Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock

Abstract

Objective: The aim of this study was to measure the effects of a bundle of interventions in children admitted with severe sepsis or septic shock in the first hour after diagnosis on mortality. Materials and methods: A retrospective study was conducted at a pediatric intensive care unit (PICU) between January 2014 and January 2016. Three interventions (intravenous [IV] antibiotic, fluid boluses, and vasopressor administration) applied in the first hour of severe sepsis or septic shock diagnosis were analyzed according to their adherence rates. The main outcome was mortality. Odds ratios were calculated. Results: Of a total of 530 PICU admissions, 105 patients met the criteria for sepsis, 53 (50.5%) with severe sepsis and 52 (49.5%) with septic shock. Seventy-two (68.6%) patients received IV antibiotic within the first hour, 65 (61.9%) received IV fluid bolus, and 55 (53.3%) received a vasopressor drug. Fifty-two (49.5%) patients received concomitant IV antibiotics and fluid bolus. Blood cultures were collected before IV antibiotic administration in 87 (82.9%) out of 105 patients. Thirteen (12.4%) patients died, 1 with severe sepsis and 12 with septic shock. In a univariate analysis, the odds ratios for death and IV antibiotic were 6.39 (p value = 0.081, 95% CI = 0.795-51.465), 4.77 for fluid bolus between 21 and 40 mL/kg (p value = 0.013, 95% CI = 1.395-16.336), and 3.23 for vasopressor administration (p value < 0.0001, 95% CI = 1.734-6.018). In a multivariate analysis, the odds ratio of fluid bolus between 21 and 40 mL/kg was 42.66 (p value = 0.005, 95% CI = 3.117-583.841) and noradrenaline use was 23.93 (p value = 0.010, 95% CI = 2.124-269.750). Conclusion: Adherence was observed for more than half of the single interventions as IV antibiotic, fluid resuscitation, and vasopressor administration in the first hour. The antibiotic administration alone was not associated with high mortality. Vasopressor administration was related to higher mortality but moderate fluid bolus was a protective factor associated with lower mortality.

Epidemiology of paediatric severe sepsis and septic shock in Turkey: Prevalence, results and treatments study

“…In our study, treatment with antibiotics were initiated in 98.8% of patients with septic shock and severe sepsis. In another study reported that antibiotics were initiated in 68.6% of patients with severe sepsis and septic shock 23 . The mortality rate was found to be lower in patients who started antibiotics early compared to those who started late (septic shock: 22% vs. 34%, severe sepsis: 10% vs. 15%) 24 .…”

Lebensrettende Maßnahmen bei Kindern (Paediatric Life Support, PLS)

“…Es wurden 2 Leitlinien [ 24 , 29 ] und 10 Beobachtungsstudien zu diesem Thema identifiziert (Anhang RR 8.2; [ 320 , 329 – 337 ]). Antibiotika sind ein notwendiger Bestandteil der Sepsistherapie und in internationalen Leitlinien wird die frühe Gabe (in der ersten Stunde) von Breitbandantibiotika empirisch empfohlen.…”

“…Während viele verschiedene Beobachtungsstudien einen positiven Einfluss auf das Outcome der Implementierung dieses Therapiebündels zeigten, war dieser Effekt in anderen Studien weitaus geringer [317,[320][321][322][323][324][325][326][327][328]. Gründe für solche Unterschiede sind nicht immer leicht zu identifizieren, können jedoch mit Selektionsbias, Unterschieden in den Implementierungsstrategien oder Unterschieden in der Handhabung der Kontrollpopulationen zusammenhängen.…”

Management of Neonatal Hypotension and Shock

“…In a recent retrospective study in older children, moderate fluid administration, compared to larger volumes, was found to be associated with improved survival [31]. The Fluid Expansion as Supportive Therapy (FEAST) study showed increased mortality in pediatric participants in receipt of 40 mL/kg of volume (either saline or albumin) compared to those who did not receive a bolus [32].…”