Intensive Care Medicine

, Volume 34, Issue 6, pp 1065–1075 | Cite as

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

  • Cláudio F. de OliveiraEmail author
  • Débora S. F. de Oliveira
  • Adriana F. C. Gottschald
  • Juliana D. G. Moura
  • Graziela A. Costa
  • Andréa C. Ventura
  • José Carlos Fernandes
  • Flávio A. C. Vaz
  • Joseph A. Carcillo
  • Emanuel P. Rivers
  • Eduardo J. Troster
Pediatric Original



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.


Child 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. 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
  2. 2.
    Pollack MM, Fields AI, Ruttimann UE (1985) Distributions of cardiopulmonary variables in paediatric survivors and nonsurvivors of septic shock. Crit Care Med 13:454–459PubMedCrossRefGoogle Scholar
  3. 3.
    Carcillo JA, Davis AL, Zaritsky A (1991) Role of early fluid resuscitation in paediatric septic shock. JAMA 266:1242–1245PubMedCrossRefGoogle Scholar
  4. 4.
    Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC (2003) The epidemiology of severe sepsis in the United States. Am J Respir Crit Care Med 167:695–703PubMedCrossRefGoogle Scholar
  5. 5.
    Pollard AJ, Britto J, Nadel S, DeMunter C, Habibi P, Levin M (1999) Emergency management of meningococcal disease. Arch Dis Child 80:290–296PubMedCrossRefGoogle Scholar
  6. 6.
    Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29:1303–1310PubMedCrossRefGoogle Scholar
  7. 7.
    Kutko MC, Calarco MP, Flaherty MB, Helmrich RF, Ushay HM, Pon S, Greenwald BM (2003) Mortality rates in paediatric septic shock with and without multiple organ system failure. Pediatr Crit Care Med 4:333–337PubMedCrossRefGoogle Scholar
  8. 8.
    Khilnani P, Sarma D, Zimmerman J (2006) Epidemiology and peculiarities of pediatric multiple organ dysfunction syndrome in New Delhi, India. Intensive Care Med 32:1856–1862PubMedCrossRefGoogle Scholar
  9. 9.
    Sarthi M, Lodha R, Vivekanandhan S, Arora NK (2007) Adrenal status in children with septic shock using low-dose stimulation test. Pediatr Crit Care Med 8:23–28PubMedCrossRefGoogle Scholar
  10. 10.
    Chang P, Hsu HY, Chang MH, Lin FY (1999) Shock in the paediatric emergency service: five years' experience. Acta Paediatr Taiwan 40:9–12PubMedGoogle Scholar
  11. 11.
    Branco RG, Garcia PC, Piva JP, Casartelli CH, Seibel V, Tasker RC (2005) Glucose level and risk of mortality in paediatric septic shock. Pediatr Crit Care Med 6:470–472PubMedCrossRefGoogle Scholar
  12. 12.
    Wilkinson JD, Pollack M, Glass NL, Kanter RK, Katz RW, Steinhart CM (1987) Mortality associated with multiple organ system failure and sepsis in paediatric intensive care unit. J Pediatr 111:324–328PubMedCrossRefGoogle Scholar
  13. 13.
    Proulx F, Fayon M, Farrell CA, Lacroix J, Gauthier M (1996) Epidemiology of sepsis and multiple organ dysfunction syndrome in children. Chest 109:1033–1037PubMedCrossRefGoogle Scholar
  14. 14.
    Plotz FB, Hulst HE, Twisk JW, Bökenkamp A, Markhorst DG, van Wijk JA (2005) Effect of acute renal failure on outcome in children with severe septic shock. Pediatr Nephrol 20:1177–1181PubMedCrossRefGoogle Scholar
  15. 15.
    Pancera CF, Costa CM, Hayashi M, Lamelas RG, Camargo B (2004) Severe sepsis and septic shock in children with cancer. Rev Assoc Med Bras 50:439–443PubMedCrossRefGoogle Scholar
  16. 16.
    Booy R, Habibi P, Nadel S, de Munter C, Britto J, Morrison A, Levin M, Meningococcal Research Group (2001) Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery. Arch Dis Child 85:386–390PubMedCrossRefGoogle Scholar
  17. 17.
    Carcillo JA, Fields AI, American College of Critical Care Medicine Task Force Committee Members (2002) Clinical practice parameters for hemodynamic support of paediatric and neonatal patients in septic shock. Crit Care Med 30:1365–1378PubMedCrossRefGoogle Scholar
  18. 18.
    Ceneviva G, Paschall JA, Maffei F, Carcillo JA (1998) Hemodynamic support in fluid-refractory paediatric septic shock. Paediatrics 102:1–6CrossRefGoogle Scholar
  19. 19.
    Pizarro CF, Troster EJ, Damiani D, Carcillo JA (2005) Absolute and relative adrenal insufficiency in children with septic shock. Crit Care Med 33:855–859PubMedCrossRefGoogle Scholar
  20. 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. 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. 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
  23. 23.
    Wilkinson JD, Pollack MM, Ruttimann UE, Glass NL, Yeh TS (1986) Outcome of paediatric patients with multiple organ system failure. Crit Care Med 14:271–274PubMedCrossRefGoogle Scholar
  24. 24.
    Wilkinson JD, Pollack MM, Glass NL, Kanter RK, Katz RW, Steinhart CM (1987) Mortality associated with multiple organ system failure and sepsis in paediatric intensive care unit. J Pediatr 111:324–328PubMedCrossRefGoogle Scholar
  25. 25.
    Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME, Orr RA (2003) Early reversal of paediatric-neonatal septic shock by community physicians is associated with improved outcome. Paediatrics 112:793–799CrossRefGoogle Scholar
  26. 26.
    Ninis N, Phillips C, Bailey L, Pollock JI, Nadel S, Britto J, Maconochie I, Winrow A, Coen PG, Booy R, Levin M (2005) The role of healthcare delivery in the outcome of meningococcal disease in children: case–control study of fatal and non-fatal cases. BMJ 330:1475PubMedCrossRefGoogle Scholar
  27. 27.
    Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 345:1368–1377PubMedCrossRefGoogle Scholar
  28. 28.
    Krafft P, Steltzer H, Hiesmayr M, Klimscha W, Hammerle AF (1993) Mixed venous oxygen saturation in critically ill septic shock patients. The role of defined events. Chest 103:900–906PubMedCrossRefGoogle Scholar
  29. 29.
    Gattinoni L, Brazzi L, Pelosi P, Latini R, Tognoni G, Pesenti A, Fumagalli R (1995) A trial of goal-oriented hemodynamic therapy on critically ill patients. NEJM 333:1025–1032PubMedCrossRefGoogle Scholar
  30. 30.
    Pearse RM, Rhodes A (2005) Mixed and central venous oxygen saturation. In: Vincent JL (ed) Yearbook of intensive care and emergency medicine. Springer, Berlin Heidelberg New York, pp 592–602CrossRefGoogle Scholar
  31. 31.
    Scheinman MM, Brown MA, Rapaport E (1969) Critical assessment of use of central venous oxygen saturation as a mirror of mixed venous oxygen in severely ill cardiac patients. Circulation 40:165–172PubMedGoogle Scholar
  32. 32.
    Varpula M, Karlsson S, Ruokonen E, Pettila V (2006) Mixed venous oxygen saturation cannot be estimated by central venous oxygen saturation in septic shock. Intensive Care Med 32:1336–1343PubMedCrossRefGoogle Scholar
  33. 33.
    Dueck MH, Klimek M, Appenrodt S, Weigand C, Boerner U (2005) Trends but not individual values of central venous oxygen saturation agree with mixed venous oxygen saturation during varying hemodynamic conditions. Anesthesiology 103:249–257PubMedCrossRefGoogle Scholar
  34. 34.
    Chawla LS, Zia H, Gutierrez G, Katz NM, Seneff MG, Shah M (2004) Lack of equivalence between central and mixed venous oxygen saturation. Chest 126:1891–1896PubMedCrossRefGoogle Scholar
  35. 35.
    Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki L-M, Pettilä V (2005) Hemodynamic variables related to outcome in septic shock. Intensive Care Med 31:1066–1071PubMedCrossRefGoogle Scholar
  36. 36.
    Schranz D, Schmitt S, Oelert H, Schmid F, Huth R, Zimmer B, Schuind A, Vogel K, Stopfkuchen H, Jüngst BK (1989) Continuous monitoring of mixed venous oxygen saturation in infants after cardiac surgery. Intensive Care Med 15:228–232PubMedCrossRefGoogle Scholar
  37. 37.
    Hirschl RB (1994) Oxygen delivery in the paediatric surgical patient. Curr Opin Pediatr 6:341–347PubMedCrossRefGoogle Scholar
  38. 38.
    Estenssoro E, Gonzalez F, Laffaire E, Canales H, Sáenz G, Reina R, Dubin A (2005) Shock on admission day is the best predictor of prolonged mechanical ventilation in the ICU. Chest 127:598–603PubMedCrossRefGoogle Scholar
  39. 39.
    Rossi C, Simini B, Brazzi L, Rossi G, Radrizzani D, Iapichino G, Bertolini G, Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva (2006) Variable costs of ICU patients: a multicenter prospective study. Intensive Care Med 32:545–552PubMedCrossRefGoogle Scholar
  40. 40.
    Odetola FO, Gebremariam A, Freed GL (2007) Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis. Pediatrics 119:487–494PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Cláudio F. de Oliveira
    • 1
    • 5
    Email author
  • Débora S. F. de Oliveira
    • 1
  • Adriana F. C. Gottschald
    • 1
  • Juliana D. G. Moura
    • 1
  • Graziela A. Costa
    • 1
  • Andréa C. Ventura
    • 2
  • José Carlos Fernandes
    • 2
  • Flávio A. C. Vaz
    • 1
  • Joseph A. Carcillo
    • 3
  • Emanuel P. Rivers
    • 4
  • Eduardo J. Troster
    • 1
  1. 1.Paediatric Intensive Care Unit, Department of PaediatricsInstituto da Criança Pedro de Alcântra da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
  2. 2.Paediatric Intensive Care UnitHospital Universitário da Universidade de São PauloSão PauloBrazil
  3. 3.Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  4. 4.Departments of Emergency Medicine and SurgeryHenry Ford Health SystemsDetroitUSA
  5. 5.São PauloBrazil

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