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Early Treatment of Pediatric Septic Shock in Community Hospitals Saves Lives

But rapid and aggressive therapy to reverse shock continues to be underused.

To determine whether early resuscitation and reversal of septic shock by community hospital physicians are associated with improved outcome in children, these authors reviewed cases of septic shock that were retrospectively identified from the interfacility transport database at Children's Hospital of Pittsburgh over 9 years. Resuscitation practices of the community physicians were compared with those outlined in the recently published American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) septic shock guidelines, which recommend rapid, stepwise performance of therapeutic interventions to restore normal blood pressure and perfusion.

Of 91 patients who met the criteria for septic shock, 26 (29%) died. Nonsurvivors and survivors did not differ in age, sex, comorbid conditions, transport characteristics, or culture-positive sepsis, but the Pediatric Risk for Mortality (PRISM) score was significantly higher in nonsurvivors (26 vs. 11; P<0.001). Shock was reversed in 24 patients (26%), and reversal was associated with a 9-fold increase in survival. When resuscitation and therapeutic interventions were consistent with the guidelines, the odds of survival increased 6-fold. (The previous two survival calculations were adjusted for PRISM score). For each hour of persistent shock and for each hour of delay in resuscitation, the odds of mortality increased 2-fold and 1.5-fold, respectively. Overall, only 45% of patients received appropriate fluid therapy (defined as any volume that resulted in shock reversal or 60 mL/kg for patients with persistent shock), and resuscitation practices were consistent with the guidelines for only 30%. Nonsurvivors received more mechanical ventilation and pressor support than survivors.

Comment: We continue to learn more about the value of optimized resuscitation of patients in shock, and these results mirror those seen in adults. These studies argue for an aggressive approach to sepsis, not unlike a trauma resuscitation. Early shock reversal increases the odds of survival, but community physicians continue to underuse this therapy. Septic shock should be treated with rapid successive 20-mL/kg boluses of isotonic crystalloid or colloid to a maximum of 60 mL/kg or until resolution, followed by inotropic support and other appropriate therapies. Emergency physicians should review the ACCM-PALS guidelines.

— Jill M. Baren, MD, FACEP

Published in Journal Watch Emergency Medicine January 6, 2004

Citation(s):

Han YY et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003 Oct; 112:793-9.

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