Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine

Joe Brierley, Joseph A. Carcillo, Karen Choong, Tim Cornell, Allan Decaen, Andreas Deymann, Allan Doctor, Alan Davis, John Duff, Marc Andre Dugas, Alan Duncan, Barry Evans, Jonathan Feldman, Kathryn Felmet, Gene Fisher, Lorry Frankel, Howard Jeffries, Bruce Greenwald, Juan Gutierrez, Mark HallYong Y. Han, James Hanson, Jan Hazelzet, Lynn Hernan, Jane Kiff, Niranjan Kissoon, Alexander Kon, Jose Irazusta, John Lin, Angie Lorts, Michelle Mariscalco, Renuka Mehta, Simon Nadel, Trung Nguyen, Carol Nicholson, Mark Peters, Regina Okhuysen-Cawley, Tom Poulton, Monica Relves, Agustin Rodriguez, Ranna Rozenfeld, Eduardo Schnitzler, Tom Shanley, Sara Skache, Peter Skippen, Adalberto Torres, Bettina Von Dessauer, Jacki Weingarten, Timothy Yeh, Arno Zaritsky, Bonnie Stojadinovic, Jerry Zimmerman, Aaron Zuckerberg

Research output: Contribution to journalArticle

663 Scopus citations

Abstract

BACKGROUND:: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE:: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS:: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS:: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS:: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION:: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill ≤2 secs, and 2) subsequent intensive care unit hemodynamic support directed to goals of central venous oxygen saturation >70% and cardiac index 3.3-6.0 L/min/m.

Original languageEnglish (US)
Pages (from-to)666-688
Number of pages23
JournalCritical care medicine
Volume37
Issue number2
DOIs
StatePublished - Feb 2009

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Keywords

  • Guidelines
  • Sepsis
  • Severe sepsis

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Brierley, J., Carcillo, J. A., Choong, K., Cornell, T., Decaen, A., Deymann, A., Doctor, A., Davis, A., Duff, J., Dugas, M. A., Duncan, A., Evans, B., Feldman, J., Felmet, K., Fisher, G., Frankel, L., Jeffries, H., Greenwald, B., Gutierrez, J., ... Zuckerberg, A. (2009). Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Critical care medicine, 37(2), 666-688. https://doi.org/10.1097/CCM.0b013e31819323c6