Abstract
BackgroundPediatric sepsis represents an important cause of mortality in pediatric intensive care units (PICU). Although adherence to published guidelines for the management of severe sepsis patients is known to lower mortality, actual adherence to these recommendations is low. The aim of this study was to describe the initial management of pediatric patients with severe sepsis, as well as to describe the main barriers to the adherence to current guidelines on management of these patients.MethodsA survey using a case scenario to assess the management of a child with severe sepsis was designed and sent out to all PICU medical directors of the 20 institutions member of the “Réseau Mère- Enfant de la Francophonie”. Participants were asked to describe in detail the usual management of these patients in their institution with regard to investigations, fluid and catecholamine management, intubation, and specific treatments. Participants were also asked to identify the main barriers to the application of the Surviving Sepsis Campaign guidelines in their center.ResultsTwelve PICU medical directors answered the survey. Only two elements of the severe sepsis bundles had a low stated compliance rate: “maintain adequate central venous pressure” and “glycemic control” had a stated compliance of 8% and 25% respectively. All other elements of the bundles had a reported compliance of over 90%. Furthermore, the most important barriers to the adherence to Surviving Sepsis Campaign guidelines were the unavailability of continuous central venous oxygen saturation (ScvO2) monitoring and the absence of a locally written protocol.ConclusionsIn this survey, pediatric intensivists reported high adherence to the current recommendations in the management of pediatric severe sepsis regarding antibiotic administration, rapid fluid resuscitation, and administration of catecholamines and steroids, if needed. Technical difficulties in obtaining continuous ScvO2 monitoring and absence of a locally written protocol were the main barriers to the uniform application of current guidelines. We believe that the development of locally written protocols and of specialized teams could add to the achievement of the goal that every child in sepsis should be treated according to the latest evidence to heighten his chances of survival.
Highlights
Pediatric sepsis represents an important cause of mortality in pediatric intensive care units (PICU)
The survey results show that administration of antibiotics in the first hour, aggressive fluid resuscitation, adding catecholamines, if needed, and administration of steroids in refractory shock were all used in the management of a child in sepsis suggesting that little or no controversy remains with respect to these intervention types
Compliance to the Surviving Sepsis Campaign guidelines was only 8% for the resuscitation bundle and 25% for the sepsis management bundle, but this is largely due to a single recommendation in each bundle with very low compliance
Summary
Pediatric sepsis represents an important cause of mortality in pediatric intensive care units (PICU). The objectives of these recommendations were to standardize patient care and further reduce mortality and morbidity in pediatric sepsis These guidelines represent best clinical practice; stronger evidence is lacking to confirm the components of these recommendations; almost all levels of references and recommendations in pediatric septic shock treatment are low [6,7,8]. Adherence to these recommendations is known to lower mortality in pediatric septic patients as shown in a study by Han et al (mortality 8% vs 38%) [9]. The literature identifies several barriers that limit adherence to current guidelines, including lack of early recognition of severe sepsis and septic shock as well as treatment delay, difficulties in obtaining adequate vascular access and advanced airway management, central venous pressure and central venous oxygen saturation (ScvO2) monitoring, shortage of health care providers, absence of goals and treatment protocols, difficulties in obtaining specialized transport and access to pediatric intensive care beds, as well as educational gaps [2,7,8,9,11,12]
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