Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock - 20/08/22

Doi : 10.1016/j.annemergmed.2022.04.008

Matthew A. Eisenberg, MD, MPH ^a,^b,^⁎ , Ruth Riggs ^c, Raina Paul, MD ^d, Fran Balamuth, MD, PhD ^e, Troy Richardson, PhD ^c, Heidi G. DeSouza, MPH ^c, Mary Kate Abbadesa, MSN, ACCNS-P ^e, Theodore K.M. DeMartini, MD ^f, Meg Frizzola, DO ^g,^h, Roni Lane, MD ⁱ, Julia Lloyd, MD ^j, Elliot Melendez, MD ^k, Nikhil Patankar, MD, MBA ^l, Lori Rutman, MD, MPH ^m,ⁿ, Amanda Sebring, MD ^o, Zebulon Timmons, MD ^p, Halden F. Scott, MD, MSCS ^q
for the
IPSO collaborative investigators^¹
IPSO collaborative investigators are found in the supplementary meterial (Collaborative investigators).
Jeffery J. Auletta, MD, Katie Barchi, MSN RN, Benjamin R. Braun, MD MS, Richard J. Brilli, MD, FAAP, MCCM, Deborah R. Campbell, RN-BC, MSN, CPHQ, T-CHEST, CCRN alumna, Richard E. Chinnock, MD MHCM, Jacqueline B. Corboy, MD MS, Holly E. Depinet, MD, Jill Dykstra-Nykanen, RN MSN CPHQ, Karen A. Genzel, MSN APRN ACCNS-P CPEN, Hana Hakim, MD MS CIC, Jonathan D. Hron, MD, Leslie A. Hueschen, MD, W. Charles Huskins, MD MSc, Sarah B. Kandil, MD, Yu Kawai, MD, V. Matt Laurich, MD, Jeremy M. Loberger, MD, Charles G. Macias, MD MPH, Joan E. Mackenzie, MS APRN CPNP, Elizabeth H. Mack, MD MS, Ashish S. Nagpal, MD, Matthew Niedner, MD, Daniel B. Park, MD MBA, Faisal Razzaqi, MD, Wendi S. Redfern, MSN RN ACNS-BC CCRN, Johanna R. Rosen, MD, Ranna A. Rozenfeld, MD FAAP FCCM, Sam Selby, DO, Matthew P. Sharron, MD, Jonathan A. Silverman, MD MPH, Lawrence D. Spack, MD FAAP, Erika L. Stalets, MD MS, Roopa Thukaram, MD, Beth A. Wathen, MSN RN CCRN-K, Jennifer J. Wilkes, MD MSCE, Jennifer K. Workman, MD MSCI, Jennifer C. Zuccaro, MD

^a Division of Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Boston, MA
^b Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
^c Children’s Hospital Association, Lenexa, KS
^d Division of Emergency Medicine, Advocate Children’s Hospital, Park Ridge, IL
^e Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
^f Division of Pediatric Critical Care, Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA
^g Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
^h Department of Pediatrics, Thomas Jefferson University, Wilmington, DE
ⁱ Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City, UT
^j Division of Pediatric Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
^k Division of Pediatric Critical Care, Connecticut Children’s Medical Center, Hartford, CT
^l Beacon Critical Kids, Beacon Children’s Hospital, Beacon Health System and Indiana University School of Medicine, South Bend, IN
^m Department of Pediatrics, University of Washington, Seattle, WA
ⁿ Division of Emergency Medicine, Seattle Children’s Hospital, Seattle, WA
^o Division of Pediatric Critical Care, Department of Pediatrics, Levine Children’s Hospital, Charlotte, NC
^p Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital and Medical Center Omaha, Omaha, NE
^q Section of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO

^∗Corresponding Author.

Abstract

Study objective

To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock.

Methods

This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure.

Results

Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.)

Conclusion

In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Objective

Population

Data Collection

Variables and Outcomes

	Please see page 214 for the Editor’s Capsule Summary of this article.
	Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: MAE and HFS conceptualized the study, created the study design, analyzed the data, and drafted the manuscript. RP and FB conceptualized the study, created the study design, analyzed the data, and reviewed and revised the manuscript. RR, TR, and HGD created the study design, collected and managed the data, performed statistical analysis, and reviewed and revised the manuscript. MKA, TKMD, MF, RL, JL, EM, NP, LR, AS, and ZT participated in study design and data analysis and reviewed and revised the manuscript. The IPSO collaborative investigators collected and managed data, including quality control, and reviewed the manuscript. MAE takes responsibility for the paper as a whole.
	All authors attest to meeting the four ICMJE.org authorship criteria:(1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Scott’s institution received career development salary support for this article from the Agency for Healthcare Research and Quality (K08HS025696). Dr. Huskins is a member of the Advisory Board, ADMA Biologics; member of the Endpoint Adjudication Committee, Pfizer; and holds stock in Pfizer, Bristol Meyers Squibb, and Zimmer Biomet. Drs. Balamuth, Brilli, Macias, Neidner, Paul, Richardson and Scott, and Ms. Riggs and Ms. DeSouza, as members of the Improving Pediatric Sepsis Outcomes Steering Committee, received travel support from the Children’s Hospital Association for attendance at biannual leadership meetings. Supported by the Children’s Hospital Association and Quality Improvement Learning Collaborative participant fees and in-kind support from the Children’s Hospital Association.
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Vol 80 - N° 3

P. 213-224 - septembre 2022 Retour au numéro

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Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock - 20/08/22

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