Early goal-directed therapy in pediatric septic shock: comparison of outcomes "with" and "without" intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*.

OBJECTIVE: To evaluate the effect of intermittent central venous oxygen saturation monitoring (ScvO(2)) on critical outcomes in children with septic shock, as continuous monitoring may not be feasible in most resource-restricted settings. DESIGN: Prospective cohort study. SETTING: PICU of a tertiary care teaching hospital. PATIENTS: Consecutive children younger than 17 years with fluid refractory septic shock admitted to our ICU from November 2010 to October 2012 were included. INTERVENTIONS: Enrolled children were subjected to subclavian/internal jugular catheter insertion. Those in whom it was successful formed the "exposed" group (ScvO(2) group), whereas the rest constituted the control group (no ScvO(2) group). In the former group, intermittent ScvO(2) monitoring at 1, 3, and 6 hours was used to guide resuscitation, whereas in the latter, only clinical variables were used. MEASUREMENTS AND MAIN RESULTS: The major outcomes were in-hospital mortality and achievement of therapeutic goals within first 6 hours. One hundred twenty children were enrolled in the study-63 in the ScvO(2) group and 57 in the no ScvO(2) group. Baseline characteristics including the organ dysfunction and mortality risk scores were comparable between the groups. Children in the ScvO(2) group had significantly lower in-hospital mortality (33.3% vs 54%; relative risk, 0.61; 95% CI, 0.4, 0.93; number needed to treat, 5; 95% CI, 3, 27). A greater proportion of children in exposed group achieved therapeutic endpoints in first 6 hours (43% vs 23%, p = 0.02) and during entire ICU stay (71% vs 51%, p = 0.02). The mean number of dysfunctional organs was also significantly lesser in ScvO(2) group in comparison with no ScvO(2) group (2 vs 3, p < 0.001). CONCLUSION: Early goal-directed therapy using intermittent ScvO(2) monitoring seemed to reduce the mortality rates and improved organ dysfunction in children with septic shock as compared with those without such monitoring.

Skin grafting for necrotizing fasciitis in a child with nephrotic syndrome.

Necrotizing fasciitis is a rare complication of nephrotic syndrome in children, with a high mortality rate. We report a case with successful outcome with judicious intravenous antibiotics and skin grafting of the bilateral lower thighs.