Don’t Drown Them Babies – Does 30 mL/kg Reduce Pediatric Septic Shock Mortality?
July 12, 2022
Written by Clay Smith
In children with hypotensive septic shock, there was no 30-day mortality benefit to receiving ≥30 mL/kg isotonic fluid within the first hour.
Why does this matter?
Pediatric Surviving Sepsis guidelines recommend one to two 10-20 mL/kg isotonic fluid boluses in children with septic shock and abnormal perfusion when an ICU is available. In adults, there is a somewhat arbitrary goal of 30 mL/kg. What is the right fluid volume target in children: less than or ≥ 30mL/kg?
Is IPSO facto?
This was a retrospective study from the Improving Pediatric Sepsis Outcomes (IPSO) multicenter quality improvement collaborative, which included 1,204 propensity matched children with hypotensive septic shock. There was no 30-day mortality benefit for those who had ≥30 mL/kg vs <30 mL/kg fluid within the first hour of ED arrival. In a post-hoc, there was also no mortality difference if the cut point was less than or ≥40 mL/kg or if less than or ≥60 mL/kg. Although no amount of propensity matching can remove all bias from retrospective data, what I take away is that maybe I don’t need to give 2 x 20 mL/kg fluid boluses before I consider starting epinephrine in similarly ill children. If nothing else, I learn that more wasn’t better. As we are starting to learn in adults, it may be advantageous to start vasopressors sooner in septic children with poor perfusion or overt hypotension.
- I noticed this footnote in the 2020 Peds Surviving Sepsis: “Fluid in mL/kg should be dosed as ideal body weight.” Wow, I learn something new every day…I love this job!
- I can’t help it…just a few more common sense reminders from Ped Surviving Sepsis that are worth repeating.
- Check a glucose in sick kids.
- Consider stress-dose hydrocortisone in refractory shock.
- If children have ongoing fluid loss (i.e. profuse diarrhea), replace losses even if it means a lot of fluid.
- Check cardiac function in kids with poor perfusion or hypotension. Myocarditis may be subtle and does not need fluid.
Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock. Ann Emerg Med. 2022 May 28;S0196-0644(22)00245-1. doi: 10.1016/j.annemergmed.2022.04.008. Online ahead of print.