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Evolution of haemodynamics and outcome of fluid-refractory septic shock in children

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Abstract

Background

Maintaining threshold values of cardiac output (CO) and systemic vascular resistance (SVR) when used as part of the American College of Critical Care Medicine (ACCM) haemodynamic protocol improves the outcomes in paediatric septic shock.

Objective

We observed the evolution of CO and SVR during the intensive care admission of children with fluid-refractory septic shock and report this together with the eventual outcomes.

Design

Prospective observational study.

Setting

Tertiary care Paediatric Intensive Care Unit (PICU) in London.

Methods

Children admitted in fluid refractory septic shock to the Intensive Care Unit over a period of 36 months were studied. Post liver re-transplant children and delayed septic shock admissions were excluded. A non-invasive ultrasound cardiac output monitor device (USCOM) was used to measure serial haemodynamics. Children were allocated at presentation into one of two categories: (1) hospital-acquired infection and (2) community-acquired infection. Vasopressor, inotrope or inodilator therapies were titrated to maintain threshold cardiovascular parameters as per the ACCM guidelines.

Results

Thirty-six children [19 male, mean age (SD) 6.78 (5.86) years] were admitted with fluid-refractory septic shock and studied. At presentation, all 18 children with hospital-acquired (HA) sepsis and 3 from among the community-acquired (CA) sepsis group were in ‘warm shock’ (SVRI < 800 dyne s/cm5/m2) whereas 15 of the 18 children with community-acquired sepsis and none in the hospital-acquired group were in ‘cold shock’ [cardiac index (CI) < 3.3 l/min/m2]. All 21 children in ‘warm shock’ were initially commenced on a vasopressor (noradrenaline). Despite an initial good response, four patients developed low CI and needed adrenaline. Similarly, all 15 children in cold shock were initially commenced on adrenaline. However, two of them subsequently required noradrenaline. Five others needed milrinone as an inodilator. In general, both groups of children had normalised SVRI and CI within 42 h of therapy but required variable doses of vasopressors, inotropes or inodilators in a heterogeneous manner. The overall 28-day survival rate was 88.9 % in both groups. Central venous oxygen saturation (ScvO2) was significantly (p = 0.003) lower in the community-acquired group (mean 51.72 % ± 4.26) when compared to the hospital-acquired group (mean 58.72 % ± 1.36) at presentation but showed steady improvement during therapy. Gram-positive organisms were predominant in blood cultures, 61 % in HA and 56 % in CA groups.

Conclusions

In general, we found children with community-acquired septic shock presented in cold shock whereas hospital-acquired septic shock children manifested warm shock. Both types evolved in a heterogeneous manner needing frequent revision of cardiovascular support therapy. However the 28-day survival in both groups was the same at 89 %. Frequent measurements of haemodynamics using non-invasive ultrasound helped in fine tuning cardiovascular therapies.

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Acknowledgments

CDA Goonasekera was supported by Commonwealth Scholarship Commission, London. Y. Wang was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The authors thank all medical and nursing staff of the Paediatric Intensive Care Unit for their overwhelming support during this study.

Conflicts of interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Paediatric Intensive Care Unit, King’s College Hospital, Denmark Hill, London, SE5 9RS, UK

    Akash Deep & Chulananda D. A. Goonasekera

  2. Division of Health and Social Care Research, King’s College London, London, UK

    Yanzhong Wang

  3. Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Children’s Hospital, London, UK

    Joe Brierley

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  1. Akash Deep
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  2. Chulananda D. A. Goonasekera
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Correspondence to Akash Deep.

Electronic supplementary material

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Table 1 Demographic data of septic children (DOC 38 kb)

Table 2 Clinical characteristics of septic children who died (DOC 31 kb)

134_2013_3003_MOESM3_ESM.doc

A figure showing the proportion of children in the CA and HA groups needing inotropes (adrenaline), vasopressors (Noradrenaline) and inodilators (Milrinone) at 6-h intervals during the first 42 h of intensive care displayed with a line graph on a time scale (DOC 35 kb)

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Deep, A., Goonasekera, C.D.A., Wang, Y. et al. Evolution of haemodynamics and outcome of fluid-refractory septic shock in children. Intensive Care Med 39, 1602–1609 (2013). https://doi.org/10.1007/s00134-013-3003-z

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  • DOI: https://doi.org/10.1007/s00134-013-3003-z

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