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Fluid Resuscitation in Septic Shock

Question Type:
Intervention
Full Question:
Among infants and children who are in septic shock in any setting (P), does I1 - does the use of restrictive volumes of resuscitation fluid (less than 20 mL/kg)

I2 - or the use of noncrystalloid fluids (I), compared with C1 - when compared with nonrestrictive volumes (greater than or equal to 20 mL/kg)

C2 - when compared with crystalloid fluids (C), change survival to hospital discharge, Need for mechanical ventilation or vasopressor support, complications, Time to resolution of Shock, hospital length of stay, ventilator free days, total IV fluids administered (O)?
Consensus on Science:
For the critical outcome of survival to hospital discharge, for the use of restrictive fluids in sepsis/septic shock, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 pediatric RCT(Santhanam 2008, 647-655) enrolling 147 patients showing no benefit (RR, 0.99; 95% CI, 0.86–1.16), and from 1 observational pediatric study(Carcillo 1991, 1242-1245) enrolling 34 patients showing no benefit (RR, 0.71; 95% CI, 0.35–1.44). For the use of restrictive fluids in severe malaria, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 2 pediatric RCT(Maitland 2005, 393-400; Maitland 2005, 538-545) enrolling 106 patients showing no benefit (RR, 1.09; 95% CI, 0.94–1.27). For the use of restrictive fluids in dengue shock syndrome, we identified no studies. For the use of restrictive fluids in “severe febrile illness” with some but not all signs of shock, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Maitland 2011, 2483-2495; Maitland 2013, 68) enrolling 2091 patients showing benefit (RR, 1.05; 95% CI, 1.03–1.07). For the critical outcome of survival to hospital discharge, for the use of noncrystalloid fluids in sepsis/septic shock, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 pediatric RCT(Upadhyay 2005, 223-231) enrolling 60 patients showing no benefit (RR, 1.13; 95% CI, 0.77–1.63). For the use of noncrystalloid fluids in severe malaria, we identified no studies. For the use of noncrystalloid fluids in dengue shock syndrome, we identified moderate-quality evidence (downgraded for risk of bias) from 4 pediatric RCTs(Dung 1999, 787-794; Ngo 2001, 204-213; Cifra 2003, 95-100; Wills 2005, 877-889) enrolling 682 patients showing no benefit (RR, 0.98; 95% CI, 0.96–1.00). For the use of noncrystalloid fluids in “severe febrile illness” with some but not all signs of shock, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 pediatric RCT(Maitland 2011, 2483-2495) enrolling 2097 patients showing no benefit (RR, 0.99; 95% CI, 0.97–1.03). For the critical outcome of complications (need for transfusion and diuretic therapy), for the use of restrictive fluids in sepsis/septic shock, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, imprecision) from 1 observational pediatric study(Carcillo 1991, 1242-1245) enrolling 34 patients showing no benefit (RR, 1.43; 95% CI, 0.71–2.88). For the use of restrictive fluids in severe malaria, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 2 pediatric RCTs(Maitland 2005, 393-400; Maitland 2005, 538-545) enrolling 106 patients showing no benefit (0% versus 5.4%; P=0.09). For the use of restrictive fluids in dengue shock syndrome, we identified no studies. For the use of restrictive fluids in “severe febrile illness” with some but not all signs of shock, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 pediatric RCT(Maitland 2011, 2483-2495) enrolling 2091 patients showing no benefit (RR, 0.59; 95% CI, 0.3–1.17). For the critical outcome of complications (need for transfusion and diuretic therapy), for the use of noncrystalloid fluids in sepsis/septic shock, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 pediatric RCT(Upadhyay 2005, 223-231) enrolling 60 patients showing no benefit (RR, 1.18; 95% CI, 0.48–2.87). For the use of noncrystalloid fluids in severe malaria, we identified very-low-quality evidence (downgraded for imprecision) from 1 observational pediatric study(Maitland 2003, 426-431) enrolling 52 patients showing no benefit (0% versus 0%). For the use of noncrystalloid fluids in dengue shock syndrome, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 4 pediatric RCTs(Dung 1999, 787-794; Ngo 2001, 204-213; Cifra 2003, 95-100; Wills 2005, 877-889) enrolling 682 patients showing no benefit (RR, 1.3; 95% CI, 0.95–1.79). For the use of noncrystalloid fluids in “severe febrile illness” with some but not all signs of shock, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 pediatric RCT(Maitland 2011, 2483-2495) enrolling 2097 patients showing no benefit (RR, 1.17; 95% CI, 0.68–2.02). For the critical outcome of complications (need for rescue fluid), for the use of restrictive fluids in sepsis/septic shock, we identified no studies. For the use of restrictive fluids in severe malaria, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 2 pediatric RCTs(Maitland 2005, 393-400; Maitland 2005, 538-545) enrolling 106 patients showing harm (17.6% versus 0.0%; P
Treatment Recommendation:
We suggest using an initial fluid bolus of 20 mL/kg for infants and children with shock, with subsequent patient reassessment, for patients with the following disease states:• Severe sepsis (weak recommendation, low quality)• Severe malaria (weak recommendation, low quality)• Dengue shock syndrome (weak recommendation, low quality)We suggest against the routine use of bolus intravenous fluids (crystalloids or colloids) for infants and children with a “severe febrile illness” and who are not in shock (weak recommendation, low-quality evidence). Reassessment, regardless of therapy administered should be emphasized so that deterioration is detected at an early stage.Values, Preferences, and Task Force InsightsIn making these recommendations, we place a higher value on allocating resources to the frequent assessment of infants or children with some or all signs of shock and to reassessment of a patient’s response to fluid therapy or development of complications over any unproven benefit for critical or important outcomes.
CoSTR Attachments:
Peds 545-Resuscitation Fluids_SOF_n.docx    

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