Treatment Of Pediatric Septic Shock Research Articles

Diagnosis and treatment of pediatric septic shock in pediatric intensive care units from hospitals of different levels

Objective: To investigate the differences in clinical characteristics, diagnosis, and treatment of pediatric septic shock in pediatric intensive care unit (PICU) among hospitals of different levels. Methods: This retrospective study enrolled 368 children with septic shock treated in the PICU of Beijing Children's Hospital, Henan Children's Hospital, and Baoding Children's Hospital from January 2018 to December 2021. Their clinical data were collected, including the general information, location of onset (community or hospital-acquired), severity, pathogen positivity, consistence of guideline (the rate of standard attainment at 6 h after resuscitation and the rate of anti-infective drug administration within 1 h after diagnosis), treatment, and in-hospital mortality. The 3 hospitals were national, provincial, and municipal, respectively. Furthermore, the patients were divided into the tumor group and the non-tumor group, and into the in-hospital referral group and the outpatient or emergency admission group. Chi-square test and Mann-Whitney U test were used to analyze the data. Results: The 368 patients aged 32 (11, 98) months, of whom 223 were males and 145 females. There were 215, 107, and 46 patients with septic shock, with males of 141, 51, and 31 cases, from the national, provincial, and municipal hospitals, respectively. The difference in pediatric risk of mortality Ⅲ (PRISM Ⅲ) scores among the national,provincial and municipal group was statistically significant (26(19, 32) vs.19(12, 26) vs. 12(6, 19), Z=60.25,P<0.001). The difference in community acquired septic shock among the national,provincial and municipal group was statistically significant (31.6%(68/215) vs. 84.1%(90/107) vs. 91.3%(42/46), χ2=108.26,P<0.001). There were no significant differences in compliance with guidelines among the 3 groups (P>0.05). The main bacteria detected in the national group were Klebsiella pneumoniae (15.4% (12/78)) and Staphylococcus aureus (15.4% (12/78)); in the provincial group were Staphylococcus aureus (19.0% (12/63)) and Pseudomonas aeruginosa (12.7% (8/63)), and in the municipal group were Streptococcus pneumoniae (40.0% (10/25)) and Enteric bacilli (16.0% (4/25)). The difference in the proportion of virus and the proportion of 3 or more initial antimicrobials used among the national,provincial and municipal group was statistically significant (27.7% (43/155) vs. 14.9% (13/87) vs. 9.1% (3/33), 22.8%(49/215) vs. 11.2%(12/107) vs. 6.5%(3/46), χ2=8.82, 10.99, both P<0.05). There was no difference in the in-hospital mortality among the 3 groups (P>0.05). Regarding the subgroups of tumor and non-tumor, the national group had higher PRISM Ⅲ (31(24, 38) vs. 22 (21, 28) vs.16 (9, 22), 24 (18, 30) vs. 17(8, 24) vs. 10 (5, 16), Z=30.34, 10.45, both P<0.001), and it was the same for the subgroups of in-hospital referral and out-patient or emergency admission (29 (21, 39) vs. 23 (17, 30) vs. 15 (10, 29), 23 (17, 29) vs. 18 (10, 24) vs. 11 (5, 16), Z=20.33, 14.25, both P<0.001) as compared to the provincial and municipal group. There was no significant difference in the in-hospital mortality among the 2 pairs of subgroups (all P>0.05). Conclusion: There are differences in the severity, location of onset, pathogen composition, and initial antibiotics of pediatric septic shock in children's hospitals of different levels, but no differences in compliance with guidelines and in-hospital survival rate.

The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock.

Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes. Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity. Twelve academic PICUs in the United States. Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration. None. Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212). This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.

Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department.

Mortality in pediatric septic shock remains unacceptably high. Delays in vasopressor administration have been associated with an increased risk of mortality. Current treatment guidelines suggest the use of a peripheral vascular line (PVL) for inotropic administration in fluid-refractory septic shock when a central vascular line is not already in place. The aim of this study was to report local adverse effects associated with inotropic drug administration through a PVL at a pediatric emergency department setting in the first hour of treatment of septic shock. A prospective, descriptive, observational cohort study of patients with septic shock requiring PVL inotropic administration was conducted at the pediatric emergency department of a tertiary care pediatric hospital. For the infusion and postplacement care of the PVL for vasoactive drugs, an institutional nursing protocol was used. We included 49 patients; 51% had an underlying disease. Eighty-four percent of the children included had a clinical "cold shock." The most frequently used vasoactive drug was epinephrine (72%). One patient presented with local complications. At our center, infusion of vasoactive drugs through a PVL was shown to be safe and allowed for adherence to the current guidelines for pediatric septic shock.

Matched Retrospective Cohort Study of Thiamine to Treat Persistent Hyperlactatemia in Pediatric Septic Shock.

Thiamine deficiency may propagate lactate production by limiting pyruvate dehydrogenase activity, and studies suggest benefit for thiamine administration in septic adults. We studied the effect of thiamine on physiologic and clinical outcomes for children with septic shock and hyperlactatemia. Retrospective matched cohort study. Single academic PICU. Six thiamine-treated cases and nine matched controls. None. The primary outcome was change in blood lactate from prethiamine (T0, cases) or maximum (T0, controls) lactate through 24 hours later (T24). Secondary outcomes were change in lactate over 48 hours (T48) and 72 hours (T72), time to lactate normalization, changes in vasoactive-inotrope score, organ dysfunction severity (daily Pediatric Logistic Organ Dysfunction 2 score), and creatinine, PICU length of stay, and hospital mortality. Lactate was greater than 5 mmol/L for a median of 39 hours (range, 16.1-64.3 hr) prior to thiamine administration for cases compared with 3.4 hours (range, 0-22.9 hr) prior to maximum lactate for controls (p = 0.002). There was no difference in median (interquartile range) change in lactate from T0 to T24 between thiamine-treated cases and controls (-9.0, -17.0 to -5.0 vs -7.2, -9.0 to -5.3 mmol/L, p = 0.78), with both groups exhibiting a rapid decrease in lactate. There were also no differences in secondary outcomes between groups. Treatment of pediatric septic shock with thiamine was followed by rapid improvement in physiologic and clinical outcomes after prolonged hyperlactatemia. Although we are not able to infer that thiamine provided benefit over usual care, the rapid decline in lactate after thiamine despite a prolonged period of hyperlactatemia raises the possibility that thiamine helped to reverse lactate production.

Improving Aseptic Technique During the Treatment of Pediatric Septic Shock

Rapid fluid resuscitation is used to treat pediatric septic shock. However, achieving fluid delivery goals while maintaining aseptic technique can be challenging. Two methods of fluid resuscitation—the commonly used push-pull technique (PPT) and a new fluid infusion technique using the LifeFlow device (410 Medical, Inc; Durham, NC)—were compared in a simulated patient model. PPT was associated with multiple aseptic technique violations related to contamination of the syringe barrel. This study confirms the risk of PPT-associated syringe contamination and suggests that this risk could be mitigated with the use of a protected syringe system, such as LifeFlow.

Treatment of Pediatric Septic Shock With the Surviving Sepsis Campaign Guidelines and PICU Patient Outcomes.

The Surviving Sepsis Campaign recommends rapid recognition and treatment of severe sepsis and septic shock. Few reports have evaluated the impact of these recommendations in pediatrics. We sought to determine if outcomes in patients who received initial care compliant with the Surviving Sepsis Campaign time goals differed from those treated more slowly. Single center retrospective cohort study. Emergency department and PICU at an academic children's hospital. Three hundred twenty-one patients treated for septic shock in the emergency department and admitted directly to the PICU. None. The exposure was receipt of emergency department care compliant with the Surviving Sepsis Campaign recommendations (delivery of IV fluids, IV antibiotics, and vasoactive infusions within 1 hr of shock recognition). The primary outcome was development of new or progressive multiple organ dysfunction syndrome. Secondary outcomes included mortality, need for mechanical ventilation or vasoactive medications, and hospital and PICU length of stay. Of the 321 children studied, 117 received Surviving Sepsis Campaign compliant care in the emergency department and 204 did not. New or progressive multiple organ dysfunction syndrome developed in nine of the patients (7.7%) who received Surviving Sepsis Campaign compliant care and 25 (12.3%) who did not (p = 0.26). There were 17 deaths; overall mortality rate was 5%. There were no significant differences between groups in any of the secondary outcomes. Although only 36% of patients met the Surviving Sepsis Campaign guideline recommendation of bundled care within 1 hour of shock recognition, 75% of patients received the recommended interventions in less than 3 hours. Treatment for pediatric septic shock in compliance with the Surviving Sepsis Campaign recommendations was not associated with better outcomes compared with children whose initial therapies in the emergency department were administered more slowly. However, all patients were treated rapidly and we report low morbidity and mortality. This underscores the importance of rapid recognition and treatment of septic shock.

Tributo ao centenário da Síndrome de Waterhouse-Friderichsen: relato de caso

The Waterhouse-Friderichsen Syndrome was first reported by Rupert Waterhouse exactly 100 years ago on March 4th, 1911. It is an acute infectious disease that generally progress to a lethal outcome despite the adoption of all available resources of an intensive therapy unit. We describe an illustrative case of meningococcal meningitis C. This report details the clinical, pathological and therapeutic features of a patient of 3 years and 4 months who had a fulminating evolution, despite adherence to updated recommendations for the treatment of pediatric septic shock. We stress the little change in clinical and pathological aspects of Waterhouse-Friderichsen Syndrome during the last 100 years, despite tremendous advances in therapy and technology of the pediatric intensive care.

A network system for the treatment of pediatric septic shock

We show the effect of a network system in the treatment of pediatric septic shock, especially for children with Waterhouse–Friderichsen syndrome. In 2003 we founded a pediatric intensive care network with 15 children's hospitals in Lower Saxony, Germany. The aims were the standardisation of clinical therapies, implementation of training programs and the installation of an emergency system in the region of lower Saxony.

Decision points in the management of pediatric septic shock

Care of the pediatric patient with septic shock demands critical appraisal of numerous clinical and laboratory findings. Many vital decision points commonly are encountered during the course of each patient's disease. The aim of this article is to discuss each major decision point in the diagnosis and treatment of pediatric septic shock encountered by the bedside physician with respect to the current medical literature. Decision points reviewed include identification of epidemiological factors; choice of antimicrobial therapy; interpretation of hemodynamic pathophysiology; decision to initiate and the interpretation of invasive monitoring; and therapies for fluid resuscitation, pharmacological support of the circulation, and immunomodulation. Copyright © 2000 by W.B. Saunders Company

Pediatric septic shock.

1. Stephen M. Schexnayder, MD* 1. 2. *Associate Professor of Pediatrics & Internal Medicine, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR. After completing this article, readers should be able to: 1. Explain how the host’s immune response may cause toxic effects during sepsis. 2. Delineate the cornerstone of resuscitation in patients who have septic shock. 3. List the factors to be considered when prescribing empiric antimicrobial therapy for septic shock. 4. Explain when referral and transport arrangements should be made for patients in septic shock. Despite major advances in vaccines in the past two decades, septic shock continues to be an important pediatric problem. It is a frequent reason for admission to a pediatric intensive care unit, and this complex problem requires prompt recognition and intervention to improve the likelihood of a good outcome. Because the clinical picture of sepsis is not unique to infectious conditions, a number of definitions have been advocated. Investigators in the field have separated the clinical spectrum of sepsis into the categories of bacteremia, systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, and multiple organ dysfunction syndrome. Clinical observations over the past two decades have led to the description of the systemic inflammatory response syndrome (SIRS) and have identified the major role that endothelium plays in the pathogenesis of this disorder. Infection is one of the major causes of SIRS, but a number of other entities, including trauma, acute respiratory distress syndrome, neoplasms, burns, and pancreatitis, also have been recognized as triggers for this complex series of pathophysiologic events. Although initially written with adult vital sign parameters, the principles behind the definitions shown in Table 1⇓ are valid, and modifications have been proposed for applying them to children. View this table: Table 1. Definitions of the Systemic Inflammatory Response Syndrome Sepsis is a recognized important cause of death, with the highest mortality rate occurring among infants. The most recent data report 5.9 deaths per 100,000 population in infants, with the fatality rate decreasing …