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Don’t Drown Them Babies – Does 30 mL/kg Reduce Pediatric Septic Shock Mortality?

July 12, 2022

Written by Clay Smith

Spoon Feed
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.

Another Spoonful

  • 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.

What are your thoughts?