RESUMO
Our objective was to compare norepinephrine plus dobutamine versus epinephrine as the first-line agent in children with fluid refractory cold septic shock. DESIGN: Open-label randomized controlled study. SETTING: A single-center PICU from North India. PATIENTS: Children 2 months to less than 18 years old with fluid refractory cold septic shock. INTERVENTIONS: In the intervention group, norepinephrine and dobutamine were started and in the control group, epinephrine was started as the first-line vasoactive agent. The primary outcome was the proportion attaining shock resolution (attaining all the therapeutic endpoints) at 1 hour of therapy. MEASUREMENTS AND MAIN RESULTS: We enrolled 67 children: 34 in the norepinephrine plus dobutamine group (intervention) and 33 in the epinephrine group (control). There was no difference in shock resolution at 1 hour (17.6% vs 9%; risk ratio [RR], 2.0; 95% CI, 0.54-7.35; p = 0.25), 6 hours (76.4% vs 54.5%; RR, 1.69; 95% CI, 0.92-3.13; p = 0.06), and 24 hours between the intervention and control groups, respectively. Children in the norepinephrine plus dobutamine group attained shock resolution earlier (measured from starting of vasoactive agents to attaining all the therapeutic endpoints) (hazard ratio, 1.84 [1.1-3.08]). The difference in 28-day mortality was not significant (23.5% vs 39.3% in the intervention and control groups, respectively [RR, 0.59; 95% CI, 0.28-1.25]). CONCLUSIONS: In children with fluid refractory cold septic shock, with use of norepinephrine plus dobutamine as first-line agents, the difference in the proportion of children attaining shock resolution at 1 hour between the groups was inconclusive. However, the time to shock resolution was earlier in the norepinephrine plus dobutamine group. Also, fewer children in the intervention group were refractory to treatment. Further studies powered to detect (or exclude) an important difference would be required to test this intervention.
RESUMO
OBJECTIVE: To compare patient outcomes using the Pediatric Index of Mortality-3 (PIM-3) model with PIM-2 model for children admitted to the intensive care unit. METHODS: We prospectively recorded the baseline characteristics, variables of PIM-3 and PIM-2 at admission, and outcomes of children ≤17 years over a period of 11 months. We used Area Under Receiver Operating Characteristics (AU-ROC) curves and Goodness-of-fit (GOF) tests to determine which of the two models had better discrimination and calibration. RESULTS: Out of 202 children enrolled, 69 (34%) died. Sepsis and pneumonia were the common admitting diagnoses. The AU-ROC was better for PIM-3 (0.75) as compared to PIM-2 (0.69; P=0.001). The GOF-P value was 0.001 for both models, that indicated poor calibration of both (P<0.001). The AU-ROC curves were acceptable across different age and diagnostic sub-groups. CONCLUSION: PIM-3 had better discrimination when compared to PIM-2 in our unit. Both models had poor calibration across deciles of risk.
