Adherence to Advance Directives

Abstract

Source:Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003;112:793-799. T imely resuscitation of infants and children with septic shock appears to improve outcome. 1 The American College of Critical Care Medicine (ACCM) has recently published guidelines for the hemodynamic management of neonatal and pediatric septic shock that emphasize early and aggressive fluid therapy and use of vasoactive infusions. 2 A retrospective review from the University of Pittsburgh, Pa, sought to determine if early reversal of septic shock by community physicians would improve survival, and if outcome was influenced by providing treatment consistent with the ACCM guidelines.The authors report the management and outcome of 91 infants and children (average age 22 months, range 1-131) who were transported to a pediatric tertiary care center after presentation to a community hospital with septic shock. Patients were included if they had signs of sepsis with decreased perfusion, with or without hypotension. Reversal of shock was defined as improvement in capillary refill time to less than 3 seconds and correction of hypotension, if present. Overall mortality was 26%. Shock reversal in response to therapy occurred in 26% of patients prior to arrival of the pediatric transport team (median response time, 75 minutes), and resulted in a survival rate of 96%. Thirty percent of the patients received treatment that was consistent with the ACCM guidelines, which was associated with a 92% survival. For each hour that the patient remained in shock, the odds of mortality, adjusted for PRISM (Pediatric Risk for Mortality) score, more than doubled.While patients whose shock was reversed prior to transport had improved survival, the study does not support the hypothesis that improved outcome was the result of the community physicians' management. Survivors received less fluid resuscitation than nonsurvivors (median 20 mL/kg versus 32.9 mL/kg) and were significantly less likely to receive vasoactive infusions (25% versus 42%) or to be intubated (38% versus 73%). These results suggest that severity of illness at presentation is the most important factor in determining outcome, and those patients who improved in response to fluid therapy, with or without vasoactive infusions, were more likely to survive than those whose shock was unresponsive to these measures. The overall mortality rate of 26% is higher than the reported mortality rate from severe sepsis in pediatric patients, which is approximately 10%. 3 This may indicate that non-survivors experienced a delay in presentation, recognition of shock, or transfer to the tertiary care center. Furthermore, the authors do not state whether PRISM scores reflected pre-or post-resuscitation status; therefore, adjustment of mortality rates for severity of illness may only indicate that non-survivors were more severely ill. The observation that survival was increased when patients received resu...