title: Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world.
abstract: OBJECTIVE
  To analyze mortality rates of children with severe sepsis and septic shock in relation to time-sensitive fluid resuscitation and treatments received and to define barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines in a pediatric intensive care unit in a developing country.
  
  
  METHODS
  Retrospective chart review and prospective analysis of septic shock treatment in a pediatric intensive care unit of a tertiary care teaching hospital. Ninety patients with severe sepsis or septic shock admitted between July 2002 and June 2003 were included in this study.
  
  
  RESULTS
  Of the 90 patients, 83% had septic shock and 17% had severe sepsis; 80 patients had preexisting severe chronic diseases. Patients with septic shock who received less than a 20-mL/kg dose of resuscitation fluid in the first hour of treatment had a mortality rate of 73%, whereas patients who received more than a 40-mL/kg dose in the first hour of treatment had a mortality rate of 33% (P < 0.05). Patients treated less than 30 minutes after diagnosis of severe sepsis and septic shock had a significantly lower mortality rate (40%) than patients treated more than 60 minutes after diagnosis (P < 0.05). Controlling for the risk of mortality, early fluid resuscitation was associated with a 3-fold reduction in the odds of death (odds ratio, 0.33; 95% confidence interval, 0.13-0.85). The most important barriers to achieve adequate severe sepsis and septic shock treatment were lack of adequate vascular access, lack of recognition of early shock, shortage of health care providers, and nonuse of goals and treatment protocols.
  
  
  CONCLUSIONS
  The mortality rate was higher for children older than 2 years, for those who received less than 40 mL/kg in the first hour, and for those whose treatment was not initiated in the first 30 minutes after the diagnosis of septic shock. The acknowledgment of existing barriers to a timely fluid administration and the establishment of objectives to overcome these barriers may lead to a more successful implementation of the American College of Critical Care Medicine guidelines and reduced mortality rates for children with septic shock in the developing world.
authors.affiliation: Department of Pediatrics, Faculdade de Medicina, Pediatric Intensive Care Unit, Instituto da Criança Pedro de Alcântra, Universidade de São Paulo, São Paulo, Brazil.
authors.forename: Cláudio F
authors.initials: CF
authors.lastname: Oliveira
authors.forename: Flávio R
authors.initials: FR
authors.lastname: Nogueira de Sá
authors.forename: Débora S F
authors.initials: DS
authors.lastname: Oliveira
authors.forename: Adriana F C
authors.initials: AF
authors.lastname: Gottschald
authors.forename: Juliana D G
authors.initials: JD
authors.lastname: Moura
authors.forename: Audrey R O
authors.initials: AR
authors.lastname: Shibata
authors.forename: Eduardo J
authors.initials: EJ
authors.lastname: Troster
authors.forename: Flávio A C
authors.initials: FA
authors.lastname: Vaz
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Carcillo
mesh_terms: D000367:Age Factors; D001938:Brazil / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D015897:Comorbidity; D003428:Cross Infection / Q000382:microbiology / Q000401:mortality / Q000628:therapy; D003906:Developing Countries; D042241:Early Diagnosis; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D019983:Guideline Adherence; D017052:Hospital Mortality; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric / Q000706:statistics & numerical data; D008297:Male; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D018805:Sepsis / Q000382:microbiology / Q000401:mortality / Q000628:therapy*; D012772:Shock, Septic / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D000078329:Workforce