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VOLUME 25 , ISSUE 8 ( August, 2021 ) > List of Articles

Pediatric Critical Care

Practices of Initiation of Vasoactive Drugs in Relation to Resuscitation Fluids in Children with Septic Shock: A Prospective Observational Study

Karanvir, Shalu Gupta

Keywords : Fluid overload, pediatric intensive care unit, Resuscitation fluid, Sepsis, Septic shock, Vasoactive drugs

Citation Information : K, Gupta S. Practices of Initiation of Vasoactive Drugs in Relation to Resuscitation Fluids in Children with Septic Shock: A Prospective Observational Study. Indian J Crit Care Med 2021; 25 (8):928-933.

DOI: 10.5005/jp-journals-10071-23954

License: CC BY-NC 4.0

Published Online: 12-08-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Abstract

Background: The role of vasoactive medications in septic shock is well-defined, but the appropriate time of initiation of these medications in reference to fluid boluses is not clear. We planned to study prospectively the practices and outcome of initiation of vasoactive infusions with respect to resuscitation fluids boluses in pediatric septic shock. Patients and methods: Children aged 1 month to 18 years diagnosed with septic shock were enrolled to receive fluid resuscitation boluses along with vasoactive drugs. The primary outcome was to look at various practices of the initiation of vasoactive infusions; accordingly, patients were categorized into three groups: N1 received vasoactive infusions after completion of the first bolus (20 mL/kg), N2 after the second (40 mL/kg), and N3 after the third fluid (60 mL/kg) bolus. Secondary outcomes were to compare the time taken, amount of fluid required to achieve hemodynamic stability, total fluid required, and complications in the first 24 hours of treatment and mortality. Results: Hundred children were enrolled and grouped into N1, N2, and N3 with 46, 10, and 44 patients, respectively. The volume of fluid required to achieve the resolution of shock in N1 (40 ± 10 mL/kg) was significantly less than in N2 (70 ± 10 mL/kg) and N3 (70 ± 20 mL/kg); p = 0.02. The time taken to achieve hemodynamic stability was significantly less in N1 (115 ± 45 minutes) than in N2 (196 ± 32 minutes) and N3 (212 ± 44 minutes); p = 0.02. The volume of intravenous fluid required in the first 24 hours (p = 0.02) and complications were lower in the N1 group (p = 0.04). No statistical difference in mortality was seen. Conclusion: Early initiation of vasoactive infusions (after the first bolus) resulted in less total fluid volume, lesser time to achieve hemodynamic stability, less fluid boluses, less length of stay in the pediatric intensive care unit, and lesser complications in the first 24 hours. Highlight: Early initiation of vasoactive infusions—after completion of the first fluid bolus resulted in less need for further fluid boluses, lesser time for shock resolution, lesser fluid overload, and less PICU stay—in pediatric septic shock.


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  1. Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med 2003;167(5):695–670. DOI: 10.1164/rccm.200207-682OC.
  2. Fleischmann-Struzek C, Goldfarb DM, Schlattmann P, Schlapbach LJ, Reinhart K, Kissoon N. The global burden of paediatric and neonatal sepsis: a systematic review. Lancet Respir Med 2018;6(3):223–230. DOI: 10.1016/S2213-2600(18)30063-8.
  3. Brierly J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, et al. Clinical practice, parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from American College of Critical Care Medicine. Crit Care Med 2009;37(2):666–688. DOI: 10.1097/CCM.0b013e31819323c6.
  4. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality after fluid bolus in Africa children with severe infection. N Engl J Med 2011;364(26):2483–2495. DOI: 10.1056/NEJMoa1101549.
  5. Levin M, Cunnington AJ, Wilson C, Nadel S, Lang HJ, Ninis N, et al. Effects of saline or albumin fluid bolus in resuscitation: evidence from re-analysis of the FEAST trial. Lancet Respir Med 2019;7(7):581–593. DOI: 10.1016/S2213-2600(19)30114-6.
  6. Le Doux D, Astiz ME, Carpati CM, Rackow EC. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000;28(8):2729–2732. DOI: 10.1097/00003246-200008000-00007.
  7. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign guidelines committee including the pediatric subgroup: surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41(2):580–637. DOI: 10.1097/CCM.0b013e31827e83af.
  8. Beck V, Chateau D, Bryson LG, Pisipati A, Zanotti, Parrillo JE, et al. Timing of inotropes initiation and mortality in septic shock. Crit Care Med 2014;18(3):R97. DOI: 10.1186/cc13868.
  9. Hamzaoui O, Georger JF, Monnet X, Ksouri H, Maizel J, Richard C, et al. Early administration of nor epinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension. Crit Care 2010;14(4):R142. DOI: 10.1186/cc9207.
  10. Subramanian S, Yilmaz M, Rehman A, Hubmayr RD, Afessa B, Gajic O. Liberal vs. conservative vasopressor use to maintain mean arterial blood pressure during resuscitation of septic shock: an observational study. Intensive Care Med 2008;34(1):157–162. DOI: 10.1007/s00134-007-0862-1.
  11. Santhanam I, Sangareddi S, Venkataraman S, Kissoon N, Thiruvengadamudayan V, Kasthuri RK. A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Pediatr Emerg Care 2008;24(10):647–655. DOI: 10.1097/PEC.0b013e31818844cf.
  12. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign. International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008;34(1):17–60. DOI: 10.1007/s00134-007-0934-2.
  13. Taneja K, Kumar V, Anand R, Pemde HK. Normative data for IVC diameter and its correlation with the somatic parameters in Healthy Indian Children. Indian J Pediatr 2018;85(2):108–112. DOI: 10.1007/s12098-017-2440-z.
  14. Silverman HJ, Peneranda R, Orens JB, Lee NH. Impaired beta-adrenergic receptor stimulation of cyclic adenosine monophosphate in human septic shock: association with myocardial hyporesponsiveness to catecholamines. Crit Care Med 1993;21(1):31–39. DOI: 10.1097/00003246-199301000-00010.
  15. Scarpace PJ, Abrass IB. Desensitization of adenylate cyclase and down regulation of beta adrenergic receptors after in vivo administration of beta agonist. J Pharmacol Exp Ther 1982;223(2):327–331. PMID: 6127402.
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