Targeted hemodynamic support can improve outcomes in pediatric septic shock
Year: 2018
Type: article
Study design: Observational Study
Abstract: Background : Sepsis and septic shock poses significant burden of mortality and morbidity. There is abundant literature to state that Inotrope score(IS) and vasopressor-inotrope score(VIS) are important predictors of outcomes and need for rescue therapies such as ECMO after cardiac surgery. However, studies relating VIS to outcomes in pediatric septic shock are sparse. Methods : Retrospective review of patient charts diagnosed to have fluid refractory septic shock admitted to our tertiary care PICU between April 2014 and June 2016.Patient management with fluids and vasoactive agents were titrated using multimodal monitoring. In addition to demographics, type of infections and severity score, we collected hemodynamic data including type and dose of inotrope and/or vasopressor infusions. Max48hr-VIS in PICU was recorded and subjects were stratified in to low-VIS(score =20) and high-VIS(score >20) groups. Data related to time to resolution of shock, days of mechanical ventilation, number of organ dysfunction, PICU length of stay and hospital length of stay were collected. Statistical analysis was performed using the Windows SPSS software version-16. Continuous and categorical variables were expressed and compared using appropriate statistical tests. Results : Twenty-three children were eligible for inclusion. The mean age was 68 months. Seven (30.4%) had pre-existing comorbidities. Fourteen(60.8%) had culture positive sepsis; of these gram-negative bacilli were the most common. 12 children(52%) had myocardial dysfunction. 17 children(73.9%) developed two or more organ dysfunction including cardiovascular system, and 8(34.7%) had three or more organ dysfunction including cardiovascular system. The average PELOD score was 15.2. Median time to resolution of shock was 24hrs(IQR 24 - 45hrs). 20 children were ventilated with median duration of ventilation was 48 hrs(IQR 36 – 90 hrs). Median length of PICU stay and hospital stay were 5 days(IQR3.5 –6.5days) and 8 days(IQR 6 – 17.5 days) respectively. Two children died with a mortality of 8.7%. The mean max 48hr-VIS was 41.29 +/-33.9 Max 48hr-VIS positively correlated with PICU stay(r=0.828, p=0.0001), organ dysfunction (r= 0.842, p=0.0001), time to resolution of shock(r= 0.525,p=0.014) and duration of mechanical ventilation(r= 0.468,p=0.037 ) but did not correlate well with hospital stay (r=0.398 ,p=0.06) . Mean max 48hr-VIS for survivors was 34.04 +/- 25.05 which was significantly less than in non-survivors 117.5 +/- 10.6(p=0.0001). There were 13 children in the high-VIS group and 10 children in the low-VIS group. The High-VIS group had worse outcomes compared to low-VIS group. All 8 children who had 3 or more organ dysfunction were in the high-VIS group (p=0.002). The median duration of mechanical ventilation and median length of PICU stay was higher in high VIS group compared to low VIS group. Mortality in the high-VIS group was 15.3%.The low mortality rate even in the high VIS group could be attributed to multimodal monitoring – tailored interventions in our patient population. Conclusion : Max 48hr -VIS positively correlated with PICU mortality, PICU stay, organ dysfunction, time to resolution of shock and duration of mechanical ventilation in children with fluid refractory septic shock. Larger prospective study is needed to identify a far higher VIS cut-off for predicting mortality and morbidity from septic shock.
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W3035515225