Relationship of Fluid Administration Amount and Resuscitation Response

toward Mortality Rate in Pediatric Patients with Shock

Kurniawan T Kadafi
Pediatric Department, Faculty of Medicine, Brawijaya University
Abstract
Objective: To determine the relationship between amount of fluid given to shock patient at first
hour after diagnosis with mortality rate and relationship between fluid resuscitation response
with mortality rate.
Methods: Prospective study in twenty-five patients with septic shock and non-septic shock who
were diagnosed in the Emergency Room (ER), High Care Unit (HCU), Pediatric Intensive Care
Unit (PICU) and pediatric ward in Saiful Anwar Hospital. The study were held on January 1,
2014 until May 31, 2014.
Results: From 25 subjects with age ranged from 1-18 years, 36% (9/25 patients) diagnosed with
septic shock and 64% (16/25 patients) diagnosed with non-septic shock. Total mortality rate of
all shock patients was 44% (11/25 patients). All septic shock patients which received 20-40 cc/
kg of fluid resuscitation remains alive, whereas all patients receiving fluid 40 cc / kg were
died. Septic shock patients and non-septic shock which receive fluids resuscitation at 40 cc/kg
has mortality rate of 66.7%. 100% of patients who responsive toward fluid resuscitation remains
alive, while unresponsive patients with fluid resuscitation and inotropic drugs has mortality rate
of 57.9%.
Conclusion: Fluid resuscitation over 40cc / kg is related with increase of mortality rate. Patients
responsiveness against fluid resuscitation is associated with decrease of mortality rate.
Introduction
Shock is one of the most frequently encountered problems in emergency condition such
as pediatric intensive care unit (PICU). Shock described as clinical syndrome which is caused by
interference or delivery of oxygen and nutrients substrate that induce failure of metabolic needs
fulfillment (1). Severe sepsis and septic shock considered as serious problem in children with 6080% mortality rate each year. In Saiful Anwar Hospital, septic shock mortality rate was
60%. Quick and accurate shock management in the first hour can improve patient outcomes,
either for septic or non septic shock (2, 3)
The American College of Critical Care Medicine (ACCM) issued an article in July 2002 entitled
Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock
which explains the initial resuscitation fluid resuscitation is essential for septic shock patients
survival. Health professionals should well understand shock criteria and fluid management thus
they can recognize early stages of shock (compensated shock) and able to do rapid fluid
correction with isotonic fluid to restore circulating volume. Early phase of shock symptoms
according to the American College of Critical Care Medicine were decreased perfusion
characterized by decreased mental status, capillary refill> 2 seconds (cold shock) or flash

capillary refill (warm shock), or bounding (warm shock) peripheral pulses, mottled cool
extremities (cold shock), or Decreased urine output <1 mL / kg / h. (4-6)
Timing and amount of fluid administration for resuscitation will also affects outcome of shock
patients. Incorrect fluid administration and long response time for fluid replacement in shock
patients, especially septic shock may increase mortality. (7)
The purpose of this study was to determine the relationship of fluid administration amount and
resuscitation response toward outcome in all patients with both septic and non-septic shock in
Pediatrics ward, IRD, High Care Unit and Pediatric Care Unit in Saiful Anwar Hospital.
Method
This study was conducted prospectively from January 1, 2014 until May 31, 2014 in the
Emergency Room (ER), High Care Unit (HCU), Pediatric Intensive Care Unit (PICU) and
pediatrics ward of Saiful Anwar Hospital. Shock and septic shock diagnosed according to the
American College of Critical Care Medicine shock criteria (3, 4, 6, 7). Pediatric patients (age 1
month - 18 years) which is diagnosed with shock grouped into septic shock and non-septic shock
group. Fluid resuscitation time was measured since patients diagnosed with shock (decreased
mental status, capillary refill> 2 seconds (cold shock) or flash capillary refill (warm shock), or
bounding (warm shock) peripheral pulses, mottled cool extremities (cold shock), or Decreased
urine output <1 mL / kg / h) arrive at the ER, HCU, PICU or even pediatrics ward of Saiful
Anwar Hospital. Analyzed variables were gender, shock type, nutritional status, fluid
administration amount, fluid resuscitation response, and clinical outcome. Liquid crystalloid and
colloid fluids was used for resuscitation. Correlation of fluid resuscitation amount, fluid
resuscitation response, and clinical outcome was analyzed using chi-square test.
Result
Characteristics of Subjects
25 subjects with age ranged from 1-18 years. A total of 36% (9/25) diagnosed with septic shock
and 64% (16/25) diagnosed with non-septic shock. Total mortality rate of shock patients was
44% (11/25 patients) (Table 1).
Variables

The study population (N = 25)

Sex n (%)
Male

14 (56)

Female

11 (44)

Type Shock
Septic Shock

9 (36)

Non Septic Shock

16 (64)

The amount of fluid within the first 1 hour

20 cc / kg

13 (52)

20-40 cc / kg

6 (24)

40 cc / kg

6 (24)

Nutritional Status
Malnutrition

4 (25)

Nutrition Less

7 (28)

Good Nutrition

12 (48)

Nutrition More

1 (43)

Obesity

1 (43)

Relationship amount of fluid administered and mortality

This research show that all septic shock patients which received 20-40 cc/ kg of fluid
resuscitation remains alive (100%), whereas all patients receiving fluid 40 cc / kg were died
(100%). Nevertheless, there were no significant relationship between all treatment groups and
mortality (p = 0.06) (Figure 1). Most of non-septic shock patients receiving 20 cc/kg and 20-40
cc/kg fluid resuscitation remains alive (Figure 2). Whereas septic and non-septic shock patient
receiving 40 cc/kg fluid resuscitation has the highest mortality rate (66.7%) (Figure 3), but there
were no significant relationship between all treatment groups and mortality (p = 0.087)

Figure 1. Mortality of patients with septic shock versus first- hour resuscitation volume (p =
0.06)

Figure 2. Mortality of patients with non-septic shock versus first- hour resuscitation volume (p =
0.87)
All of the patients whom responsive toward fluid resuscitation are remains alive (100%),
whereas 57.9% of patients whom unresponsive toward fluid resuscitation and inotropic drugs
were died. There is significant difference between the fluid resuscitation response and mortality
rate (p = 0.013).

Figure 3. Patients with septic and non-septic shock mortality versus first- hour resuscitation
volume (p = 0.21)

Discussion
Recognizing shock in children remains big challenge in developing countries, including
Indonesia. Many health professionals only able to recognize shock after patients experiencing
hypotension, whereas shock actually has been occurred before hypotension. Early shock
recognition will improve its clinical outcomes. (3, 8) Previous study show that the incidence of
septic shock is more common in boys (65%) than girls (35%), this is consistent with our study
whereas the incidence of both septic and non-septic shock was higher in boys (56%) rather than
girls (44%). (2) The overall mortality rate of shock remains high in both developed countries and
developing countries such as Indonesia. Oliviera et al, show that Brazils mortality rate of septic
shock patients in children aged less than 2 years is 44%, and more than 2 years is 72%. Cristiane
et al, reported that total mortality from septic shock was 39%. Mortality of septic shock in earlier
study in Malang is 60%, whereas our study mortality both septic and non-septic shock septic was
44%. (2, 7, 9)
Shock patient, especially septic shock is related to hypovolemia due to vasodilation, increase of
microvascular permeability and capillary leakage of proteins serum. Therefore, it is
recommended to administer of 20 ml/kg, up to 60 ml / kg fluid bolus in the first 1 hour of
resuscitation. In our study, all patients with septic shock received 20-40 cc/kg of fluid
resuscitation remains alive, whereas all patients receiving 40 cc/kg fluid resuscitation were
died. This is contrast with Joseph A. Carcillo et al, research which conclude that fluid
resuscitation with more than 40 cc / kg in the first hour was associated with increase of survival
rate, as well as lower incidence of persistent hypovolemia and prevent pulmonary
edema. Research done by Oliviera et al, show that septic shock patients who received fluid
resuscitation less than 40 cc / kg in the first hour will significantly increase its mortality
rate. This difference may due to simple and limited monitoring method in the study. To evaluate
the patient responsiveness after resuscitation whether they still need more fluids or not, we are
using Passive Leg Raising (PLR). (10, 11) We did not evaluate ultrasound monitoring to see
collapse of Vena Cava Inferior which is more sensitive to evaluate patient's responsiveness
toward fluid administration. Simple monitoring allows less accurate observation thus there is
possibility that the patient have fluid overload condition which is also may increase mortality
rate. Moreover, the results of our study have no significant statistical differences. (1, 3, 7) Excess
fluid administration which cause fluid overload can lead into increase length of stay in the PICU,
duration of use ventilators and increase of mortality rate. (12)
Non Septic shock describes as shock that is not included in septic shock criteria or other
distributive shock such as hypovolemic shock, cardiogenic shock and obstructive shock. In our
study, most patients with non-septic shock who received 20 cc/kg and 20-40 cc/kg remains alive
even though there is no significant differences. This study showed that non-septic shock require
less fluid for resuscitation. In cardiogenic shock, there are failure of cardiac compensatory
mechanisms to support the body hemodynamics. This was caused by cardiac pumping problem
rather than fluid volume loss. Whereas in hypovolemic shock, inadequate blood circulation
volume will be the main cause of failure to support body hemodynamics. Therefore, main

approach to tackle hypovolemic shock is fluid replacement. Contrast with septic shock or other
distributive shock which its main problem were vasodilatation and increased microvascular
permeability. This will cause similar condition with severe hypovolemia which require a lot of
fluid resuscitation. (8, 13)
Our research was contradict with Maitland research. Maitland show that using 20-40 cc /
kg of crystalloid fluid resuscitation or 5% albumin will increase mortality rate within 48 hours
and 4 weeks in pediatric patients with impaired perfusion in Africa. This condition may due to
different mechanism of impaired perfusion such as from lung compliance disorders, myocardial
dysfunction and increase of intracranial pressure. (14)
Shock will be responsive toward resuscitation that is given shortly after occurrence of
metabolic stress and acute decrease of oxygen delivery which cause decrease of ATP
production. (15) Research conducted by Cristiane et al, showed that mortality of shock patients
which responsive toward fluid resuscitation was 0%. This finding is consistent to our finding in
which all shock patients that responsive toward fluid administration remains alive. Responsive
patient respond toward fluid resuscitation will have its mortality rate decreased because increase
of intravascular volume will provide adequate improvement of oxygen delivery to the cell. (7, 9)
The mortality rate in patients with refractory or persistent shock in this study was 57.9%.
Research done by Gary Ceneviva show that refractory or persistent septic shock will have
mortality rate of 33%. High mortality in patients with refractory or persistent shock were
associated with myocardial dysfunction. In refractory shock, Cardiac Output maintenance is
required to to improve survival rates. (16) Refractory shock absolutely needs vasoactive drugs.
Refractory shock marked with appearance of overload signs after administration of 60 cc / kg of
fluid (15)
In conclusion rapid fluid resuscitation over 40cc / kg is associated with increase of
mortality rate. Patients who are responsive toward fluid resuscitation is associated with decrease
of mortality rate.
REFERENCES
1. Wheeler DS, Basu RK. Pediatric Shock: An Overview. The Open Pediatric Medicine
Journal. 2013;7:1-8.
2. Yuliarto S, Kadafi KT, Nugrahani IT, Aminingrum R, Asariati H. The Barrier of Surviving
Sepsis Campaign Guideline 2012 Implementation for Children at Tertiary Hospital. Jurnal
Kedokteran Brawijaya. 2013;28(1):49-52.
3. Carcillo JA, Davis AL, Zaritsky A. Role of Early Fluid Resuscitation in Pediatric Septic
Shock. JAMA. 1991;266:1242-5.
4. Brierley J, Carcillo JA, Choong K, Cornell T, DeCaen A, Deymann A, et al. Clinical practice
parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update
from the American College of Critical Care Medicine. Critical Care Medicine. 2009;37:66688.

5. Akech SO, Karisa J, Nakamya P, Mwanamvua Boga1 KM. Phase II trial of isotonic fluid
resuscitation in Kenyan children with severe malnutrition and hypovolaemia. BMC
Pediatrics 2010;10:71.
6. Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric
and neonatal patients in septic shock.
Jornal de Pediatria. 2002;78(6):449-66.
7. Oliveira C, Nogueira de S FR, Oliveira DSF, Gottschald AFC, Moura J, Shibata A, et al.
Time- and Fluid-Sensitive Resuscitation for Hemodynamic Support of Children in Septic
Shock: Barriers to the Implementation of the American College of Critical Care
Medicine/Pediatric Advanced Life Support Guidelines in a Pediatric Intensive Care Unit in a
Developing World. Pediatric Emergency Care. 2008;12:810-5.
8. Nadel S, Kisson N, Ranjit S. Recognition and intial management of shock. In: Nicholas DG,
editor. Rogers' Textbook of Pediatric Intensive Care: Lippincott Williams and Wilkins;
2008. p. 372-83.
9. Pizarro CF, Troster EJ, Damiani D, Carcillo JA. Absolute and relative adrenal insufficiency
in children with septic shock. Pediatric Critical Care. 2005;33:855-9
10. Marik PE, Monnet X, Teboul J-L. Hemodynamic parameters to guide fluid therapy

. Annals of Intensive Care. 2011;1(1):1-9.

11. Zhou-zhou Dong1 QF, Xia Zheng2, Heng Shi2. Passive leg raising as an indicator of f luid
responsiveness in patients with severe sepsis. World Journal Emergency Medicine.
2012;3(3):191.
12. Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is
associated with impaired oxygenation and morbidity in critically ill children. Pediatric
Critical Care Med. 2012;13(3):253-8.
13. Hobson MJ, Chima RS. Pediatric Hypovolemic Shock. The Open Pediatric Medicine
Journal, 2013, 7, (Suppl 1: M3) 10-15. 2013;7(1):10-5.
14. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, et al. Mortality
after Fluid Bolus in African Children with Severe Infection. New England Journal Medicine.
2011;364:2483-95.
15. Carcillo JA, Han K, Lin J, Orr R. Goal-Directed Management of Pediatric Shock in the
Emergency Departmen. Clinical Pediatric Emergency Medicine 2007;8:165-75.
16. Gary Ceneviva JAP, Frank Maffei and Joseph A. Carcillo. Hemodynamic Support in Fluidrefractory Pediatric Septic Shock. Pediatrics 1998;102:e19.