ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation.
BACKGROUND
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 (ScvO(2) > or = 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.


OBJECTIVE
The purpose of this study was to compare treatment according to ACCM/PALS guidelines, performed with and without ScvO(2) 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 ScvO(2) goal-directed resuscitation.


METHODS
Twenty-eight-day mortality was the primary endpoint.


RESULTS
Of the 102 enrolled patients, 51 received ACCM/PALS with ScvO(2) goal-directed therapy and 51 received ACCM/PALS without ScvO(2) goal-directed therapy. ScvO(2) 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). ScvO(2) 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.


CONCLUSIONS
This study supports the current ACCM/PALS guidelines. Goal-directed therapy using the endpoint of a ScvO(2)> or =70% has a significant and additive impact on the outcome of children and adolescents with septic shock.
de Oliveira
Cláudio F
CF
Paediatric Intensive Care Unit, Department of Paediatrics, Instituto da Criança Pedro de Alcântra, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil. claudiof@icr.hcnet.usp.br
de Oliveira
Débora S F
DS
Gottschald
Adriana F C
AF
Moura
Juliana D G
JD
Costa
Graziela A
GA
Ventura
Andréa C
AC
Fernandes
José Carlos
JC
Vaz
Flávio A C
FA
Carcillo
Joseph A
JA
Rivers
Emanuel P
EP
Troster
Eduardo J
EJ
D002302:Cardiac Output; D002648:Child; D002675:Child, Preschool; D005260:Female; D006439:Hemodynamics; D006801:Humans; D016015:Logistic Models; D008297:Male; D008991:Monitoring, Physiologic / Q000379:methods*; D010100:Oxygen / Q000097:blood*; D017410:Practice Guidelines as Topic; D012151:Resuscitation / Q000379:methods*; D012772:Shock, Septic / Q000097:blood* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D016896:Treatment Outcome
D010100:Oxygen