Time to vasoactive agents initiation, restricted volume resuscitation effect on fluid balance and clinical outcomes in children with septic shock

Abstract Background Several studies have shown that positive fluid balance is associated with worse outcomes in pediatric severe sepsis and septic shock patients. Early vasopressor administration in children with septic shock after ≤ 40 cc/kg of fluid bolus may be beneficial. Methods This is a retrospective analytic study in children with septic shock (aged between one month and 18 years from 2012–2020.) They were recruited at a referral tertiary university hospital in Bangkok, Thailand and were treated with either restricted volume resuscitation (≤ 40 cc/kg of fluid bolus) combined with vasopressors or standard volume resuscitation. The clinical effect on fluid balance and other outcomes were measured. Results One hundred and forty-three patients were diagnosed with septic shock. Ninety-three patients started vasoactive agents at ≤ 40 mL/kg (study group) compared to 50 patients who started the vasopressor drugs after 40 mL/kg of fluid bolus (control group). Volume administered at 6, 24 and 48 hours in study group was significantly less than control group (p < 0.001). There was a trend of higher %Fluid Overload (%FO) at 24 to 72 hours in control group but it was not statistically significant. %FO at 24 hours was significantly correlated with time initiation of vasoactive agent (R2 = 0.17, p = 0.03) and length of PICU stay (R2 = 0.2, p = 0.02). In addition, the multivariate analysis showed that initial serum level of albumin was less than 3 g/dL and positive %FO of more than 10% at 24 hours significantly increased mortality by 6.3 (95% CI, 1.25 to 32.12; p = 0.03) and 6.1 folds (95% CI, 1.47 to 25.46; p = 0.01), respectively. Conclusion There was a trend of decreasing %FO overtime in study group compared to the control group. Time initiation of vasoactive agent and %FO significantly correlated with prolonged PICU stay.