A Prospective Randomized Controlled Study of Two Fluid Regimens in the Initial Management of Septic Shock in the Emergency Department

Santhanam, Indumathy; Sangareddi, Shanthi; Venkataraman, Shekhar T.; Kissoon, Niranjan; Thiruvengadamudayan, Vaidehi; Kasthuri, R. Kulandhai

doi:10.1097/pec.0b013e31818844cf

Cited by 80 publications

(92 citation statements)

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“…2 The early management of shock is associated with a lower mortality rate (5.06%, compared to 16.37%of patients with delayed treatment).1 In developing countries, referral delays and limited facilities lead to mortality rates of 47-54.6%, but this number decreases to 11.4-21.8% with early and proper treatment. 3 This finding illustrates the importance of early detection and proper treatment of shock.…”

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confidence: 96%

Lactate profiles of pediatric shock patients in Cipto Mangunkusumo General Hospital 2015: a pilot study

Yuniar

2017

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Background The 2015 Surviving Sepsis Campaign (SSC) guidelines for management of shock recommend blood lactate to assess the success of resuscitation in shock. However, a study in adults found that 1/3 of septic shock patients had normal lactate levels (alactatemia) and lower mortality rates. Objective To evaluate lactate profiles, possible factors affecting lactate levels, and mortality outcomes in pediatric shock patients in the emergency room (ER) and pediatric intensive care unit (PICU). Methods This was a retrospective study on pediatric shock patients aged 1 month to 18 years in the ER or PICU from June 2014 to December 2015. Data were taken from subjects' medical records including lactate levels, examination data required to calculate a PELOD score, and mortality outcomes. Results Of 223 shock patients evaluated, only 92 cases (41.2%) underwent lactate examinations. Of these, 59 (64.1%) had alactatemia and 33 (35.9%) had hyperlactatemia. A total of 23.7% of the alactatemia group and 36.4% of the hyperlactatemia group died, thus, the initial lactate level was not significantly associated with patient outcomes (P=0.197). The mortality rates of patients with <10% and ≥10% lactate clearance were 31.3% and 17.6%, respectively (P=0.362). Conclusion In alactatemia patients, lactate level can not be used as a goal for resuscitation. Further study is needed to find a biomarker for assessing the success of pediatric shock resuscitation. Moreover, the clinical relevance of alactatemia is uncertain in pediatric shock patients

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confidence: 96%

Lactate profiles of pediatric shock patients in Cipto Mangunkusumo General Hospital 2015: a pilot study

Yuniar

2017

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“…For the critical outcome of survival to hospital discharge, for the use of restrictive fluids in sepsis/septic shock, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 pediatric RCT 32 For the critical outcome of need for mechanical ventilation or vasopressor support, for the use of restrictive fluids in sepsis/septic shock, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, imprecision) from 1 pediatric RCT 32 enrolling 147 patients showing no benefit (RR, 1.32; 95% CI, 0.91-1.91). For the use of restrictive fluids in severe malaria, we identified no studies.…”

Section: Consensus On Sciencementioning

confidence: 99%

Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support

Caen¹,

Maconochie²,

Aickin³

et al. 2015

Circulation

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The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus.The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical.When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 days, 60 days, 180 days, and 1 year with favorable neurologic status were included in the relevant PICO questions.Each task force performed a detailed systematic review based on the recommendations of the Institute of Medicine of the National Academies 1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group.2 After identifying and prioritizing the questions to be addressed (by using the PICO format) 3 with the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk-of-bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs), 4 Quality Assessment of Diagnosti...

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“…Other end points that have been widely used in adults and may logically apply to children include central venous pressure of 8-12 mmHg and mean arterial pressure (MAP) method using a 3 way stop-cock increased the incidence of hepatomegaly and showed a trend towards a greater need for intubation [19]; this suggests need for caution with rapid administration of fluids in a setting without universal access to ventilator support. This study also did not observe faster resolution of shock in the fast infusion group [15].…”

Section: Methods Of Fluid Administrationmentioning

confidence: 85%

“…After the "golden hours", aggressive hemodynamic resuscitation is no longer effective in restoring the organ function or in decreasing the mortality [14]. In an Indian pediatric hospital, there was a 9-fold increase in the odds for survival if shock was corrected in the emergency department [15].…”

Section: Early Recognition Of Septic Shockmentioning

confidence: 99%

Management of Septic Shock

2011

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Septic shock is an important cause of mortality in children with sepsis. The incidence of septic shock is 2-4% of admissions in western pediatric intensive care units and 40%-67% for Indian PICUs. Early goal-directed resuscitation that includes aggressive fluid resuscitation of up to 60 mL/kg as boluses of 20 mL/kg by IV push, to achieve desired heart rates and blood pressure, has emerged as mainstay of treatment in the initial stage. Crystalloids are the preferred fluids, while colloids may be used in some situations. Fluid refractory shock warrants use of vasoactive drugs. Dopamine is the first choice. Dobutamine and low dose epinephrine are the preferred inotropic drugs while nor-epinephrine is a vasopressor. Children with cold shock and normal blood pressure may benefit from nitrosodilators like nitroprusside and nitroglycerine. Inodilators such as milrinone are also useful in this situation. Targeting clinical therapeutic end-points assists the management. Good supportive care is also essential for improving the outcomes.

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A Prospective Randomized Controlled Study of Two Fluid Regimens in the Initial Management of Septic Shock in the Emergency Department

Abstract: There was no difference in the overall mortality, rapidity of shock resolution, or incidence of complications between the groups. The occurrence of hepatomegaly at 20 minutes following 40 mL/kg is of concern in settings with limited access to post-resuscitation ventilator care.

Cited by 80 publications

References 18 publications

Lactate profiles of pediatric shock patients in Cipto Mangunkusumo General Hospital 2015: a pilot study

Lactate profiles of pediatric shock patients in Cipto Mangunkusumo General Hospital 2015: a pilot study

Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support

Management of Septic Shock

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