World Federation of Pediatric Intensive Care and Critical Care Societies: Global Sepsis Initiative

Clinical Presentation and Outcomes among Children with Sepsis Presenting to a Public Tertiary Hospital in Tanzania

BACKGROUND

Pediatric sepsis causes significant global morbidity and mortality and low- and middle-income countries (LMICs) bear the bulk of the burden. International sepsis guidelines may not be relevant in LMICs, especially in sub-Saharan Africa (SSA), due to resource constraints and population differences. There is a critical lack of pediatric sepsis data from SSA, without which accurate risk stratification tools and context-appropriate, evidence-based protocols cannot be developed. The study's objectives were to characterize pediatric sepsis presentations, interventions, and outcomes in a public Emergency Medicine Department (EMD) in Tanzania.

METHODS

Prospective descriptive study of children (28 days to 14 years) with sepsis [suspected infection with ≥2 clinical systemic inflammatory response syndrome (SIRS) criteria] presenting to a tertiary EMD in Dar es Salaam, Tanzania (July 1 to September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and SDs, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambaréné Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested.

RESULTS

Of the 2,232 children screened, 433 (19.4%) met inclusion criteria, and 405 were enrolled. There were 247 (61%) subjects referred from an outside facility. Approximately half (54.1%) received antibiotics in the EMD, and some form of microbiologic culture was collected in 35.8% (n = 145) of subjects. In-hospital and EMD mortality were 14.2 and 1.5%, respectively, median time to death was 3 days (IQR 1-6), and median length of stay was 6 days (IQR 1-12). SIRS criteria, the AVPU score, and the LODS had low positive (17-27.1, 33.3-43.9, 18.3-55.6%, respectively) and high negative predictive values (88.6-89.8, 86.5-91.2, 86.8-90.5%, respectively) for in-hospital mortality.

CONCLUSION

This pediatric sepsis cohort had high and early in-hospital mortality. Current criteria and tested clinical scores were inadequate for risk-stratification and mortality prediction in this population and setting. Pediatric sepsis management must take into account the local patient population, etiologies of sepsis, healthcare system, and resource availability. Only through studies such as this that generate regional data in LMICs can accurate risk stratification tools and context-appropriate, evidence-based guidelines be developed.

The Epidemiology of Sepsis in Childhood

BACKGROUND

Sepsis, or systemic inflammatory response to infection, is a major childhood disease and a common cause of death in children. Despite its importance, a global perspective on the epidemiology and mortality of pediatric sepsis across the world is still lacking.

METHODS

A non-systematic review of the medical articles published in Medline from 2005 to 2015.

RESULTS

Studies suggest that there has been a rise in the number of pediatric sepsis cases along the last two decades, which may relate to the increased survival of preterm and low birth-weight infants and children with severe chronic conditions. Children living in low-income countries represent a vulnerable population for sepsis. Despite several initiatives to improve the diagnosis and early treatment of pediatric sepsis, the mortality resulting from pediatric sepsis remains high, ranging from 5% to 40%. Poor outcomes, however, do not seem to be related to the limitation of resources but to the delay in the recognition and early treatment of sepsis.

CONCLUSIONS

Educational efforts aiming to increase the awareness on sepsis by the general public and the adherence to the treatment guidelines by healthcare providers may result in significant improvements in sepsis survival. The global attention to pediatric sepsis, however, can only be achieved with the standardization of the definitions and the use of simple and sensitive diagnostic criteria that incorporate the differences in the necessities among different settings and the availability of local resources.

A trial to determine whether septic shock-reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy versus usual care (SQUEEZE): study protocol for a pilot randomized controlled trial

BACKGROUND

Current pediatric septic shock resuscitation guidelines from the American College of Critical Care Medicine focus on the early and goal-directed administration of intravascular fluid followed by vasoactive medication infusions for persistent and fluid-refractory shock. However, accumulating adult and pediatric data suggest that excessive fluid administration is associated with worse patient outcomes and even increased risk of death. The optimal amount of intravascular fluid required in early pediatric septic shock resuscitation prior to the initiation of vasoactive support remains unanswered.

METHODS/DESIGN

The SQUEEZE Pilot Trial is a pragmatic, two-arm, parallel-group, open-label, prospective pilot randomized controlled trial. Participants are children aged 29 days to under 18 years with suspected or confirmed septic shock and a need for ongoing resuscitation. Eligible participants are enrolled under an exception to consent process and randomly assigned via concealed allocation to either the Usual Care (control) or Fluid Sparing (intervention) resuscitation strategy. The primary objective of this pilot trial is to determine feasibility, based on the ability to enroll participants and to adhere to the study protocol. The primary outcome measure by which success will be determined is participant enrollment rate ("pass" defined as at least two participants/site/month, recognizing that enrollment may be slower during the run-in phase). Secondary objectives include assessing (1) appropriateness of eligibility criteria, and (2) completeness of clinical outcomes to inform the endpoints for the planned multisite trial. To support the nested translational study, SQUEEZE-D, we will also evaluate the feasibility of describing cell-free DNA (a procoagulant molecule with prognostic utility) in blood samples obtained from children enrolled into the SQUEEZE Pilot Trial at baseline and at 24 h.

DISCUSSION

The optimal degree of fluid resuscitation and the timing of initiation of vasoactive support in order to achieve recommended therapeutic targets in children with septic shock remains unanswered. No prospective study to date has examined this important question for children in developed countries including Canada. Recruitment for the SQUEEZE Pilot Trial opened on 6 January 2014. Findings will inform the feasibility of the planned multicenter trial to answer our overall research question.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01973907 , registered on 23 October 2013.

Emerging infection and sepsis biomarkers: will they change current therapies?

INTRODUCTION

Sepsis is a heterogeneous syndrome characterized by both immune hyperactivity and relative immune suppression. Biomarkers have the potential to improve recognition and management of sepsis through three main applications: diagnosis, monitoring response to treatment, and stratifying patients based on prognosis or underlying biological response.

AREAS COVERED

This review focuses on specific examples of well-studied, evidence-supported biomarkers, and discusses their role in clinical practice with special attention to antibiotic stewardship and cost-effectiveness. Biomarkers were selected based on availability of robust prospective trials and meta-analyses which supported their role as emerging tools to improve the clinical management of sepsis. Expert commentary: Great strides have been made in candidate sepsis biomarker discovery and testing, with the biomarkers in this review showing promise. Yet sepsis remains a dynamic illness with a great degree of biological heterogeneity - heterogeneity which may be further resolved by recently discovered gene expression-based endotypes in septic shock.

Epidemiology of Sepsis in Children Admitted to PICUs in South America

OBJECTIVES

To report the prevalence of sepsis within the first 24 hours at admission and the PICU sepsis-related mortality among critically ill children admitted to PICU in South America.

DESIGN

A prospective multicenter cohort study.

SETTING

Twenty-one PICU, located in five South America countries.

PATIENTS

All children from 29 days to 17 years old admitted to the participating PICU between June 2011 and September 2011. Clinical, demographic, and laboratory data were registered within the first 24 hours at admission. Outcomes were registered upon PICU discharge or death.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 1,090 patients included in this study, 464 had sepsis. The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively. The median age of sepsis patients was 11.6 months (interquartile range, 3.2-48.7) and 43% had one or more prior chronic condition. The prevalence of sepsis was higher in infants (50.4%) and lower in adolescents (1.9%). Sepsis-related mortality was 14.2% and was consistently higher with increased disease severity: 4.4% for sepsis, 12.3% for severe sepsis, and 23.1% for septic shock. Twenty-five percent of deaths occurred within the first 24 hours at PICU admission. Multivariate analysis showed that higher Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, the presence of two or more chronic conditions, and admission from pediatric wards were independently associated with death.

CONCLUSIONS

We observed high prevalence of sepsis and sepsis-related mortality among this sample of children admitted to PICU in South America. Mortality was associated with greater severity of illness at admission and potentially associated with late PICU referral.

Evaluating sepsis training for medical students and nonphysicians in Malawi

STUDY OBJECTIVE

This study aimed to evaluate whether (regarding the Surviving Sepsis Campaign [SSC] guidelines) the training of Malawis scarce medical staff is adequate. Hospitals in Malawi have a severe shortage of human resources and therefore rely heavily on junior staff. Sepsis is a leading cause of admission to hospitals particularly in resource poor countries. It is associated with a high mortality rate. The SSC guidelines have been developed to help frontline staff diagnose and treat patients with sepsis.

DESIGN

A questionnaire consisting of 10 multiple choice questions, which was to be completed before and after a teaching module.

SETTING

Anesthesia courses at the University of Malawi.

INTERVENTION

Participants had to answer the questionnaire before and after their teaching block on anesthetics and critical care. The medical students have a 2-week teaching block, and the nonmedical staff have an intensive 3-day training course. MBBS 1 was asked only once as a baseline.

PARTICIPANTS

168 medical students and 31 nonphysician staff returned 345 questionnaires (return rate, 97.1%).

MEASUREMENTS

A total of 345 anonymous multiple choice questionnaires were completed. The same questionnaire was then repeated after their teaching block on anesthesia and critical care (not MBBS 1). The aim was for us to assess the knowledge the students had of sepsis. Overall 67% of the questions were answered correctly (2299 correct answers of 3450). The MBBS IV students had an average score of 68% to 72%, and the MBBS I students had a score of 42%. The highest score was achieved by the nonphysician clinical staff after their teaching as they improved by 11% (65%-76%).

CONCLUSIONS

Medical students and health care workers have a lack of knowledge regarding the SSC guidelines which needs to be addressed via training. The medical student teaching was not as effective as the nonphysician clinical staff course, and therefore, we need to think about restructuring their teaching block by having an intensive "Sepsis Day" that focuses on the SSC guidelines.

Steroids in fluid and/or vasoactive infusion dependent pediatric shock: study protocol for a randomized controlled trial

Background

Physicians often administer corticosteroids for the treatment of fluid and vasoactive infusion dependent pediatric shock. This use of corticosteroids is controversial, however, and has never been studied in a pediatric randomized controlled trial (RCT). This pilot trial will determine the feasibility of a larger RCT on the role of corticosteroids in pediatric shock.

Methods/design

Steroids in Fluid and/or Vasoactive Infusion Dependent Pediatric Shock (STRIPES) is a pragmatic, seven-center, double-blind, pilot RCT. We aim to randomize 72 pediatric patients with fluid and vasoactive infusion dependent shock to receive either hydrocortisone or a saline placebo for 7 days or until clinical stability, whichever occurs first. The primary outcome of this pilot trial is the feasibility of recruitment, defined as the number of patients enrolled over a 1-year period. Secondary outcomes include the frequency of, and reasons for, open-label steroid use, protocol adherence, incidence of mortality and corticosteroid-associated adverse events, time to discontinuation of inotropes, and feasibility of blood sampling.

Discussion

Corticosteroids are used for the treatment of pediatric shock without sufficient evidence to support this practice. While there is a scientific rationale and limited data supporting their use in this setting, there is also evidence from other populations suggesting potential harm. The STRIPES pilot study will assess the feasibility of a larger, much needed trial powered for clinically important outcomes.

Trial registration

ClinicalTrials.gov: NCT02044159

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1365-6) contains supplementary material, which is available to authorized users.

Caregivers' Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation

PURPOSE

Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement.

METHODS

Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison.

RESULTS

Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism.

CONCLUSIONS

Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

Three diketopiperazines from marine-derived bacteria inhibit LPS-induced endothelial inflammatory responses

Diketopiperazine is a natural products found from bacteria, fungi, marine sponges, gorgonian and red algae. They are cyclic dipeptides possessing relatively simple and rigid structures with chiral nature and various side chains. Endothelial dysfunction is a key pathological feature of many inflammatory diseases, including sepsis. In the present study, three (1-3) of diketopiperazines were isolated from two strains of marine-derived bacteria. The compounds were investigated for their effects against lipopolysaccharide (LPS)-mediated endothelial inflammatory responses in vitro and in vivo. From 1 μM, 1-3 inhibited LPS-induced hyperpermeability, adhesion, and migration of leukocytes across a human endothelial cell monolayer and in mice in a dose-dependent manner suggesting that 1-3 may serve as potential scaffolds for the development of therapeutic agents to treat vascular inflammatory disorders.

Could Biomarkers Direct Therapy for the Septic Patient?

Sepsis is a serious medical condition caused by a severe systemic inflammatory response to a bacterial, fungal, or viral infection that most commonly affects neonates and the elderly. Advances in understanding the pathophysiology of sepsis have resulted in guidelines for care that have helped reduce the risk of dying from sepsis for both children and older adults. Still, over the past three decades, a large number of clinical trials have been undertaken to evaluate pharmacological agents for sepsis. Unfortunately, all of these trials have failed, with the use of some agents even shown to be harmful. One key issue in these trials was the heterogeneity of the patient population that participated. What has emerged is the need to target therapeutic interventions to the specific patient's underlying pathophysiological processes, rather than looking for a universal therapy that would be effective in a "typical" septic patient, who does not exist. This review supports the concept that identification of the right biomarkers that can direct therapy and provide timely feedback on its effectiveness will enable critical care physicians to decrease mortality of patients with sepsis and improve the quality of life of survivors.

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death

Purpose

Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.

Methods

A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.

Results

The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.

Conclusions

The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.

Standard instruction versus simulation: Educating registered nurses in the early recognition of patient deterioration in paediatric critical care

Identifying and stabilising deterioration in a child with significant clinical compromise is both a challenging and necessary role of the paediatric critical care nurse. Within adult critical care research, high fidelity patient simulation (HFPS) has been shown to positively impact learner outcomes regarding identification and management of a deteriorating patient; however, there is a paucity of evidence examining the use of HFPS in paediatric nursing education. The aim of this study was to investigate the effect of HFPS on nurses' self-efficacy and knowledge for recognising and managing paediatric deterioration. Further, participants' perceptions of the learning experiences specific to the identification and management of a deteriorating child were also explored. Registered nurses working in a tertiary-referral paediatric critical care unit were recruited for this quasi-experimental study. Using a pre-test/post-test control-group design, participants were assigned to one of two learning experiences: HFPS or standard instruction. Following the learning experience, nurses were also invited to participate in semi-structured interviews. 30 nurses participated in the study (control n=15, experiment n=15). Participants in the HFPS intervention were most likely to demonstrate an increase in both perceived self-efficacy (p=<0.01) and knowledge (p=<0.01). No statistically significant change was observed in control group scores. The mean difference in self-efficacy gain score between the two groups was 5.67 score units higher for the experiment group compared to the control. HFPS also yielded higher follow-up knowledge scores (p=0.01) compared to standard instruction. Ten nurses participated in semi-structured interviews. Thematic analysis of the interview data identified four themes: self-awareness, hands-on learning, teamwork, and maximising learning. The results of this study suggest that HFPS can positively influence nurses' self-efficacy and knowledge test scores specific to the recognition and management of paediatric deterioration.

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.

Corticosteroids in Pediatric Shock: A Call to Arms

OBJECTIVE

To identify the issues needing to be resolved to design, implement, and complete a definitive randomized controlled trial of adjunctive corticosteroid use in children with septic shock.

DESIGN

Pediatric studies from MEDLINE (1946 to January 2015) and Embase (1947 to January 2015) that addressed adrenal function or steroid use in critically ill children with systemic inflammatory response syndrome, sepsis, or septic shock were reviewed and their relevant points discussed.

RESULTS

There is considerable interest in the field of corticosteroids in pediatric septic shock, which has not as yet translated into a much needed randomized controlled trial. We found that the issues that need to be resolved include identification of the target population, achievement of individual and community equipoise, selection of a patient centered, clinically meaningful primary outcome measure, and consideration of the adverse effects of corticosteroids.

CONCLUSIONS

We strongly believe that the time has come to conduct a trial on the use of corticosteroids in pediatric septic shock and that the question to be answered is Will corticosteroids given to children with septic shock result in a benefit to some patients without resulting in harm to others? Answering this question will require a collaborative and committed effort on the parts of ethics boards, families, clinicians, and researchers to actually make it happen once and for all, and we propose an international planning meeting of interested parties to achieve agreement on these identified issues.

Electroacupuncture at Bilateral Zusanli Points (ST36) Protects Intestinal Mucosal Immune Barrier in Sepsis

Sepsis results in high morbidity and mortality. Immunomodulation strategies could be an adjunctive therapy to treat sepsis. Acupuncture has also been used widely for many years in China to treat sepsis. However, the underlying mechanisms are not well-defined. We demonstrated here that EA preconditioning at ST36 obviously ameliorated CLP-induced intestinal injury and high permeability and reduced the mortality of CLP-induced sepsis rats. Moreover, electroacupuncture (EA) pretreatment exerted protective effects on intestinal mucosal immune barrier by increasing the concentration of sIgA and the percentage of CD3+, γ/δ, and CD4+ T cells and the ratio of CD4+/CD8+ T cells. Although EA at ST36 treatments immediately after closing the abdomen in the CLP procedure with low-frequency or high-frequency could not reduce the mortality of CLP-induced sepsis in rats, these EA treatments could also significantly improve intestinal injury index in rats with sepsis and obviously protected intestinal mucosal immune barrier. In conclusion, our findings demonstrated that EA at ST36 could improve intestinal mucosal immune barrier in sepsis induced by CLP, while the precise mechanism underlying the effects needs to be further elucidated.

Sepsis guidelines: Suggestions to improve adherence

The context in which a sepsis guideline is to be used is important and to a large extent determines whether it will be implemented successfully. Factors such as lack of time and resources, lack of reimbursement and organizational constraints may also preclude adoption of guidelines. Thus, sepsis guidelines have been adapted to suit the resources in both resource rich and poor regions of the world. However, even when resources are present, physicians' may not follow guidelines due a myriad of reasons including a lack of agreement with the sepsis guideline or with guidelines in general, as well as lack of motivation and expectations of the desired outcomes. A holistic approach is necessary to address all issues that may be impediments to guideline adoption and adherence. This approach would include a rigorous transparent method to craft the guideline, which includes both clinicians and policy makers and addresses cultural and resource issues.

Procalcitonin: potential role in diagnosis and management of sepsis

Sepsis is an important cause of worldwide morbidity and mortality. Early recognition and diagnosis are keys to achieving improved outcomes. Procalcitonin has been widely investigated as a potential biomarker for sepsis. Furthermore, management of sepsis and other infectious disease is becoming increasingly complicated by the emergence of antibiotic resistant strains of pathogens. Good antibiotic governance is important in reducing the risk of the development of further antibiotic resistance. We reviewed the current literature on the use of procalcitonin in sepsis to determine whether it should be recommended for use in either of these roles. Procalcitonin should not be used as a stand-alone diagnostic test to rule-in or rule-out sepsis or bacterial infection, or for prognostication, in the absence of clinical judgment. Used as part of a clinical algorithm, however, it has been shown to reduce antibiotic prescribing in critical care environments and for respiratory tract infections.

In-hospital pediatric cardiac arrest in Honduras

OBJECTIVES

The objective of this study was to analyze the characteristic and the prognostic factors of in-hospital pediatric cardiac arrest (CA) in a public hospital Honduras.

METHODS

A prospective observational study was performed on pediatric in-hospital CA as a part of a multicenter international study. One hundred forty-six children were studied. The primary end point was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality.

RESULTS

Cardiac arrest occurred in the emergency department in 66.9%. Respiratory diseases and sepsis were predominant causes of CA. Return of spontaneous circulation was achieved in 60% of patients, and 22.6% survived to hospital discharge. The factors related with mortality were nonrespiratory cause of CA (odds ratio [OR], 2.55; P = 0.045), adrenaline administration (OR, 4.96; P = 0.008), and a duration of cardiopulmonary resuscitation more than 10 minutes (OR, 3.40; P = 0.012).

CONCLUSIONS

In-hospital CA in children in a developing country has low survival. Patients with nonrespiratory causes and those who need adrenaline administration and prolonged resuscitation had worse prognosis.

The passive leg raise test to predict fluid responsiveness in children--preliminary observations

OBJECTIVE

To assess whether the passive leg raising (PLR) test can predict fluid responsiveness in pediatric patients.

METHODS

This was a prospective observational study in a tertiary care pediatric center. Hemodynamic parameters including heart rate, stroke volume and cardiac output were assessed at baseline, after passive leg raising (PLR), at second baseline, and after volume loading (10 mL/kg normal saline in 10 min). Cutoff values of 7.5 and 10 % increase in cardiac index (CI) with passive leg raising were explored as predictors of volume loading response.

RESULTS

Overall, the changes in CI with passive leg raising varied widely and was a poor predictor of response to volume loading in children under 5 years of age. Of 40 patients, 23 had greater than 10 % increase in CI with PLR which predicted fluid responsiveness with a sensitivity of 94 % (95 % confidence interval 71,100) and specificity of 26 % (95 % confidence interval 10,48). Sensitivity was higher (100 % vs. 91 %) and specificity similar (27 % vs. 25 %) in predicting CI for those over 5 as compared to under 5 y, respectively. In patients over 5 y, simple linear regression revealed a positive correlation (R(2) = 21) while R(2) values were much lower (0-0.07) for those under 5 y.

CONCLUSIONS

Cardiac index changes after PLR varies widely in children and may be a poor predictor to volume loading in children under 5-y-old. However, in those over 5 y, PLR may be helpful in predicting fluid responsiveness in pediatric patients.

Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis

OBJECTIVES

Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock.

DESIGN

Retrospective observational study.

SETTING

PICU at an academic medical center.

PATIENTS

One hundred thirty patients treated for severe sepsis or septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure-free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74-277 min) and to first appropriate antimicrobial was 177 minutes (90-550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27-12.06) and 3.59 (95% CI, 1.09-11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45-16.2) and 4.92 (95% CI, 1.30-18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure-free days (16 [interquartile range, 1-23] vs 20 [interquartile range, 6-26]; p = 0.04).

CONCLUSIONS

Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.

An epidemiologic survey of pediatric sepsis in regional hospitals in China

OBJECTIVE

To determine the prevalence, treatment, and outcomes of sepsis at regional hospitals in Huai'an, Jiangsu, China.

DESIGN

Prospective data registry using a descriptive clinical epidemiologic approach through a collaborative network.

SETTING

Pediatric departments in 11 regional city and county referral hospitals serving 843,000 children (exclusive of neonates).

SUBJECTS

All admissions (n = 27,836) of patients from 28 days to 15 years old from September 1, 2010, to August 31, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 1,530 patients met the 2005 international consensus definition of sepsis, corresponding to an estimated incidence of 181/100,000 children, with 80% under 5 years old, and in 10% (153), severe sepsis or septic shock developed. The overall case fatality rate for sepsis was 3.5% (53/1,530) or 34.6% (53/153) in those in whom severe sepsis or septic shock developed. Treatment varied widely and in many instances did not conform to international guidelines as reflected by inadequate use of antibiotics, corticosteroids, vasoactive agents, and inotropes.

CONCLUSIONS

We first report the prevalence and outcome of pediatric sepsis based on a regional hospital network in China. The diverse treatment approaches and practice at low-level clinics suggest the need for clinical implementation of internationally recognized strategy to improve the care standard in resource-limited regional hospitals.

Systems for Paediatric Sepsis: A Global Survey

OBJECTIVES

To evaluate the resources available for early diagnosis and treatment of paediatric sepsis at hospitals in developing and developed countries.

METHODS

This was a voluntary online survey involving 101 hospitals from 41 countries solicited through the World Federation of Pediatric Intensive and Critical Care Societies contact list and website. The survey was designed to assess the spectrum of sepsis epidemiology, patterns of applied therapies, availability of resources and barriers to optimal sepsis treatment.

RESULTS

Ninety per cent of respondents represented a tertiary or general hospital with paediatric intensive care facilities, including 63% from developed countries. Adequate triage services were absent in more than 20% of centres. Insufficiently trained personnel and lack of a sepsis protocol was reported in 40% of all sites. While there were specific guidelines for sepsis management in 78% of centres (n = 100), protocols for assessing sepsis patients were not applied in nearly 70% of centres. Lack of parental recognition of sepsis and failure of referring centres to diagnose sepsis were identified as major barriers by more than 50% of respondents.

CONCLUSIONS

Even among centres with no significant resource constraints and advanced medical systems, significant deficits in sepsis care exist. Early recognition and management remain a key issue and may be addressed through improved triage, augmented support for referring centres and public awareness. Focussed research is necessary at the institutional level to identify and address specific barriers.

The role of high mobility group box 1 in innate immunity

With growing accounts of inflammatory diseases such as sepsis, greater understanding the immune system and the mechanisms of cellular immunity have become primary objectives in immunology studies. High mobility group box 1 (HMGB1) is a ubiquitous nuclear protein that is implicated in various aspects of the innate immune system as a damage-associated molecular pattern molecule and a late mediator of inflammation, as well as in principal cellular processes, such as autophagy and apoptosis. HMGB1 functions in the nucleus as a DNA chaperone; however, it exhibits cytokine-like activity when secreted by injurious or infectious stimuli. Extracellular HMGB1 acts through specific receptors to promote activation of the NF-κB signaling pathway, leading to production of cytokines and chemokines. These findings further implicate HMGB1 in lethal inflammatory diseases as a crucial regulator of inflammatory, injurious, and infectious responses. In this paper, we summarize the role of HMGB1 in inflammatory and non-inflammatory states and assess potential therapeutic approaches targeting HMGB1 in inflammatory diseases.

Global health care of the critically ill in low-resource settings

The care of the critically ill patient in low-resource settings is challenging because of many factors, including limitations in the existing infrastructure, lack of disposables, and low numbers of trained healthcare workers. Although cost constraints in low-resource settings have traditionally caused critical care to be relegated to a low priority, ethical issues and the potential for mitigation of the lethal effects of often reversible acute conditions, such as sepsis and traumatic hemorrhage, argue for prudent deployment of critical care resources. Given these challenges, issues that require prioritization include timely and reliable delivery of evidence-based or generally accepted interventions to acutely ill patients before the development of organ failure, context-specific adaptation and evaluation of clinical evidence, and sustained investments in quality improvement and health systems strengthening. Specific examples include fluid resuscitation algorithms for patients with sepsis and reliable, low-cost, high-flow oxygen concentrators for patients with pneumonia. The lessons from new research on clinical management and sustainable education and quality improvement approaches will likely improve the care of critically ill patients worldwide.

The Golden Hours in Paediatric Septic Shock—Current Updates and Recommendations

Introduction: Paediatric sepsis is a global health problem. It is the leading cause of mortality in infants and children worldwide. Appropriate and timely initial management in the first hours, often termed as the “golden hours”, has great impact on survival. The aim of this paper is to summarise the current literature and updates on the initial management of paediatric sepsis. Materials and Methods: A comprehensive literature search was performed via PubMed using the search terms: ‘sepsis’, ‘septic shock’, ‘paediatric’ and ‘early goal-directed therapy’. Original and review articles were identified and selected based on relevance to this review. Results: Early recognition, prompt fluid resuscitation and timely administration of antibiotics remain key in the resuscitation of the septic child. Use of steroids and tight glycaemic control in this setting remain controversial. Conclusion: The use of early goal-directed therapy has had significant impact on patient outcomes and protocolised resuscitation of children in septic shock is recommended. Key words: Child, Early goal-directed therapy, Emergency, Sepsis

Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP

BACKGROUND AND OBJECTIVE

The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear.

PURPOSE

To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children.

MATERIALS AND METHODS

Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded.

RESULTS

A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 μg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%.

CONCLUSIONS

A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.

State of the art in the clinical treatment of endotoxic shock

Sepsis is a major health problem and remains an important cause of death worldwide. The failure to convert advances in our understanding of the biologic features of sepsis into effective new therapies questions the current approach to the development of sepsis drugs, and suggests a need for newer and better clinical trial design. Blood purification for sepsis is a promising therapeutic strategy to improve survival and reduce organ failure in patients with severe sepsis and septic shock.

Mortality in a pediatric secondary-care hospital in post-conflict Liberia in 2009

OBJECTIVE

To describe and analyze the causes of death in a pediatric secondary-care hospital (run by Médecins sans Frontières), in Monrovia, Liberia, 6 years post-civil war, to determine the quality of care and mortality in a setting with limited resources.

METHODS

Data were retrospectively collected from March 2009 to October 2009. Patient charts and laboratory records were reviewed to verify cause of death. Additionally, charts of patients aged over 1 month with an infectious cause of death were analyzed for decompensated septic shock, or fluid-refractory septic shock.

RESULTS

Of 8,254 admitted pediatric patients, 531 died, with a mortality rate of 6.4%. Ninety percent of deaths occurred in children <5 years old. Most deaths occurred within 24 hours of admission. The main cause of death (76%) was infectious disease. Seventy-eight (23.6%) patients >1 month old with infectious disease met the criteria for septic shock, and 28 (8.6%) for decompensated or fluid-refractory septic shock.

CONCLUSION

Since the end of Liberia's devastating civil war, Island Hospital has improved care and mortality outcomes, despite operating with limited resources. Based on the available data, mortality in Island Hospital appears to be lower than that of other Liberian and African institutions and similar to other hospitals run by Médecins sans Frontières across Africa. This can be explained by the financial and logistic support of Médecins sans Frontières. The highest mortality burden is related to infectious diseases and neonatal conditions. The mortality of sepsis varied among different infections. This suggests that further mortality reduction can be obtained by tackling sepsis management and improving neonatal care.

Immunomodulation in sepsis: the role of endotoxin removal by polymyxin B-immobilized cartridge

Severe sepsis results in high morbidity and mortality. Immunomodulation strategies could be an adjunctive therapy to treat sepsis. Endotoxin is a component of gram-negative bacteria and plays an important role in the pathogenesis of septic shock when it is recognized by immune cells. Removal of endotoxin could be an effective adjunctive approach to the management of sepsis. Devices to adsorb endotoxin or inflammatory cytokines have been designed as a strategy to treat severe sepsis, especially sepsis caused by gram-negative bacteria. Polymyxin B-immobilized cartridge has been successfully used to treat patients with sepsis of abdominal origin. Although this cartridge was conceived to adsorb endotoxin, several other immunological mechanisms have been elucidated, and this device has also yielded promising results in patients with nonseptic respiratory failure. In this paper, we summarize the immune modulation actions of Polymyxin B-immobilized cartridge to explore its potential usefulness beyond endotoxin elimination.

Prognostic value of shock index in children with septic shock

OBJECTIVES

Septic shock is frequent in children and is associated with high mortality and morbidity rates. Early recognition of severe sepsis improve outcome. Shock index (SI), ratio of heart rate (HR) and systolic blood pressure (SBP), may be a good noninvasive measure of hemodynamic instability that has been poorly studied in children. The aim of the study was to explore the usefulness of SI as an early index of prognosis for septic shock in children.

METHODS

The study was retrospective and performed in 1 pediatric intensive care unit at a university hospital. The following specific data were collected at 0, 1, 2, 4, and 6 hours after admission: HR and SBP for SI calculation and lactate concentration. Patients were divided into 2 groups according to their outcome (death/survival).

RESULTS

A total of 146 children admitted with septic shock between January 2000 and April 2010 were included. Shock index was significantly different between survivors and nonsurvivors at 0, 4, and 6 hours after admission (P = 0.02, P = 0.03, and P = 0.008, respectively). Age-adjusted SIs were different between survivors and nonsurvivors at 0 and 6 hours, with a relative risk of death at these time points of 1.85 (1.04-3.26) (P = 0.03) and 2.17 (1.18-3.96) (P = 0.01), respectively. Moreover, an abnormal SI both at admission and at 6 hours was predictive of death with relative risk of 1.36 (1.05-1.76).

CONCLUSIONS

In our population of children with septic shock, SI was a clinically relevant and easily calculated predictor of mortality. It could be a better measure of hemodynamic status than HR and SBP alone, allowing for the early recognition of severe sepsis.

[Sepsis : putting knowledge into practice]

Sepsis is a complex systemic inflammatory reaction in response to an infection and must be treated as an emergency. The diagnosis of sepsis is often delayed even though early goal-directed resuscitation and therapy with antibiotics within the first hours can reduce sepsis-related mortality. This article presents the most important points concerning the pathophysiology, diagnosis and therapy of sepsis.

Preventing intensive care admissions for sepsis in tropical Africa (PICASTA): an extension of the international pediatric global sepsis initiative: an African perspective

BACKGROUND

The Global Sepsis Initiative recommends prevention of sepsis through immunizations, vitamins, breast feeding, and other important interventions. In our study, we consider a second set of proposals for preventing intensive care admissions for sepsis in tropical Africa, which have been specifically designed to further prevent ICU admissions for sepsis in the group A nation hospital setting.

OBJECTIVES

To reduce admissions with severe sepsis in an ICU of a group A nation through the identification of challenges leading to preventable, foreseeable, or nosocomial sepsis specific to our setting.

METHODS

Malawi is one of the poorest countries in the world. Lacking the ability to comply with standard sepsis treatment, we conducted over 4 years several studies, audits, and surveys to identify challenges leading to preventable pediatric sepsis in our setting. We developed a method to identify malnourished children through a "gatekeeper" in the theaters without any equipment, tried to implement the World Health Organization's Safe Surgery Campaign checklist, evaluated our educational courses for the districts to improve the quality of referrals, looked into the extreme fasting times discovered in our hospital, trained different cadres in the districts to deal with peripartal and posttraumatic sepsis, and identified the needs in human resources to deal with pediatric sepsis in our setting.

RESULTS

Six foci were identified as promising to work on in future. Focus 1: Preventing elective operations and procedures in malnourished children in the hospital and in the district: 134 of 145 nurses (92.4%) and even 25 of 31 African laymen (80.6%) were able to identify malnourished children with their own fingers. Focus 2: Preventing sepsis-related problems in emergencies through the implementation of the Safe Surgery Campaign checklist: only 100 of 689 forms (14.5%) were filled in due to challenges in ownership, communication responsibility, and time constraints. Focus 3: Preventing sepsis through the reduction of unwise referrals: our courses toward this topic reached 82-100% satisfaction of the 391 participants for relevance, presentation applicability, content, and teaching technique. Focus 4: Preventing sepsis-related problems through reduction of excessive fasting times in our hospital: necessity for action was documented by a mean fasting time of 10.2 hours (SD, 4.4 hr). Focus 5: Concentration on two extremely sepsis-relevant health challenges for children in Malawian districts, trauma and peripartal complications: numbers after our courses in the trained two districts showed a reduction in the maternal mortality rate (from 150.3 to 55 and 234.2 to 75.2), an inconclusive result for posttraumatic deaths and the identification of 44 future instructors. Focus 6: Implementation of a Master in Medicine (anesthesia and intensive care) and improvement of training in anesthesia for all cadres resulted in the first five anesthetic registrars in training and enhanced numbers in all other cadres in anesthesia dealing in own responsibility with pediatric sepsis.

CONCLUSIONS

Every hospital can try to improve sepsis prevention on a local level by the Preventing Intensive Care Admissions for Sepsis in Tropical Africa approach. This will help support the promotion of the regionally adjusted Global Sepsis Initiative guidelines and the future global implementation of feasible bundles as a gold standard for resource-poor countries.

Metabolomics as a novel approach for early diagnosis of pediatric septic shock and its mortality

RATIONALE

Septic shock is a significant cause of morbidity and mortality in the pediatric population. Early recognition of septic shock and appropriate treatment increase survival rate; thus, developing new diagnostic tools may improve patients' outcomes.

OBJECTIVES

To determine whether a metabolomics approach could be useful in the diagnosis and prognosis of septic shock in pediatric intensive care unit (PICUs).

METHODS

Serum samples were collected from 60 patients with septic shock, 40 PICU patients with systemic inflammatory response syndrome (not suspected of having an infection), and 40 healthy children. Proton nuclear magnetic resonance spectroscopy spectra were analyzed and quantified using targeted profiling methodology.

MEASUREMENTS AND MAIN RESULTS

Multivariate statistical analysis was applied to detect specific patterns in metabolic profiles and to highlight differences between patient samples. Supervised analysis afforded good predictive models and managed to separate patient populations. Some of the metabolite concentrations identified in serum samples changed markedly, indicating their influence on the separation between patient groups. These metabolites represent a composite biopattern of the pediatric metabolic response to septic shock and might be considered as the basis for a biomarker panel for the diagnosis of septic shock and its mortality in PICU.

CONCLUSIONS

Our results indicate that nuclear magnetic resonance metabolite profiling might serve as a promising approach for the diagnosis and prediction of mortality in septic shock in a pediatric population and that quantitative metabolomics methods can be applied in the clinical evaluations of pediatric septic shock.

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012

OBJECTIVE

To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.

DESIGN

A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.

METHODS

The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.

RESULTS

Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).

CONCLUSIONS

Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.