Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine*

Abstract

Background The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote “best practices” and to improve patient outcomes. Objective 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. Participants Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001–2006). Methods The Pubmed/MEDLINE literature database (1966–2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. Results The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%–3% in previously healthy, and 7%– 10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. Conclusion The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill ≤2 secs, and 2) subsequent intensive care unit hemodynamic support directed to goals of central venous oxygen saturation >70% and cardiac index 3.3–6.0 L/min/m2.

Reflectance spectroscopy: to shed new light on the capillary refill test

“…Classically the CR test illustrates the role of the skin as a mirror of the circulatory well-being of the body as a whole [36]. Beecher defined in 1947 the possible outcomes of CR time as i) normal, ii) definite slowing or iii) very sluggish, correlating outcome with no, slight/moderate and severe shock [37].…”

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

“…Therefore, a separate and independent chapter on pediatric patients was originally planned for inclusion in the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 during its creation. The clinical questions (CQs) presented in this chapter were formulated in reference to the aforementioned SSCG 201229 and the consensus statement for the management of pediatric severe sepsis in 2014452 (included the American College of Critical Care Medicine/Pediatric Advanced Life Support (ACCM/PALS) algorism453), while considering the degree to which they could be supported by the related literature and their importance in the clinical setting.…”

Ten concerns about blood pressure measurement and targets in paediatric sepsis

“…Current paediatric sepsis guidelines suggest that resuscitation is titrated against clinical markers of hypovolaemia and end organ perfusion (1), including blood pressure (BP), heart rate and capillary refill time. BP is often used both as a defining feature of shock and as a target for therapy.…”