ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation
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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.
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.
Twenty-eight-day mortality was the primary endpoint.
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.
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.
KeywordsChild Sepsis Resuscitation Central venous oxygen saturation Cardiac output Goal-directed therapy
We are indebted to the nursing and medical staff of the intensive care units; to Professor Claudio Leone, for statistical advice; and to Dr. Crésio Romeu Pereira, for assistance with study design.
- 1.DuPont HL, Spink WW (1968) Infectious due to gram negative organisms: an analysis of 860 patients with bacteremia at University of Minnesota Medical Center, 1958–1966. Medicine (Baltimore) 48:307–311Google Scholar
- 20.Oliveira CF, Troster E, Oliveira DSF, Gottschald A, Moura J, Costa G, Vaz F, Carcillo JA, Rivers E (2007) An outcomes comparison of ACCM/PALS guidelines for paediatric septic shock with and without central venous oxygen saturation monitoring. Pediatr Crit Care Med 8:A237–A238Google Scholar
- 21.Carcillo JA, Hazelzet JA (2005) Sepsis and multiple organ system failure in children. In: Fink MP, Abraham E, Vincent JL, Kochanek PM (eds) Textbook of critical care. Elsevier Saunders, Philadelphia, pp 1267–1273Google Scholar
- 22.Oliveira CF, Troster EJ, Vaz FAC (2005) Description of technique for continuous monitoring of central venous oxygen saturation in infants and children with septic shock. Case reports. Revista Brasileira Terapia Intensiva 17:305–308Google Scholar