, Volume 34, Issue 6, pp 1065-1075
Date: 28 Mar 2008

ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation

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Abstract

Introduction

The ACCM/PALS guidelines address early correction of paediatric septic shock using conventional measures. In the evolution of these recommendations, indirect measures of the balance between systemic oxygen delivery and demands using central venous or superior vena cava oxygen saturation (ScvO2 ≥ 70%) in a goal-directed approach have been added. However, while these additional goal-directed endpoints are based on evidence-based adult studies, the extrapolation to the paediatric patient remains unvalidated.

Objective

The purpose of this study was to compare treatment according to ACCM/PALS guidelines, performed with and without ScvO2 goal-directed therapy, on the morbidity and mortality rate of children with severe sepsis and septic shock.

Design, participants and interventions

Children and adolescents with severe sepsis or fluid-refractory septic shock were randomly assigned to ACCM/PALS with or without ScvO2 goal-directed resuscitation.

Measurements

Twenty-eight-day mortality was the primary endpoint.

Results

Of the 102 enrolled patients, 51 received ACCM/PALS with ScvO2 goal-directed therapy and 51 received ACCM/PALS without ScvO2 goal-directed therapy. ScvO2 goal-directed therapy resulted in less mortality (28-day mortality 11.8% vs. 39.2%, p = 0.002), and fewer new organ dysfunctions (p = 0.03). ScvO2 goal-directed therapy resulted in more crystalloid (28 (20–40) vs. 5 (0–20) ml/kg, p < 0.0001), blood transfusion (45.1% vs. 15.7%, p = 0.002) and inotropic (29.4% vs. 7.8%, p = 0.01) support in the first 6 h.

Conclusions

This study supports the current ACCM/PALS guidelines. Goal-directed therapy using the endpoint of a ScvO2 ≥ 70% has a significant and additive impact on the outcome of children and adolescents with septic shock.

This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-008-1086-8.
Trial registration: ClinicalTrials.gov identifier NCT00407823.
Conflicts of interest: In the past year, Dr. Rivers received research support from the National Institutes of Health, Hutchinson Technologies, Biosite Inc. and Edwards Lifesciences. Dr. Carcillo received funding from the National Institute of Health. The remaining authors have no conflict of interests to disclose.
Support: Supported by FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo – The State of São Paulo Research Foundation) and Edwards Lifesciences. FAPESP financed the acquisition of ScvO2 catheters, and Edwards Lifesciences provided ScvO2 monitors. Design and conduct of the study, collection, management, analysis and interpretation of the data, and preparation, review and approval of the manuscript, were done independently by the authors, who are not governed by the funding sponsors.