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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 6  |  Page : 208-212

The impact of adherence to the American College of Critical Care Medicine 2017 guidelines in the management of septic shock in pediatric intensive care units: A prospective observational study


1 Department of Pediatrics, Shri Rammurti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Department of Surgery, Shri Rammurti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
3 Department of Pediatrics, Ruhellkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Date of Submission03-Jun-2022
Date of Decision16-Oct-2022
Date of Acceptance04-Nov-2022
Date of Web Publication22-Nov-2022

Correspondence Address:
Dr. Preeti Lata Rai
Department of Pediatrics, Ruhellkhand Medical College and Hospital, Bareilly - 243 006, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_48_22

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  Abstract 


Background: Despite tremendous advances and new guidelines for the management of pediatric septic shock, the mortality and morbidity associated with it remain unacceptably high. This study was conducted to evaluate the impact of adherence to the American College of Critical Care Medicine (ACCM) guidelines in the management of septic shock in pediatric intensive care units (PICU).
Subjects and Methods: This was a hospital-based prospective observational study conducted in the 15-bedded PICU of a tertiary care hospital in Utter Pradesh, India. Children from 1 month to 18 years of age admitted to the PICU with septic shock were included in the study as per definitions given by ACCM guidelines. The children who were managed strictly adhering to ACCM guidelines were labeled as the adherent group and those who were managed with any deviation from these guidelines were considered as the nonadherent group. The two groups were compared with respect to outcome.
Results: In this study, the prevalence of septic shock was 54.4% in PICU. Out of 124 cases of septic shock, 93 were from the adherent group and 31 were from the nonadherent group. Recovery was significantly higher (p-0.012) in children among the adherent group (56 [60.21%] vs. 11 [35.48%]) than in the nonadherent group. The hemodynamic stability achieved within 48 h among the adherent group was higher in comparison to the nonadherent group (39 [56%] vs. 6 [8.5%]) making this a significant (P = 0.007) observation.
Conclusions: Strict adherence to the ACCM guidelines was associated with favorable outcomes in the management of septic shock in children.

Keywords: American College of Critical Care Medicine, adherence, deviations, outcome, septic shock


How to cite this article:
Kochar G, Tripathi PK, Rai PL, Prasad PL. The impact of adherence to the American College of Critical Care Medicine 2017 guidelines in the management of septic shock in pediatric intensive care units: A prospective observational study. J Pediatr Crit Care 2022;9:208-12

How to cite this URL:
Kochar G, Tripathi PK, Rai PL, Prasad PL. The impact of adherence to the American College of Critical Care Medicine 2017 guidelines in the management of septic shock in pediatric intensive care units: A prospective observational study. J Pediatr Crit Care [serial online] 2022 [cited 2022 Dec 8];9:208-12. Available from: http://www.jpcc.org.in/text.asp?2022/9/6/208/361674




  Introduction Top


Sepsis and septic shock are major health-care problems affecting millions of people all over the world each year.[1] More than 6 million deaths of newborns and small children in developing nations due to sepsis have been reported by The World Federation of Pediatric Intensive and Critical Care Societies.[2]Despite tremendous advances, the mortality and morbidity due to pediatric shock remain unacceptably high. A high incidence of bacterial, parasitic, and HIV infection, poor hygienic standards, low vaccination rates, huge burden of malnutrition, and lack of resources, explain the dismally high number of deaths from sepsis in developing nations.[3],[4],[5]

Until 2001, there was an absence of protocolized management of sepsis and septic shock in pediatrics, and mortality was as high as 40%–50%.[6] The therapeutic determinants of sepsis survival in children are rapid resuscitation, source control, and immune suppression withdrawal or immune restoration. In an effort to increase global awareness of sepsis as the major preventable cause of child mortality and prevent sepsis deaths, the American College of Critical Care Medicine (ACCM) formulated the first protocol for the identification and management of septic shock in pediatrics.[7],[8]

The formulation of the recent guidelines and initiatives shows that the progress from sepsis to severe sepsis and septic shock can be effectively halted and reversed. The ACCM guidelines for the management of pediatric shock currently represent the best practice to manage pediatric septic shock.[5] With the advent of guidelines for the management of septic shock, the overall survival of children has improved.[9] In India, the mortality rate due to septic shock was reported to be 47% which is comparable to the global figure of around 50%.[10]This can be further controlled and a decline in this rate is possible if one adheres to ACCM guidelines in managing septic shock. Improved compliance with 1st h (also known as the golden hour) and stabilization along with guideline recommendations have reduced hospital mortalities from 4% to 2% in resource-rich developed and developing nations,[11] however, adherence to these recommendations remains low.[12] Keeping this in mind, this study was taken up to evaluate the impact of adherence to ACCM guidelines in diagnosing, managing, and studying the outcome of septic shock cases.


  Materials and Methods Top


This hospital-based prospective observational study was conducted in the 15-bedded pediatric intensive care unit (PICU) from November 2018 to October 2019, a tertiary care hospital in the Rohilkhand region of Uttar Pradesh, India. After the institutional ethics committee approval (SRMSIMS/2016-17/69-K) and written informed consent from parents, all children of age 1 month to 18 years with Septic shock as per the ACCM guidelines admitted in PICU were enrolled in this study. Children with shock than septic shock were excluded from the study.

Septic shock was defined as sepsis and cardiovascular organ dysfunction. Severe sepsis was defined as sepsis with the presence of one of the following:[13]

  • Cardiovascular dysfunction
  • Acute respiratory distress syndrome, or
  • Two or more other organ dysfunctions (respiratory, renal, neurologic, hematological, or hepatic).


The resuscitation measures adopted in the 1st h of the presentation are as per the ACCM guidelines (commonly known as the golden hour).[12]

After achieving therapeutic endpoints with the administration of fluid boluses, the shock would be labeled as a fluid-responsive shock. At the end of 15 min, if shock persisted, despite giving fluid boluses of 60 ml/kg or developed signs of fluid overload at any point of fluid administration, then this was labeled as a fluid refractory shock. Vasopressor was initiated in such cases and if the shock reversed at the end of 30 min, it was labeled as a catecholamine-responsive shock. At the end of 60 min, despite initiating vasopressors such as epinephrine, dopamine, or norepinephrine and titrating to its maximum dose, there was no improvement in the clinical therapeutic parameters; this was called catecholamine refractory shock.

Children who were managed strictly as per the ACCM guidelines in terms of timing and quantity of fluid boluses, timing to initiate the inotropes and time-bound changes in inotropes as per multimodal monitoring were labeled as an adherent group. The decision to deviation from ACCM guidelines in the management was taken by the investigator in consultation with incharge intensivist depending on prior treatment and monitoring response in the PICU. These deviations were evaluated at the end of 1 h after the initiation of the management of septic shock. The children who were treated with deviation from ACCM guidelines were labeled as a nonadherent group. The two groups were compared with the outcome.


  Results Top


There were 241 children, diagnosed with shock admitted to our PICU during the study. One hundred and thirty-one cases had septic shock and but seven children were excluded as the guardians refused to give consent and 124 cases were included in the study [Figure 1].
Figure 1: Study population

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The prevalence of septic shock was 54.4% in PICU in our study. Males (1.7:1) were affected more than females. Most of the cases belonged to the age groups between 10 and 14 years (28.2%), followed by 4–6 years (22.6%). Clinical parameters of shock in the study population are shown in [Table 1]. The distribution of the study population according to the site of infection among septic shock is shown in [Table 2]. Out of 124 children with septic shock, 93 were treated adhering to ACCM guidelines and were labeled as an adherent group, and 31 children treated with deviation from guidelines were included in the nonadherent group.
Table 1: Distribution of study population as per the clinical criteria of septic shock

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Table 2: Distribution of cases according to the site of infection

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Out of 124 cases, 30 were fluid responsive, 23 were fluid refractory, 28 were catecholamine responsive, and 43 were catecholamine refractory. The distribution of cases as per the subtypes of septic shock among the two groups is shown in [Table 3]. All the cases of fluid-responsive shock belonged to the adherent group, whereas 48% of catecholamine-refractory shock cases were from the nonadherent group. The most common reason for deviation was “no fluid bolus given” as treatment instructions were contrary to the guidelines.
Table 3: Distribution of cases as per subtypes of septic shock among two groups

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Sixty-seven (54%) children recovered, 25 (20%) children succumbed, whereas 32 (26%) children had left against medical advice during treatment. A comparison of the overall outcome between the two groups is shown in [Table 4]. Recovery was significantly higher (P = 0.012) in children among the adherent group (56 [60.21%] vs. 11 [35.48%]) as compared to the nonadherent group. [Table 5] reflects the hemodynamic stability in 1st 48 h and its comparison between the two groups. The hemodynamic stability achieved within 48 h among the adherent group (39 [56%] vs. 6 [8.5%]) was also significantly (P = 0.007) higher than the nonadherent group.
Table 4: Comparison of overall outcome between two groups

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Table 5: Comparison of hemodynamic stability achieved in the first 48 h among two groups

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  Discussion Top


There were 241 children admitted to our PICU and 131 cases were diagnosed with septic shock. However, only 124 cases could be enrolled in our study as seven patients declined to participate. Septic shock accounted for 58.4% of the total admissions in the intensive care.

Our study evaluated children with septic shock only as per the clinical criteria of septic shock as per the ACCM guidelines and found 92.7% of cases reported fever followed by hypotension in 83.9% of cases. Tachycardia was seen in 76.6%. Nearly equal distribution was reported with vasodilatation and temperature abnormality. The least common parameter was oliguria 7.3%, and the high proportion of hypotension in our study indicates that there is a delay in recognizing shock in its early stages. This may be due to the fact being a tertiary care center, many cases are referrals from nearby rural and urban areas and thus there maybe a delay in reaching the hospital with adequate care and infrastructure. A study done in Indonesia has found diminished peripheral pulses in 97.8% of children, tachycardia in 97.3%, delayed capillary refill time in 94.6%, altered mental status in 86.6%, decreased urine output (<1 mL/kg/h) in 44.6%, and low blood pressure in 32.6% of cases.[14]

Of the total 124 children with septic shock enrolled in our study, 93 cases (75%) adhered to the ACCM guidelines 2017 for the management of septic shock. On the contrary, a prospective study done by Paul et al. found only 19% adherence to the PALS sepsis guidelines in 2006.[15] In the present study, all cases of fluid-responsive shock were from the adherent group. However, 48.3% of cases from the nonadherent group resulted had catecholamine refractory shock. This emphasizes the importance of early recognition of shock and taking appropriate intervention at the earliest. The reasons for deviations were not adhering to the First Golden Hour Management, that is, the administration of fluid boluses at the time of admission. “no fluid bolus” was found to be the most common reason for deviation as the patient was directly started with inotropes.

Among the 93 cases, recovery was significantly higher (P = 0.012) in children among the adherent group (56 [60.21%] vs. 11 [35.48%]) as compared to the nonadherent group. No study to date has compared the outcome of septic shock after adhering to the guidelines versus not adhering to them. A 3-year study in a developing country with a similar demographic profile as the index study reported declining mortality rates from 42% to 19% after the implementation of Surviving Sepsis Guidelines 2012.[15],[16] Similarly, in our study, the mortality in the group adherent to ACCM guidelines is only 15% as against 36% in the nonadherent group which is double (P = 0.014).

The hemodynamic stability achieved within 48 h among the adherent group (39 [56%] vs. 6 [8.5%]) was significant (P- 0.007) higher than the nonadherent group. No similar study was found where the duration of hemodynamic stabilization was assessed by comparing the compliance to the ACCM guidelines.

Limitations of the study

This study is single centered on a small study population. The study focused only on adherence to the First Golden Hour Management from ACCM guidelines.


  Conclusions Top


This study reflects that strict adherence to ACCM guidelines affects the outcome favorably.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010;376:1339-46.  Back to cited text no. 1
    
2.
Available from: http://www.wfpiccs.org/projects/sepsis-initiative. [Last accessed on 2022 Jun 02].  Back to cited text no. 2
    
3.
Becker JU, Theodosis C, Jacob ST, Wira CR, Groce NE. Surviving sepsis in low-income and middle-income countries: New directions for care and research. Lancet Infect Dis 2009;9:577-82.  Back to cited text no. 3
    
4.
World Health Organization. The Global Burden of Disease: 2004 Update. Switzerland: World Health Organization; 2008.  Back to cited text no. 4
    
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Aneja RK, Carcillo JA. Differences between adult and pediatric septic shock. Minerva Anestesiol 2011;77:986-92.  Back to cited text no. 5
    
6.
Ismail J, Jayashree M. Advances in the management of pediatric septic shock: Old questions, new answers. Indian Pediatr 2018;55:319-25.  Back to cited text no. 6
    
7.
DuPont HL, Spink WW. Infections due to gram-negative organisms: An analysis of 860 patients with bacteremia at the University of Minnesota Medical Center, 1958-1966. Medicine (Baltimore) 1969;48:307-32.  Back to cited text no. 7
    
8.
Booy R, Habibi P, Nadel S, Munter C de, Britto J, Morrison A, et al. Meningococcal research group: Reduction in case fatality rate from 79 meningococcal disease associated with improved healthcare delivery. Arch Dis Child 2001;85:386-90.  Back to cited text no. 8
    
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Militaru M, Martinovici D. Our experience in pediatric sepsis. Jurnalul Pediatrului 2005;8:26-31.  Back to cited text no. 9
    
10.
Singh D, Chopra A, Pooni PA, Bhatia RC. A clinical profile of shock in children in Punjab, India. Indian Pediatr 2006;43:619-23.  Back to cited text no. 10
    
11.
Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, et al. American college of critical care medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 2017;45:1061-93.  Back to cited text no. 11
    
12.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.  Back to cited text no. 12
    
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Kliegman RM, Stanton BF, Geme St JW, Schor NF. Nelson Textbook of Paediatrics 21st ed. Philadelphia: Elsevier; 2019. p. 578.  Back to cited text no. 13
    
14.
Rusmawatiningtyas D, Nurnaningsih N. Mortality rates in pediatric septic shock. Paediatrica Indonesiana 2016;56:304-10.  Back to cited text no. 14
    
15.
Paul R, Neuman MI, Monuteaux MC, Melendez E. Adherence to PALS Sepsis guidelines and hospital length of stay. Pediatrics 2012;130:e273-80.  Back to cited text no. 15
    
16.
Samransamruajkit R, Uppala R, Pongsanon K, Deelodejanawong J, Sritippayawan S, Prapphal N. Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP. Indian J Crit Care Med 2014;18:70-6.  Back to cited text no. 16
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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