The American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock: Executive Summary

Davis, Alan L.; Carcillo, Joseph A.; Aneja, Rajesh K.; Deymann, Andreas J.; Lin, John C.; Nguyen, Trung C.; Okhuysen-Cawley, Regina; Relvas, Monica S.; Rozenfeld, Ranna A.; Skippen, Peter; Stojadinovic, Bonnie J.; Williams, Eric A.; Yeh, Tim S.; Balamuth, Fran; Brierley, Joe; Caen, Allan R. de; Cheifetz, Ira M.; Choong, Karen; Conway, Edward E.; Cornell, Timothy T.; Doctor, Allan; Dugas, M; Feldman, Jonathan D.; Fitzgerald, Julie C.; Flori, Heidi R.; Fortenberry, James D.; Graciano, Ana Lía; Greenwald, Bruce M.; Hall, Mark W.; Han, Yong; Hernan, Lynn J.; Irazuzta, José; Iselin, Elizabeth; Jagt, Élise W. van der; Jeffries, Howard E.; Kache, Saraswati; Katyal, Chhavi; Kissoon, Niranjan; Kon, Alexander A.; Kutko, Martha C.; MacLaren, Graeme; Maul, Timothy M.; Mehta, Renuka; Odetola, Fola; Parbuoni, Kristine A.; Paul, Raina; Peters, Mark; Ranjit, Suchitra; Reuter‐Rice, Karin; Schnitzler, Eduardo; Scott, Halden F.; Torres, Adalberto; Weingarten-Abrams, Jacki; Weiss, Scott L.; Zimmerman, Jerry J.; Zuckerberg, Aaron L.

doi:10.1097/pcc.0000000000001259

Cited by 177 publications

(298 citation statements)

References 210 publications

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“…Systemic inflammatory response syndrome (SIRS) was manifested by most children with HPeV, yet it did not translate into increased mortality consistent with recent studies validating sepsis definitions . Importantly, sepsis guidelines recommend the use of tachycardia as a trigger for sepsis management . Three out of four cases in our study received resuscitation fluid bolus therapy >40 mL/kg, consistent with other reports .…”

Section: Discussionsupporting

confidence: 87%

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Paediatric intensive care admissions during the 2015–2016 Queensland human parechovirus outbreak

McKenna

Joseph

Sargent

et al. 2019

J Paediatrics Child Health

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Aim: The human parechovirus (HPeV) has emerged as a pathogen causing sepsis-like presentations in young infants, but there is a lack of data on HPeV presentations requiring intensive care support. We aimed to characterise the clinical presentation, disease severity, management and outcome of a population-based cohort of children with microbiologically confirmed HPeV infection requiring admission to paediatric intensive care units (PICUs) in Queensland, Australia during a recent outbreak. Methods: This was a multicentre retrospective study of children admitted to PICU between 1 January 2015 and 31 December 2016 with confirmed HPeV infection. Results: Thirty infants (median age 20 days) with HPeV genotype 3 were admitted to PICU, representing 16% of all children with HPeV admitted to hospital and 6.4% of non-elective PICU admissions in children <1 year of age. Children requiring PICU admission were younger than children admitted to hospital (P = 0.001). Apnoea, haemodynamic instability with tachycardia and seizures represented the main reasons for PICU admission. Eleven children (37%) required mechanical ventilation for a median duration of 62 h, 22 (73%) received fluid boluses and 7 (23%) were treated with vasoactive agents for a median duration of 53 h. Median length of stay was 2.62 days. A total of 24 children (80%) fulfilled sepsis criteria, 14 (47%) severe sepsis and 7 (23%) septic shock criteria. Eight (27%) had abnormal brain magnetic resonance imaging. No patient died. Conclusions: We confirm that HPeV infection is an important cause of sepsis-like syndrome in infants with substantial associated morbidity. Optimal management and long-term outcomes require further investigation.

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Section: Discussionsupporting

confidence: 87%

“…Vasoactive‐Inotrope Score (VIS), a clinical score tool used to quantify the need for cardiovascular support based on the doses of vasoactive infusions, was calculated as per Gaies et al . Tachycardia was defined as a heart rate >160 beats per minute in infants …”

Section: Methodsmentioning

confidence: 99%

Paediatric intensive care admissions during the 2015–2016 Queensland human parechovirus outbreak

McKenna

Joseph

Sargent

et al. 2019

J Paediatrics Child Health

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“…Although there is debate about the appropriate volume and rate of fluid administration in children with septic shock, crystalloid fluid resuscitation is recommended as a critical, early intervention to address hypovolemia . Most fluid resuscitation of children with septic shock occurs within the initial hours after sepsis recognition.…”

Section: Discussionmentioning

confidence: 99%

“…All patients >6 months and <18 years of age with suspected septic shock treated in the ED were eligible for enrollment. Suspected septic shock was defined by clinician decision to treat suspected bacterial infection with parenteral antibiotics, collection of a blood culture, and intent to administer at least two fluid boluses for abnormal perfusion (defined as the treating clinician's determination that either hypotension or flash/delayed capillary refill was present) . Enrollment was open at all times during the 6‐month study period.…”

Section: Methodsmentioning

confidence: 99%

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Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study

Balamuth

Kittick

McBride

et al. 2019

Academic Emergency Medicine

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Background: Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment. However, the optimal type of crystalloid fluid is unknown. We aimed to determine the feasibility of conducting a pragmatic randomized trial to compare balanced (lactated Ringer's [LR]) with 0.9% normal saline (NS) fluid resuscitation in children with suspected septic shock.Methods: Open-label pragmatic randomized controlled trial at a single academic children's hospital from January to August 2018. Eligible patients were >6 months to <18 years old who were treated in the emergency department for suspected septic shock, operationalized as blood culture, parenteral antibiotics, and fluid resuscitation for abnormal perfusion. Screening, enrollment, and randomization were carried out by the clinical team as part of routine care. Patients were randomized to receive either LR or NS for up to 48 hours following randomization. Other than fluid type, all treatment decisions were at the clinical team's discretion. Feasibility outcomes included proportion of eligible patients enrolled, acceptability of enrollment via the U.S. federal exception from informed consent (EFIC) regulations, and adherence to randomized study fluid administration.Results: Of 59 eligible patients, 50 (85%) were enrolled and randomized. Twenty-four were randomized to LR and 26 to NS. Only one (2%) of 44 patients enrolled using EFIC withdrew before study completion. Total median (interquartile range [IQR]) crystalloid fluid volume received during the intervention window was 107 (60 to 155) mL/ kg and 98 (63 to 128) mL/kg in the LR and NS arms, respectively (p = 0.50). Patients randomized to LR received a median (IQR) of only 20% (13 to 32) of all study fluid as NS compared to 99% (64% to 100%) of study fluid as NS in the NS arm (absolute difference = 79%, 95% CI = 48% to 85%).C onclusions: A pragmatic study design proved feasible to study comparative effectiveness of LR versus NS fluid resuscitation for pediatric septic shock.From the

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Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis

Lane,

Richardson,

Scott

et al. 2024

JAMA Netw Open

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ImportancePediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes.ObjectiveTo determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis.Design, Setting, and ParticipantsThis retrospective cohort study used data from 51 US children’s hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024.ExposureThe number of minutes from emergency department arrival to antibiotic administration.Main Outcomes and MeasuresThe primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome.ResultsA total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes.Conclusions and RelevanceIn this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.

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The American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock: Executive Summary

Abstract: Background: The American College of Critical Care Medicine (ACCM) provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock.

Cited by 177 publications

References 210 publications

Paediatric intensive care admissions during the 2015–2016 Queensland human parechovirus outbreak

Paediatric intensive care admissions during the 2015–2016 Queensland human parechovirus outbreak

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study

Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis

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