Skip to main content

Advertisement

SpringerLink
Log in

‘Intermittent’ versus ‘continuous’ ScvO2 monitoring in children with septic shock: a randomised, non-inferiority trial

  • Pediatric Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Purpose

To compare the effect of ‘intermittent’ central venous oxygen saturation (ScvO2) monitoring with ‘continuous’ ScvO2 monitoring on shock resolution and mortality in children with septic shock.

Methods

Primary outcome was the achievement of therapeutic goals or shock resolution in the first 6 h. We randomly assigned children < 17 years’ age with septic shock to ‘intermittent ScvO2’ or ‘continuous ScvO2’ groups. All children were subjected to subclavian/internal jugular line insertion and managed as per Surviving Sepsis Campaign Guidelines. To guide resuscitation, we used ScvO2 estimated at other clinical and laboratory parameters were monitored similarly in both groups.

Results

We enrolled 75 and 77 children [median (IQR) age: 6 (1.5–10) years] in the ‘intermittent’ and ‘continuous’ groups, respectively. Baseline characteristics were comparable between the groups. When compared to the ‘continuous’ group, fewer children in the ‘intermittent’ group achieved shock resolution within first 6 h [19% vs. 36%; relative risk (RR) 0.51; 95% CI 0.29–0.89; risk difference − 18.0%; 95% CI − 32.0 to − 4.0]. The lower bound of confidence interval, however, crossed the pre-specified non-inferiority margin. There was no difference in the proportion of children attaining shock resolution within 24 h (63% vs. 69%; RR 0.86; 95% CI 0.68–1.08) or risk of mortality between the groups (47% vs. 43%; RR 1.06; 95% CI 0.74–1.51).

Conclusions

Given that a greater proportion of children attained therapeutic end points in the first 6 h, continuous monitoring of ScvO2 should preferably be used to titrate therapy in the first few hours in children with septic shock. In the absence of such facility, intermittent monitoring of ScvO2 can be used to titrate therapy in these children, given the lack of difference in the proportion of patients achieving shock resolution at 24 h or in risk of mortality between the intermittent and continuous groups.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Jaramillo-Bustamante JC, Marín-Agudelo A, Fernández-Laverde M, Bareño-Silva J (2012) Epidemiology of sepsis in pediatric intensive care units: first Colombian multicenter study. Pediatr Crit Care Med 13:501–508

    Article  Google Scholar 

  2. Sankar J, Dhochak N, Kumar K, Singh M, Sankar MJ, Lodha R (2019) Comparison of international pediatric sepsis consensus conference versus sepsis-3 definitions for children presenting with septic shock to a tertiary care center in India: a retrospective study. Pediatr Crit Care Med 20:e122–e129

    Article  Google Scholar 

  3. Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS (2013) Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med 14:686–693

    Article  Google Scholar 

  4. Weiss SL, Fitzgerald JC, Pappachan J et al (2017) Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resource Evaluation (CORE) and Australian and New Zealand Intensive Care Society (ANZICS) Paediatric Study Group. Prediction of pediatric sepsis mortality within 1 h of intensive care admission. Prediction of pediatric sepsis mortality within 1 h of intensive care admission. Intensiv Care Med 43:1085–1096

    Article  Google Scholar 

  5. Wiens MO, Larson CP, Kumbakumba E et al (2016) Application of Sepsis definitions to pediatric patients admitted with suspected infections in uganda. Pediatr Crit Care Med 17:400–405

    Article  Google Scholar 

  6. Rivers E, Nguyen B, Havstad S et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377

    Article  CAS  Google Scholar 

  7. Focht A, Jones AE, Lowe TJ (2009) Early goal-directed therapy: improving mortality and morbidity of sepsis in the emergency department. Jt Comm J Qual Patient Saf 35:186–191

    Article  Google Scholar 

  8. Chelkeba L, Ahmadi A, Abdollahi M, Najafi A, Mojtahedzadeh M (2015) Early goal-directed therapy reduces mortality in adult patients with severe sepsis and septic shock: systematic review and meta-analysis. Indian J Crit Care Med 19:401–411

    Article  Google Scholar 

  9. Davis AL, Carcillo JA, Aneja RK et al (2017) American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 45:1061–1093

    Article  Google Scholar 

  10. Liu B, Ding X, Yang J (2016) Effect of early goal directed therapy in the treatment of severe sepsis and/or septic shock. Curr Med Res Opin 32:1773–1782

    Article  CAS  Google Scholar 

  11. ARISE Investigators; ANZICS Clinical Trials Group (2014) Goal-directed resuscitation for patients with early septic shock. N Engl J Med 371:1496–1506

    Article  Google Scholar 

  12. Investigators ProCESS, Yealy DM, Kellum JA, Huang DT et al (2014) A randomized trial of protocol-based care for early septic shock. N Engl J Med 370:1683–1693

    Article  Google Scholar 

  13. Mouncey PR, Osborn TM, Power GS, ProMISe Trial Investigators et al (2015) Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 372:1301–1311

    Article  CAS  Google Scholar 

  14. de Oliveira CF, de Oliveira DS, Gottschald AF et al (2008) ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation. Intensiv Care Med 34:1065–1075

    Article  Google Scholar 

  15. Sankar J, Sankar MJ, Suresh CP, Sankar MJ, Dubey N (2014) Early goal-directed therapy in pediatric septic shock: comparison of outcomes “with” and “without” intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study. Pediatr Crit Care Med 15:e157–e167

    Article  Google Scholar 

  16. Gross PA (2006) Hypotension and mortality in septic shock: the “golden hour”. Crit Care Med 34:1819–1820

    Article  Google Scholar 

  17. Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME, Orr RA (2003) Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 112:793–799

    Article  Google Scholar 

  18. Huh JW, Oh BJ, Lim CM, Hong SB, Koh Y (2013) Comparison of clinical outcomes between intermittent and continuous monitoring of central venous oxygen saturation (ScvO2) in patients with severe sepsis and septic shock: a pilot study. Emerg Med J 30:906–909

    Article  Google Scholar 

  19. Paula IRN, Timothy WS, Steven QS (2009) Effect of intermittent vs continuous scvo2 monitoring on sepsis bundle compliance and mortality. October 2009, Vol 136, No. 4 MeetingAbstracts

  20. Goldstein B, Giroir B, Randolph A (2005) International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensiv Crit Care Soc 6: 2–8

  21. Haque IU, Zaritsky AL (2007) Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatr Crit Care Med 8:138–144

    Article  Google Scholar 

  22. Dellinger RP, Levy MM, Rhodes A et al (2012) Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensiv Care Med 39:165–228

    Article  Google Scholar 

  23. Carcillo JA, Fields A (2002) Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. J Pediatr (Rio J) 78:449–466

    Article  Google Scholar 

  24. Pediatric Advanced Life Support Provider Manual, Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds) (2012) American Heart Association, Dallas

  25. Perner A, Haase N, Wiis J, White JO, Delaney A (2010) Central venous oxygen saturation for the diagnosis of low cardiac output in septic shock patients. Acta Anaesthesiol Scand 54:98–102

    Article  CAS  Google Scholar 

  26. Walley KR (2011) Use of central venous oxygen saturation to guide therapy. Am J Respir Crit Care Med 184:514–520

    Article  Google Scholar 

  27. Ding XF, Yang ZY, Xu ZT et al (2018) Early goal-directed and lactate-guided therapy in adult patients with severe sepsis and septic shock: a meta-analysis of randomized controlled trials. J Transl Med 16:331

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We would like to sincerely thank the contributions of Dr Vijay and the staff of the PICU towards the conduct of the trial.

Funding

The authors received Intramural Research Grant (No.F. 8-335/A-335/2-15/RS) from All India Institute of Medical Sciences for this project (~ 7000 USD).

Author information

Authors and Affiliations

  1. Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

    Jhuma Sankar, Man Singh, Kiran Kumar, M. Jeeva Sankar, Sushil Kumar Kabra & Rakesh Lodha

Authors
  1. Jhuma Sankar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Man Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kiran Kumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. M. Jeeva Sankar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sushil Kumar Kabra
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rakesh Lodha
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jhuma Sankar.

Ethics declarations

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sankar, J., Singh, M., Kumar, K. et al. ‘Intermittent’ versus ‘continuous’ ScvO2 monitoring in children with septic shock: a randomised, non-inferiority trial. Intensive Care Med 46, 82–92 (2020). https://doi.org/10.1007/s00134-019-05858-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-019-05858-w

Keywords

Search

Navigation