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A clinical and physiological prospective observational study on the management of pediatric shock in the post-fluid expansion as supportive therapy trial era

2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. ;ISSN: 1529-7535 ;EISSN: 1947-3893 ;DOI: 10.1097/PCC.0000000000002968

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  • Title:
    A clinical and physiological prospective observational study on the management of pediatric shock in the post-fluid expansion as supportive therapy trial era
  • Author: Obonyo, N ; Olupot-Olupot, P ; Mpoya, A ; Nteziyaremye, J ; Chebet, M ; Uyoga, S ; Muhindo, R ; Fanning, J ; Shiino, K ; Chan, J ; Fraser, JF ; Maitland, K
  • Subjects: 1110 Nursing ; 1114 Paediatrics and Reproductive Medicine ; Pediatrics
  • Description: Objectives: Fluid bolus resuscitation in African children is harmful. Little research has evaluated physiologic effects of maintenance-only fluid strategy. Design: We describe the efficacy of fluid-conservative resuscitation of septic shock using case-fatality, hemodynamic, and myocardial function endpoints. Setting: Pediatric wards of Mbale Regional Referral Hospital, Uganda, and Kilifi County Hospital, Kenya, conducted between October 2013 and July 2015. Data were analysed from August 2016 to July 2019. Patients: Children (≥ 60 d to ≤ 12 yr) with severe febrile illness and clinical signs of impaired perfusion. Interventions: IV maintenance fluid (4 mL/kg/hr) unless children had World Health Organization (WHO) defined shock (≥ 3 signs) where they received two fluid boluses (20 mL/kg) and transfusion if shock persisted. Clinical, electrocardiographic, echocardiographic, and laboratory data were collected at presentation, during resuscitation and on day 28. Outcome measures were 48-hour mortality, normalization of hemodynamics, and cardiac biomarkers. Measurement and Main Results: Thirty children (70% males) were recruited, six had WHO shock, all of whom died (6/6) versus three of 24 deaths in the non-WHO shock. Median fluid volume received by survivors and nonsurvivors were similar (13 [interquartile range (IQR), 9–32] vs 30 mL/kg [28–61 mL/kg], z = 1.62, p = 0.23). By 24 hours, we observed increases in median (IQR) stroke volume index (39 mL/m2 [32–42 mL/m2] to 47 mL/m2 [41–49 mL/m2]) and a measure of systolic function: fractional shortening from 30 (27–33) to 34 (31–38) from baseline including children managed with no-bolus. Children with WHO shock had a higher mean level of cardiac troponin (t = 3.58; 95% CI, 1.24–1.43; p = 0.02) and alpha-atrial natriuretic peptide (t = 16.5; 95% CI, 2.80–67.5; p < 0.01) at admission compared with non-WHO shock. Elevated troponin (> 0.1 μg/mL) and hyperlactatemia (> 4 mmol/L) were putative makers predicting outcome. Conclusions: Maintenance-only fluid therapy normalized clinical and myocardial perturbations in shock without compromising cardiac or hemodynamic function whereas fluid-bolus management of WHO shock resulted in high fatality. Troponin and lactate biomarkers of cardiac dysfunction could be promising outcome predictors in pediatric septic shock in resource-limited settings.
  • Publisher: Lippincott, Williams & Wilkins
  • Creation Date: 2022-03
  • Language: English
  • Identifier: ISSN: 1529-7535
    EISSN: 1947-3893
    DOI: 10.1097/PCC.0000000000002968
  • Source: Spiral
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