDT in managing pediatric septic shock.
Objective:
To compare early goal-directed therapy (EGDT) 'with' and 'without' intermittent superior vena cava oxygen saturation (ScvO2) monitoring in pediatric septic shock.
Design:
Open label randomized controlled trial.
Setting:
Pediatric intensive care unit in a tertiary care center.
Participants:
Children aged 1 month to 12 year with septic shock.
Intervention:
Patients not responding to fluid resuscitation (up to 40 mL/kg) were randomized to EGDT 'with' (n=59) and 'without' (n=61) ScvO2 groups. Resuscitation was guided by ScvO2 monitoring at 1-hour, 3-hour, and later on six-hourly in the 'with' ScvO2 group, and by clinical variables in the 'without' ScvO2 group.
Outcome:
Primary outcome was all-cause 28-day mortality. Secondary outcomes were time to and proportion of patients achieving therapeutic endpoints (at 6 hours and PICU stay), need for organ supports, new organ dysfunction (at 24 hours and PICU stay), and length of PICU and hospital stay.
Results:
The study was stopped after interim analysis due to lower mortality in the intervention group. There was significantly lower all-cause 28-day mortality in EDGT with ScvO2 than without ScvO2 group [37.3% vs. 57.5%, adjusted hazard ratio 0.57, 95%CI 0.33 to 0.97, P=0.04]. Therapeutic endpoints were achieved early in 'with' ScvO2 group [mean (SD) 3.6 (1.6) vs. 4.2 (1.6) h, P=0.03]. Organ dysfunction by sequential organ assessment score during PICU stay was lower in 'with' ScvO2 group [median (IQR) 5 (2,11) vs. 8 (3,13); P=0.03]. There was no significant difference in other secondary outcomes.
Conclusions:
EGDT with intermittent ScvO2 monitoring was associated with reduced mortality and improved organ dysfunction in pediatric septic shock.
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