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Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world.
Pediatr Emerg Care. 2008 Dec; 24(12):810-5.PE

Abstract

OBJECTIVES

To analyze mortality rates of children with severe sepsis and septic shock in relation to time-sensitive fluid resuscitation and treatments received and to define barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines in a pediatric intensive care unit in a developing country.

METHODS

Retrospective chart review and prospective analysis of septic shock treatment in a pediatric intensive care unit of a tertiary care teaching hospital. Ninety patients with severe sepsis or septic shock admitted between July 2002 and June 2003 were included in this study.

RESULTS

Of the 90 patients, 83% had septic shock and 17% had severe sepsis; 80 patients had preexisting severe chronic diseases. Patients with septic shock who received less than a 20-mL/kg dose of resuscitation fluid in the first hour of treatment had a mortality rate of 73%, whereas patients who received more than a 40-mL/kg dose in the first hour of treatment had a mortality rate of 33% (P < 0.05). Patients treated less than 30 minutes after diagnosis of severe sepsis and septic shock had a significantly lower mortality rate (40%) than patients treated more than 60 minutes after diagnosis (P < 0.05). Controlling for the risk of mortality, early fluid resuscitation was associated with a 3-fold reduction in the odds of death (odds ratio, 0.33; 95% confidence interval, 0.13-0.85). The most important barriers to achieve adequate severe sepsis and septic shock treatment were lack of adequate vascular access, lack of recognition of early shock, shortage of health care providers, and nonuse of goals and treatment protocols.

CONCLUSIONS

The mortality rate was higher for children older than 2 years, for those who received less than 40 mL/kg in the first hour, and for those whose treatment was not initiated in the first 30 minutes after the diagnosis of septic shock. The acknowledgment of existing barriers to a timely fluid administration and the establishment of objectives to overcome these barriers may lead to a more successful implementation of the American College of Critical Care Medicine guidelines and reduced mortality rates for children with septic shock in the developing world.

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Authors+Show Affiliations

Oliveira CF
Department of Pediatrics, Faculdade de Medicina, Pediatric Intensive Care Unit, Instituto da Criança Pedro de Alcântra, Universidade de São Paulo, São Paulo, Brazil.
Nogueira de Sá FR
No affiliation info available
Oliveira DS
No affiliation info available
Gottschald AF
No affiliation info available
Moura JD
No affiliation info available
Shibata AR
No affiliation info available
Troster EJ
No affiliation info available
Vaz FA
No affiliation info available
Carcillo JA
No affiliation info available

MeSH

Age FactorsBrazilChildChild, PreschoolCohort StudiesComorbidityCross InfectionDeveloping CountriesEarly DiagnosisFemaleFluid TherapyGuideline AdherenceHospital MortalityHospitals, TeachingHumansInfantIntensive Care Units, PediatricMalePractice Guidelines as TopicProspective StudiesResuscitationRetrospective StudiesSepsisShock, SepticTime FactorsWorkforce

Pub Type(s)

Journal Article

Language

eng

PubMed ID

19050666

Clinical Trial Links

Electronic Application of a Severe Sepsis Screening Tool and Management Bundle

Citation

Oliveira, Cláudio F., et al. "Time- and Fluid-sensitive Resuscitation for Hemodynamic Support of Children in Septic Shock: Barriers to the Implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a Pediatric Intensive Care Unit in a Developing World." Pediatric Emergency Care, vol. 24, no. 12, 2008, pp. 810-5.
Oliveira CF, Nogueira de Sá FR, Oliveira DS, et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008;24(12):810-5.
Oliveira, C. F., Nogueira de Sá, F. R., Oliveira, D. S., Gottschald, A. F., Moura, J. D., Shibata, A. R., Troster, E. J., Vaz, F. A., & Carcillo, J. A. (2008). Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatric Emergency Care, 24(12), 810-5. https://doi.org/10.1097/PEC.0b013e31818e9f3a
Oliveira CF, et al. Time- and Fluid-sensitive Resuscitation for Hemodynamic Support of Children in Septic Shock: Barriers to the Implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a Pediatric Intensive Care Unit in a Developing World. Pediatr Emerg Care. 2008;24(12):810-5. PubMed PMID: 19050666.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. AU - Oliveira,Cláudio F, AU - Nogueira de Sá,Flávio R, AU - Oliveira,Débora S F, AU - Gottschald,Adriana F C, AU - Moura,Juliana D G, AU - Shibata,Audrey R O, AU - Troster,Eduardo J, AU - Vaz,Flávio A C, AU - Carcillo,Joseph A, PY - 2008/12/4/pubmed PY - 2009/3/27/medline PY - 2008/12/4/entrez SP - 810 EP - 5 JF - Pediatric emergency care JO - Pediatr Emerg Care VL - 24 IS - 12 N2 - OBJECTIVES: To analyze mortality rates of children with severe sepsis and septic shock in relation to time-sensitive fluid resuscitation and treatments received and to define barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines in a pediatric intensive care unit in a developing country. METHODS: Retrospective chart review and prospective analysis of septic shock treatment in a pediatric intensive care unit of a tertiary care teaching hospital. Ninety patients with severe sepsis or septic shock admitted between July 2002 and June 2003 were included in this study. RESULTS: Of the 90 patients, 83% had septic shock and 17% had severe sepsis; 80 patients had preexisting severe chronic diseases. Patients with septic shock who received less than a 20-mL/kg dose of resuscitation fluid in the first hour of treatment had a mortality rate of 73%, whereas patients who received more than a 40-mL/kg dose in the first hour of treatment had a mortality rate of 33% (P < 0.05). Patients treated less than 30 minutes after diagnosis of severe sepsis and septic shock had a significantly lower mortality rate (40%) than patients treated more than 60 minutes after diagnosis (P < 0.05). Controlling for the risk of mortality, early fluid resuscitation was associated with a 3-fold reduction in the odds of death (odds ratio, 0.33; 95% confidence interval, 0.13-0.85). The most important barriers to achieve adequate severe sepsis and septic shock treatment were lack of adequate vascular access, lack of recognition of early shock, shortage of health care providers, and nonuse of goals and treatment protocols. CONCLUSIONS: The mortality rate was higher for children older than 2 years, for those who received less than 40 mL/kg in the first hour, and for those whose treatment was not initiated in the first 30 minutes after the diagnosis of septic shock. The acknowledgment of existing barriers to a timely fluid administration and the establishment of objectives to overcome these barriers may lead to a more successful implementation of the American College of Critical Care Medicine guidelines and reduced mortality rates for children with septic shock in the developing world. SN - 1535-1815 UR - https://www.unboundmedicine.com/medline/citation/19050666/Time__and_fluid_sensitive_resuscitation_for_hemodynamic_support_of_children_in_septic_shock:_barriers_to_the_implementation_of_the_American_College_of_Critical_Care_Medicine/Pediatric_Advanced_Life_Support_Guidelines_in_a_pediatric_intensive_care_unit_in_a_developing_world_ L2 - https://doi.org/10.1097/PEC.0b013e31818e9f3a DB - PRIME DP - Unbound Medicine ER -