Abstract
Introduction: Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). While standardized guidelines for sepsis and pARDS are published regularly, their implementation and adherence to guidelines are different in resource-rich and resource-limited countries. The purpose of this study was to conduct a survey to ascertain variation in current clinician-reported practice in pediatric septic shock and acute respiratory distress syndrome, and the clinician skills in a variety of hospital settings throughout Thailand.Methods: We conducted an electronic survey in pediatricians throughout the country between August 2020 and February 2021 using multiple choice questions and clinical case scenarios based on the 2017 American College of Critical Care Medicine's Consensus guideline for pediatric and neonatal septic shock and the 2015 Pediatric Acute Lung Injury Consensus Conference.Results: The survey elicited responses from 255 pediatricians (125 general pediatricians, 38 pulmonologists, 27 cardiologists, 32 intensivists, and 33 other subspecialists), with 54.5% of the respondents having <5 years of PICU experience. Among the six sepsis scenarios, 72.5 and 78.4% of the respondents had good adherence to the guidelines for managing fluid refractory shock and sedation for intubation, respectively. The ICU physicians reported greater adherence during more complex shock. In ARDS scenarios, 80.8% of the respondents reported having difficulty diagnosing ARDS mimic conditions and used lesser PEEP than the recommendation. Acceptance of permissive hypercapnia and mild hypoxemia was accepted by 62.4 and 49.4% of respondents, respectively. The ICU physicians preferred decremental PEEP titration, whereas general pediatricians preferred incremental PEEP titration.Conclusion: This survey variation could be the result of resource constraints, knowledge gaps, or ambiguous guidelines. Understanding the perspective and rationale for variation in pediatricians' practices is critical for successful guideline implementation.
Highlights
Pediatric septic shock and acute respiratory distress syndrome are major causes of morbidity and mortality in pediatric intensive care units (PICUs)
Due to the shortage of pediatric ICU physicians in our country, other specialists and general pediatricians manage the majority of critical care in PICU, which might result in a greater variation in the management and less adherence to guidelines
Pediatricians with at least 1 year of experience working in pediatric intensive care units were eligible, whose worked in the tertiary care hospitals or higher
Summary
Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). The American College of Critical Care Medicine (ACCM) [9] and the Pediatric Acute Lung Injury Consensus conference group (PALLIC) [10] had regularly published guidelines and recommendations for sepsis and pARDS to standardize patient care and improve outcomes. Adherence to these guidelines had been shown to reduce the mortality in pediatric septic shock from 38 to 8%; only 30% of the resuscitation practice adheres to standards [11]. Due to the shortage of pediatric ICU physicians in our country, other specialists and general pediatricians manage the majority of critical care in PICU, which might result in a greater variation in the management and less adherence to guidelines
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