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Published on: November 9, 2016
Practices of Initiation of Vasoactive Drugs in Relation to Resuscitation Fluids in Children with Septic Shock: A
Karanvir1, Shalu Gupta2, Virendra Kumar2
1Department of Pediatrics, ESIC Hospital and Medical College, Faridabad, Haryana, India.
Insights
Early initiation of vasoactive infusions after the first fluid bolus in pediatric septic shock leads to faster recovery and fewer complications. This approach reduces overall fluid volume and intensive care unit stay, improving patient outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Emergency Medicine
- Pediatric Infectious Diseases
Background:
- The optimal timing for initiating vasoactive medications relative to fluid resuscitation in pediatric septic shock remains unclear.
- Septic shock management guidelines emphasize fluid resuscitation, but the precise sequence with vasoactive agents requires further investigation.
- Understanding the impact of early versus delayed vasoactive drug initiation is crucial for improving patient outcomes.
Purpose of the Study:
- To prospectively evaluate the clinical practices and outcomes associated with the timing of vasoactive infusion initiation in relation to fluid boluses in pediatric septic shock.
- To compare different initiation strategies: after the first (N1), second (N2), or third (N3) fluid bolus.
- To assess secondary outcomes including time to hemodynamic stability, fluid requirements, complications, and mortality.
Main Methods:
- A prospective observational study enrolled 100 children (1 month to 18 years) diagnosed with septic shock.
- Patients were categorized into three groups based on when vasoactive infusions were started relative to 20 mL/kg fluid boluses (N1, N2, N3).
- Outcomes measured included time to hemodynamic stability, fluid volume, 24-hour complications, and mortality.
Main Results:
- The early initiation group (N1) required significantly less fluid volume (40 mL/kg) to achieve hemodynamic stability compared to N2 and N3 (70 mL/kg) (p=0.02).
- Hemodynamic stability was achieved significantly faster in the N1 group (115 minutes) versus N2 (196 minutes) and N3 (212 minutes) (p=0.02).
- The N1 group also showed lower 24-hour intravenous fluid requirements (p=0.02) and fewer complications (p=0.04), with no significant difference in mortality.
Conclusions:
- Initiating vasoactive infusions after the first fluid bolus in pediatric septic shock is associated with improved outcomes.
- Early vasoactive drug administration leads to reduced total fluid volume, faster achievement of hemodynamic stability, and fewer complications.
- This strategy may contribute to shorter intensive care unit stays and better overall management of pediatric septic shock.
Abstract:
Background: The role of vasoactive medications in septic shock is well-defined, but the appropriate time of initiation of these medications in reference to fluid boluses is not clear. We planned to study prospectively the practices and outcome of initiation of vasoactive infusions with respect to resuscitation fluids boluses in pediatric septic shock. Patients and methods: Children aged 1 month to 18 years diagnosed with septic shock were enrolled to receive fluid resuscitation boluses along with vasoactive drugs. The primary outcome was to look at various practices of the initiation of vasoactive infusions; accordingly, patients were categorized into three groups: N1 received vasoactive infusions after completion of the first bolus (20 mL/kg), N2 after the second (40 mL/kg), and N3 after the third fluid (60 mL/kg) bolus. Secondary outcomes were to compare the time taken, amount of fluid required to achieve hemodynamic stability, total fluid required, and complications in the first 24 hours of treatment and mortality. Results: Hundred children were enrolled and grouped into N1, N2, and N3 with 46, 10, and 44 patients, respectively. The volume of fluid required to achieve the resolution of shock in N1 (40 ± 10 mL/kg) was significantly less than in N2 (70 ± 10 mL/kg) and N3 (70 ± 20 mL/kg); p = 0.02. The time taken to achieve hemodynamic stability was significantly less in N1 (115 ± 45 minutes) than in N2 (196 ± 32 minutes) and N3 (212 ± 44 minutes); p = 0.02. The volume of intravenous fluid required in the first 24 hours (p = 0.02) and complications were lower in the N1 group (p = 0.04). No statistical difference in mortality was seen. Conclusion: Early initiation of vasoactive infusions (after the first bolus) resulted in less total fluid volume, lesser time to achieve hemodynamic stability, less fluid boluses, less length of stay in the pediatric intensive care unit, and lesser complications in the first 24 hours. Highlight: Early initiation of vasoactive infusions-after completion of the first fluid bolus resulted in less need for further fluid boluses, lesser time for shock resolution, lesser fluid overload, and less PICU stay-in pediatric septic shock. How to cite this article: Karanvir, Gupta S, Kumar V. Practices of Initiation of Vasoactive Drugs in Relation to Resuscitation Fluids in Children with Septic Shock: A Prospective Observational Study. Indian J Crit Care Med 2021;25(8):928-933.
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