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

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 treat3.6); 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/m2. (Crit Care Med
2009; 37:666–688)
KEY WORDS: guidelines; sepsis; severe sepsis

http://www.learnicu.org/SiteCollectionDocuments/GuidelineHemodynamicSupport.pdf

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