Background

Fluid resuscitation in sepsis is controversial. The only large randomised controlled trial (RCT) of different volume fluid bolus resuscitation in severe infection is the Fluid Expansion as Supportive Therapy (FEAST) study. FEAST was conducted in Africa, in a low resource setting, without access to intensive care; it demonstrated a lower mortality rate in children receiving restrictive fluid therapy (no bolus) compared to those given more liberal fluid therapy (20 ml/kg in the first hour). Despite these findings, the current ACCM guidance continues to recommend a liberal fluid strategy, with up to 60 ml/kg bolus fluid in the first hour of treatment.

Objectives

Review of current evidence relating to fluid resuscitation strategies in sepsis.

Methods

Literature review.

Results

Numerous observational studies support the current ACCM guidance. However, these are all before/after studies in which liberal fluid bolus therapy has formed part of a bundle of care. There have been no large scale RCTs. There have been three small RCTs of different volume resuscitation strategies in settings in which intensive care is available. These studies between them included 316 children and showed no difference in mortality between the restrictive and liberal fluid resuscitation groups. There is also emerging evidence from observational studies that fluid overload in a PICU setting is associated with poor outcomes, both in relation to length of organ support and mortality.

Conclusion

Possible strategies to limit fluid bolus resuscitation will be discussed. Non invasive haemodynamic markers of volume status and evidence based resuscitation targets should be developed to help guide treatment.

Background

We have shown that using age-adjusted admission systolic blood pressure (SBP) values (z-scores) may offer advantages in determining the associated mortality risk in a large unselected PICU population.

Objectives

We hypothesized that the SBP z-score risk profile would differ in children admitted with a primary cardiac diagnosis from the rest of the cohort.

Methods

This is a retrospective cohort study using data from 2 cardiac and 2 general PICUs from 2004-2018. We derived SBP z-scores according to the NIH Task Force definitions of normal SBP (1,2). We defined the relationship between mortality and SBP z-scores using logistic regression, adjusted for PIM-2 with the blood pressure component removed.

Results

Data from 34,745 patients were analysed (19,649 cardiac and 15,096 non-cardiac admissions). The relationship between mortality and SBP z-scores are shown in Figure 1. The relationship is U-shaped for general ICU admission, but inverse for cardiac ICU.

Conclusion

Our data show an inverse relationship between SBP z-scores and mortality in the cardiac population. The decreased risk of mortality with hypertension is potentially representative of the favourable outcome in children with good post-operative recovery of heart function. Whether manipulating blood pressure modifies the risk of death needs to be assessed in an interventional trial.

References:

(1) National Institutes of Health. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Available from:https://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf [Accessed 18/6/2018].

(2) National Institutes of Health-Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children-1987.Pediatrics. 1987. 79;1:1-25.

Background

Advanced haemodynamic monitoring is recommended in the 2017 ACCM sepsis guidelines. " For patients with persistent shock...a more accurate measurement of CO may be warranted... pulmonary artery, PiCCO, femoral artery or thermodilution catheters and/or CO estimated by Doppler ultrasound...."; and that haemodynamic support should be "directed to goals of ScvO₂ greater than 70% and cardiac index 3.3–6.0 L/min/m²”.

Objectives

This presentation asks the question - "what is the evidence for these recommendations?"

Methods

Literature review.

Results

There has only been one paediatric RCT of early goal directed therapy (EGDT), which included targeting ScvO₂ > 70%. This was conducted in a single centre in Brazil and showed a significant reduction in mortality. However, three recent large mulitcentre trials of EGDT in adults showed no benefit - consequently EGDT is no longer recommended in the adult sepsis guidelines. There is no trial data to support any specific CO target in children. A recent observational study in paediatric ED showed lactate clearance was associated with decreased organ dysfunction at 48 hours; and in adults, 6 randomized controlled trials evaluating lactate-guided resuscitation of patients with septic shock showed significant reduction in mortality compared to resuscitation without lactate monitoring. A recent single centre RCT of echocardiography guided resuscitation in children showed improvements in both shock reversal and shock reversal time.

Conclusion

There is no convincing trial data to support the use of EGDT or specific ScvO₂ or CO targets in children with septic shock. Lactate clearance and echocardiography guided resuscitation are promising and require further evaluation and clinical trials.

Background

Mortality is modelled as a quadratic function of systolic blood pressure (SBP) at admission to PICU in the Paediatric Index of Mortality score (PIM). The lowest risk of mortality is at 120 mmHg, regardless of age (1). As most children on PICU, are under 2 years of age, this is the >99^th centile.

Objectives

We sought to define the association between age-corrected SBP z-scores and mortality in critically ill children.

Methods

In this retrospective cohort study, we gathered SBP values on admission to four paediatric intensive care units (2 cardiac and 2 general) in 34,745 children from 2004-2018. We derived SBP z-scores according to the NIH Task Force definitions of normal SBP. We defined the relationship between mortality and SBP z-scores using logistic regression, adjusted for PIM-2 with the blood pressure component removed.

Results

The relationship in our cohort showed a U-shaped curve with a nadir at SBP between 111-120, or 2.25<=z<2.75 (Fig.1), though mortality was found to be relatively invariant over a wide range of SBP values (increasing only from bands 1.25<=z<1.75 and >=3.25) with narrow confidence intervals.

Conclusion

Our data support the value of using SBP z-scores rather than absolute values in children. Prospective trials examining the impact of different blood pressure targets on mortality in critically ill children are needed.

References:

(1) Shann F, Pearson G, Slater A, Wilkinson k. Paediatric index of mortality (PIM): a mortality prediction model for children in intensive care. ICM. 1997. 23:201-207.

Background

Fluid resuscitation in sepsis is controversial. The only large randomised controlled trial (RCT) of different volume fluid bolus resuscitation in severe infection is the Fluid Expansion as Supportive Therapy (FEAST) study. FEAST was conducted in Africa, in a low resource setting, without access to intensive care; it demonstrated a lower mortality rate in children receiving restrictive fluid therapy (no bolus) compared to those given more liberal fluid therapy (20 ml/kg in the first hour). Despite these findings, the current ACCM guidance continues to recommend a liberal fluid strategy, with up to 60 ml/kg bolus fluid in the first hour of treatment.

Objectives

Review of current evidence relating to fluid resuscitation strategies in sepsis.

Methods

Literature review.

Results

Numerous observational studies support the current ACCM guidance. However, these are all before/after studies in which liberal fluid bolus therapy has formed part of a bundle of care. There have been no large scale RCTs. There have been three small RCTs of different volume resuscitation strategies in settings in which intensive care is available. These studies between them included 316 children and showed no difference in mortality between the restrictive and liberal fluid resuscitation groups. There is also emerging evidence from observational studies that fluid overload in a PICU setting is associated with poor outcomes, both in relation to length of organ support and mortality.

Conclusion

Possible strategies to limit fluid bolus resuscitation will be discussed. Non invasive haemodynamic markers of volume status and evidence based resuscitation targets should be developed to help guide treatment.

Background

Advanced haemodynamic monitoring is recommended in the 2017 ACCM sepsis guidelines. " For patients with persistent shock...a more accurate measurement of CO may be warranted... pulmonary artery, PiCCO, femoral artery or thermodilution catheters and/or CO estimated by Doppler ultrasound...."; and that haemodynamic support should be "directed to goals of ScvO₂ greater than 70% and cardiac index 3.3–6.0 L/min/m²”.

Objectives

This presentation asks the question - "what is the evidence for these recommendations?"

Methods

Literature review.

Results

There has only been one paediatric RCT of early goal directed therapy (EGDT), which included targeting ScvO₂ > 70%. This was conducted in a single centre in Brazil and showed a significant reduction in mortality. However, three recent large mulitcentre trials of EGDT in adults showed no benefit - consequently EGDT is no longer recommended in the adult sepsis guidelines. There is no trial data to support any specific CO target in children. A recent observational study in paediatric ED showed lactate clearance was associated with decreased organ dysfunction at 48 hours; and in adults, 6 randomized controlled trials evaluating lactate-guided resuscitation of patients with septic shock showed significant reduction in mortality compared to resuscitation without lactate monitoring. A recent single centre RCT of echocardiography guided resuscitation in children showed improvements in both shock reversal and shock reversal time.

Conclusion

There is no convincing trial data to support the use of EGDT or specific ScvO₂ or CO targets in children with septic shock. Lactate clearance and echocardiography guided resuscitation are promising and require further evaluation and clinical trials.