As part of the Improving Pediatric Sepsis Outcomes (IPSO) collaborative work effort, pediatric researchers set out to identify whether the amount of fluid given to patients presenting with hypotensive septic shock in the first hour is associated with sepsis-attributable mortality.
What was this specific study about and what were the results?
Eisenberg: This study looked at kids who came into the emergency department with septic shock and compared those who had gotten larger fluid volumes with those who received lower fluid volumes. The cutoff we chose was 30mL/kg, looking specifically at those who got above that threshold, compared with those who got below that threshold. Then we tried to figure out if there was a different outcome in terms of how long they stayed in the hospital, how likely they were to be admitted to the intensive care unit, placed on a ventilator or to need medications to keep their blood pressure up. And, ultimately, how likely they were to die from sepsis versus survive.
Scott: The primary finding was that in children with hypotensive septic shock—the most severe initial presentation of sepsis—in the first hour after arriving to the emergency department, there was no difference in mortality between those who received more than 30mL/kg and less than 30mL/kg as long as it was received in the first hour.
Previous studies have indicated a survival benefit to receiving more fluid, but it's unclear in some of those prior studies if getting more fluids meant getting faster care. This study was unique in that we had a large cohort of children who received fast care. That comparison was made possible by the work of the IPSO collaborative and the timely care that participating hospitals provided.
Why is this study important to sepsis care and quality improvement?
Eisenberg: On one hand it's what we call a negative study since we found was no difference in the primary outcome, mortality, between the groups. So if you look at it quickly you might mistakenly say it doesn't really matter how much fluid you give.
However, what the study really enforces is that, in line with the goals of the collaborative, timely care is crucial and that getting fluids and antibiotics into kids in a timely fashion is the biggest challenge and the most important aspect of sepsis care.
The second thing is that the amount of fluid that kids get really has to be individualized. There’s no substitute for giving fluid, carefully reassessing, considering the patient's comorbidities and their response to the fluid and making subsequent decisions based on that response.
Scott: This work represents the evolution and forward progress of pediatric sepsis quality for a long time, just getting recognition that sepsis was an emergency and required timely care was the first battle. Now we can refine it and be more specific about what individual patients need. This gives room for quality improvement collaboratives to focus on metrics that continue to be supported, like getting fluid in a timely way. Let's back off setting a volume as a target of quality—volume does not necessarily mean quality.
How should this research influence pediatric health care?
Eisenberg: At our hospital, one of our sepsis quality metrics was whether the patient got a specific amount of fluid in the first hour. Now we have changed our quality metrics to how quickly did the patient get their first bolus. That quality metric ultimately affects the care at the bedside. If clinicians are thinking in terms of timeliness rather than volume hopefully that allows resources to be marshaled to the things that are most important.
Scott: IPSO did something similar. This is tricky to do in quality improvement because we have current sets of best practices, and we also have continually evolving evidence. And when IPSO started, one of the optional quality measures was 60 mL/kg in the first hour and some hospitals adopted that and some didn't. However, as evidence and guidelines evolved, IPSO revised guidelines and removed that as a quality measure. We weren’t afraid to update our guidelines.
That's really the definition of a learning health system and that was really made possible by the infrastructure of CHA and investing in this really data intensive quality improvement program, having the analysts on site to run data and incorporate data from elsewhere. This kind of project and evolving smart guidelines shows what's possible when you invest in that data infrastructure.