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Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock
Matthew A Eisenberg1, Ruth Riggs2, Raina Paul3
1Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA.
Insights
In pediatric septic shock, receiving 30 mL/kg or more of intravenous fluids in the first hour of emergency department care was not linked to higher mortality. This finding applies to children with hypotensive septic shock receiving timely fluid resuscitation.
Area of Science:
- Pediatric Emergency Medicine
- Critical Care
- Pediatric Sepsis Research
Background:
- Early fluid resuscitation is crucial for pediatric septic shock management.
- The optimal initial intravenous fluid volume in pediatric septic shock remains a subject of investigation.
- Understanding fluid volume effects on mortality is vital for clinical practice guidelines.
Purpose of the Study:
- To investigate the association between receiving ≥30 mL/kg of intravenous fluids within the first hour of emergency department (ED) arrival and sepsis-attributable mortality in children with hypotensive septic shock.
- To secondarily evaluate this association in children with suspected sepsis, irrespective of blood pressure.
Main Methods:
- Retrospective cohort study involving 57 EDs within a quality improvement collaborative.
- Propensity-score matching was used for patients with hypotensive septic shock receiving their first fluid bolus within 1 hour of ED arrival.
- Sepsis-attributable mortality was compared between groups receiving ≥30 mL/kg versus <30 mL/kg of fluid in the first hour.
Main Results:
- In propensity-matched children with hypotensive septic shock, 30-day mortality was 4.3% for those receiving ≥30 mL/kg (n=602) versus 4.2% for those receiving <30 mL/kg (n=602) (OR 1.04; 95% CI 0.59-1.83).
- Among all children with suspected sepsis, mortality was 3.0% for those receiving ≥30 mL/kg versus 2.0% for those receiving <30 mL/kg (OR 1.52; 95% CI 0.95-2.44).
Conclusions:
- In children with hypotensive septic shock receiving timely initial fluid boluses, administering ≥30 mL/kg of intravenous fluids in the first hour was not associated with increased sepsis-attributable mortality.
- The findings suggest that the standard fluid resuscitation volume in the initial hour for pediatric septic shock does not adversely affect mortality.
- Further research may explore nuances in fluid management for specific pediatric sepsis presentations.
Study Objective:
To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock.
Methods:
This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure.
Results:
Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.
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