Clinical outcomes and mortality before and after implementation of a pediatric sepsis protocol in a limited resource setting: A retrospective cohort study in Bangladesh

Abstract

BackgroundPediatric sepsis has a high mortality rate in limited resource settings. Sepsis protocols have been shown to be a cost-effective strategy to improve morbidity and mortality in a variety of populations and settings. At Dhaka Hospital in Bangladesh, mortality from pediatric sepsis in high-risk children previously approached 60%, which prompted the implementation of an evidenced-based protocol in 2010. The clinical effectiveness of this protocol had not been measured. We hypothesized that implementation of a pediatric sepsis protocol improved clinical outcomes, including reducing mortality and length of hospital stay.Materials and methodsThis was a retrospective cohort study of children 1–59 months old with a diagnosis of sepsis, severe sepsis or septic shock admitted to Dhaka Hospital from 10/25/2009-10/25/2011. The primary outcome was inpatient mortality pre- and post-protocol implementation. Secondary outcomes included fluid overload, heart failure, respiratory insufficiency, length of hospital stay, and protocol compliance, as measured by antibiotic and fluid bolus administration within 60 minutes of hospital presentation.Results404 patients were identified by a key-word search of the electronic medical record; 328 patients with a primary diagnosis of sepsis, severe sepsis, or septic shock were included (143 pre- and185 post-protocol) in the analysis. Pre- and post-protocol mortality were similar and not statistically significant (32.17% vs. 34.59%, p = 0.72). The adjusted odds ratio (AOR) for post-protocol mortality was 1.55 (95% CI, 0.88–2.71). The odds for developing fluid overload were significantly higher post-protocol (AOR 3.45, 95% CI, 2.04–5.85), as were the odds of developing heart failure (AOR 4.52, 95% CI, 1.43–14.29) and having a longer median length of stay (AOR 1.81, 95% CI 1.10–2.96). There was no statistically significant difference in respiratory insufficiency (pre- 65.7% vs. post- 70.3%, p = 0.4) or antibiotic administration between the cohorts (pre- 16.08% vs. post- 12.43%, p = 0.42).ConclusionsImplementation of a pediatric sepsis protocol did not improve all-cause mortality or length of stay and may have been associated with increased fluid overload and heart failure during the study period in a large, non-governmental hospital in Bangladesh. Similar rates of early antibiotic administration may indicate poor protocol compliance. Though evidenced-based protocols are a potential cost-effective strategy to improve outcomes, future studies should focus on optimal implementation of context-relevant sepsis protocols in limited resource settings.

Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols

“…Maitland et al reported an increase in mortality after fluids bolus in African children with severe infection (44). Studies by Kortz et al (Tanzania) and Vekaria-Hirani et al (Naroby) did not observe reduction on mortality after a protocol implementation (34,45). Kortz et al even observed an increase in length of stay after protocol implementation caused by complications of treatment (34).…”

Lebensrettende Maßnahmen bei Kindern (Paediatric Life Support, PLS)

“…Während viele verschiedene Beobachtungsstudien einen positiven Einfluss auf das Outcome der Implementierung dieses Therapiebündels zeigten, war dieser Effekt in anderen Studien weitaus geringer [317,[320][321][322][323][324][325][326][327][328]. Gründe für solche Unterschiede sind nicht immer leicht zu identifizieren, können jedoch mit Selektionsbias, Unterschieden in den Implementierungsstrategien oder Unterschieden in der Handhabung der Kontrollpopulationen zusammenhängen.…”

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

“…The EvUp also analyzed the results of 4 nonrandomized studies [34][35][36][37] and 1 study protocol. 38 The Society of Critical Care Medicine's Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children was published in February 2020, 26 immediately before the submission of this publication. In these 2020 surviving sepsis guidelines, recommendations for fluid administration differ based on the availability of intensive care within the system caring for the infant or child.…”