Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis*

Abstract

Objective To determine whether treatment with a protocolized sepsis guideline in the emergency department (ED) was associated with a lower burden of organ dysfunction (OD) by hospital day 2 compared to non-protocolized usual care in pediatric patients with severe sepsis. Design Retrospective cohort study Setting Tertiary care children’s hospital from January 1, 2012–March 31, 2014. Measurements and Main Results Subjects with international consensus defined severe sepsis and pediatric intensive care unit (PICU) admission within 24 hours of ED arrival were included. The exposure was the use of a protocolized ED sepsis guideline. The primary outcome was complete resolution of OD by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized ED guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, ED triage level, or OD on arrival to the ED. Patients treated with protocolized ED care were more likely to be free of OD on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, PIM-2 score, and timing of antibiotics and intravenous fluids (adjusted OR 4.2, 95% CI 1.7, 10.4). Conclusions Use of a protocolized ED sepsis guideline was independently associated with resolution of OD by hospital day 2 compared to non-protocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

“…In a recent single-institution study, bundle-compliant care in 1380 children with septic shock was associated with a five-times lower mortality (OR, 0.20; 95% CI, 0.07-0.53) [33]. In another study, implementation of a sepsis protocol led to a substantial increase in the proportion of children who no longer had organ dysfunction on day 2 after presentation (adjusted OR, 4.2; 95% CI, 1.7-10.4) [34]. However, it should be noted that protocols studied to date have variable components, many studies do not report adherence to specific items within protocols, and only a few studies have attempted to adjust for initial illness severity or other patient factors, making it difficult to summarize studies using the GRADE approach.…”

“…Several studies demonstrating that institutional sepsis QI efforts improve outcomes have successfully incorporated screening tools [31][32][33][34][35][36][37]. Most reported sepsis screens were designed to prompt clinicians to prioritize review of patients that had triggered the screen, hence the ultimate decision to treat or not remains with the clinician.…”

“…However, in our practice, 77% of panel members reported at least sometimes using inodilators in children with septic shock who had evidence of persistent hypoperfusion and cardiac dysfunction despite other vasoactive S32 agents, typically in a PICU with advanced hemodynamic monitoring available. Ventilation 34. We were unable to issue a recommendation about whether to intubate children with fluid-refractory, catecholamine-resistant septic shock.…”

Recomendaciones para el manejo del shock séptico en niños durante la primera hora (primera parte)

“…En establecimientos de alta complejidad, el insuficiente aporte de fluidos puede resultar en una mayor mortalidad y un mayor tiempo de estadía hospitalaria de niños con sepsis. 21,[24][25][26][27] Sin embargo, en aquellos con baja complejidad (sin asistencia respiratoria, bombas de infusión o posibilidad de monitoreo hemodinámico), los resultados pueden ser diferentes. El uso de fluidos en niños con dengue en la primera hora demostró 100 % de supervivencia; sin embargo, en niños con malaria o anemia grave, esto podría ser deletéreo.…”

“…Probablemente, debido al incumplimiento de conceptos actuales sobre la gestión de procesos sin involucrar a quienes tomaban las decisiones al lado del paciente. [24][25][26][27] Así, surge la necesidad de cambio del paradigma de GPC universalmente aplicable, sin importar el contexto y dirigida a decisiones individuales. La nueva propuesta es un abordaje basado en los procesos institucionales de cada centro con la participación de todos los intervinientes en la atención.…”