COMMENTARY |
Improved Outcomes Associated With Early Resuscitation in Septic Shock: Do We Need to Resuscitate the Patient or the Physician?
Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR 97239
Abbreviations: ACCM, American College of Critical Care Medicine • PALS, Pediatric Advanced Life Support
It is clear that early aggressive fluid resuscitation in children with septic shock results in improved survival. Children who receive larger volumes of intravenous isotonic fluid in the initial hour after presentation in septic shock have lower mortality, and children who receive >40 mL/kg of fluid do even better in terms of survival.1 Furthermore, when groups receiving smaller versus larger volumes of intravenous fluids are compared, there is no increase in acute respiratory distress syndrome or noncardiogenic pulmonary edema, 2 significant potential complications of overly-aggressive volume expansion.1 Similar findings are reported by investigators in London from their experiences with a specific type of septic shock, meningiococemia. They also report improved survival when increased fluid resuscitation was instituted as part of early resuscitation therapy.2
In the study reported by Han et al3 in this month’s issue of Pediatrics, investigators now turn their attention to evaluate how well community practitioners have adhered to recently published resuscitation guidelines for the treatment of septic shock in children.4,5 The American College of Critical Care Medicine (ACCM) recently published the Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Patients in Septic Shock,4 which have been incorporated into the most recent Pediatric Advanced Life Support (PALS) manual.5 The ACCM-PALS guidelines stress early aggressive fluid resuscitation for children with presenting evidence of hypotension, impaired organ perfusion, and shock. The present study makes a convincing argument that 1) utilization of the ACCM-PALS guidelines results in improved survival, and 2) the guidelines remain underutilized by most community practitioners when confronted with patients with septic shock resulting in significant, and potentially avoidable, mortality. Han et al go on to suggest that dissemination and adoption of current guidelines by a large segment of community physicians would directly result in improved outcomes.
The Han et al study utilizes a retrospective chart review of 91 patients who were transported by the children’s hospital transport team with a diagnosis of septic shock. The authors reviewed the medical records with specific attention to the mechanism, severity, and the community provider’s response to septic shock. The author’s impressive database of patient encounters and their subsequent analysis makes a strong case in support of their underlying hypothesis. Although the study limitations are similar to any study involving retrospective chart reviews, primarily dealing with patient inclusion criteria and lack of a complete dataset, this study represents a significant leap forward in our ability to understand and ameliorate factors relating to poor outcomes in children presenting with septic shock in a community hospital setting.
The ACCM-PALS guidelines referred to in the Han et al study were developed by a task force of experts in pediatric septic shock. All pertinent literature was reviewed and the task force guidelines were published in 2002.4 After securing the airway and establishing ventilation, pharmacologic treatment begins with fluid resuscitation, with emphasis on the need to give repeated fluid boluses of at least 20 mL/kg of isotonic solutions up to a maximum of 60 mL/kg if the child remains in shock during the resuscitation. At that time, additional intravenous fluid boluses may be indicated as may support with inotropic drugs such as dopamine or epinephrine. The practice guidelines also suggest placement of a central venous catheter to estimate ventricular filling pressures and systemic fluid status. The practice guidelines are nicely laid out, easy to understand, and have been implemented in the ACCM-PALS recommendations. However, dissemination of this knowledge past critical care and emergency medicine practitioners in children’s centers and hospitals is challenging.
If we assume that all, or nearly all, pediatricians and emergency medicine physicians who care for children are required to successfully complete and maintain updated PALS certification, will we see improved utilization of the ACCM-PALS guidelines as practitioners update their PALS certification and are educated about the guidelines? The dataset evaluated by Han et al was from 1993–2001, before publication of the most recent guidelines. PALS has always included a recommendation for aggressive fluid resuscitation, however before publication of the revised ACCM-PALS guidelines with updated fluid resuscitation parameters, there was less emphasis placed early intubation and the volume of fluids appropriate to administer before starting inotropic drugs. It will be interesting to perform a follow-up study in 1 to 2 years to evaluate community physician’s practices after dissemination of the new ACCM-PALS guidelines to see if the guidelines impact care. However, we are skeptical that the ACCM-PALS guidelines, in and of themselves, will have a significant impact on clinical outcome for the following reasons.
As Han et al suggest, we believe that there are significant barriers to the successful translation of the ACCM-PALS guidelines to the community hospital setting.4 First and foremost, community practitioners lack adequate hands-on experience in caring for children in septic shock, both in disease recognition, practical management skills (eg, tracheal intubation, central venous catheter placement, resuscitation pharmacology, etc), and coordinating the temporal aspects of a prolonged resuscitation. Even if the ACCM-PALS guidelines were widely disseminated, we believe that if a physician does not routinely treat patients with septic shock, he or she will either never learn or may rapidly forget up-to-date treatment protocols. To be fair, we recognize that this model applies to any disease infrequently encountered by a physician, whether it is a critical care physician trying to diagnose and provide current treatment for attention deficit disorder or the community hospital physician confronted with a case of meningococcemia.
Therefore, we suggest that improved outcome from septic shock and similar critical illnesses seen in the community setting will only occur with a combination of community physician education and immediate triage and communication between the community physician and pediatric acute care experts at a regional tertiary care children’s hospital. By combining the community physician’s physical presence and assessment skills at the scene with the knowledge and clinical experience of a pediatric emergency medicine or pediatric critical care physician, children may then receive the best possible care in a timely fashion. This can be done by telephone, or as recently reported, by dedicated telemedicine programs between community hospitals and pediatric intensive care units.6–9
We look forward to future studies of acutely ill and injured children similar to the Han et al study that take a step back from what we practice on a day-to-day basis and carefully evaluate systems issues that provide the infrastructure for ongoing medical education and communication between all levels of pediatric health care.
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FOOTNOTES |
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Received for publication Apr 22, 2003; Accepted Apr 23, 2003.
Address correspondence to Brahm Goldstein, MD, FAAP, FCCM, Doernbecher Children’s Hospital, Oregon Health and Science University, 707 SW Gaines St, Mail Code CDRCP, Portland, OR 97239. E-mail: goldsteb{at}ohsu.edu
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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