Early inotropic support without fluid bolus vs standard resuscitation in pediatric septic shock: A randomized controlled trial

Abstract

BACKGROUND

The current 2020 surviving sepsis guideline recommends fluid boluses of 10-20 mL/kg/bolus up to 40-60 mL/kg, but recent studies showed better outcomes when fluid boluses were restricted.

AIM

To analyze the outcome of initial resuscitation of septic shock without giving fluid bolus and early initiation of inotropes.

METHODS

In this open label, randomized controlled clinical trial conducted at the Pediatric Emergency Medicine unit of a tertiary care hospital in central India, patients aged 1 month to 14 years who were hospitalized for septic shock were randomly allocated (1:1) to receive either inotropes (Group I) or fluid bolus as per surviving sepsis guideline (Group F). We analyzed the primary endpoint (either the resolution of shock or the patient’s clinical status at 1 h from the initiation of resuscitation, whichever occurred first) by the intention-to-treat. Both the groups were compared in terms of reversal of shock, the mean time for reversal of shock, adverse effects including mortality at 48 h, and overall mortality.

RESULTS

Out of 119 patients with septic shock, 49 were included in the final analysis (24 patients in Group I and 25 patients in Group F. 16/49 (32.65%) patients had compensated shock, and 33/49 (67.35%) had hypotensive shock. During the initial resuscitation phase, shock resolved in all (100%) of the patients in Group I. In Group F only in 19/25 (76.00%) patients experienced resolution of shock. The mean time of resolution of shock was significantly shorter in Group I (83.98 + 42.02 min) compared with Group F (116.72 + 41.67 min, P = 0.015). Invasive mechanical ventilation was required in 34/49 (69.40%) and was comparable across the groups. In the comparator Group F, 16/25 (65.00%) of the patients had some features of fluid overload. There was no statistical difference in the initial vasoactive inotropic support score, the total duration of ventilation, total length of hospital stay, mortality at 48 h, and overall mortality across the two groups. In a subgroup analysis of patients with hypotensive shock, mortality at 48 h was significantly higher in patients of Group F (9/17, 52.94%) than in patients of Group I (3/16, 18.75%, P = 0.041). The overall mortality rate in the study subjects was 24/49 (49.00%), and it was positively correlated with the Pediatric Sequential Organ Failure Assessment- Lactate score and maximum vasoactive inotropic support scores.

CONCLUSION

The use of fluid boluses in pediatric septic shock is dubious and contributes to fluid overload. The management of septic shock in children involves the use of adjuncts such as bedside ultrasound, early inotropes, and restricted and well-regulated fluid boluses.

Keywords: Septic shock; Fluid restriction; Inotropes; Pediatrics; No flush

Core Tip: Recent surviving sepsis guidelines showed better outcomes when fluid boluses were restricted. This open-label study in children aged 1 month to 14 years who were hospitalized for septic shock were randomized into two groups: Group I receiving early inotropes without fluid bolus; and Group F receiving fluid bolus. There were no statistically significant differences in the initial inotropic support (vasoactive inotropic support score), the total duration of ventilation, total length of hospital stay, mortality at 48 h, or overall mortality between the two groups. Patients with hypotensive shock who received fluid boluses had significantly higher 48-h mortality.