Is There an Optimum Duration of Fluid Bolus in Pediatric Septic Shock? A Critical Appraisal of "Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial" by Sankar et al (Pediatr Crit Care Med 2017; 18:e435-e445)

Abstract

Objectives: To review the findings and discuss the implications of a longer duration for fluid boluses in the resuscitation of children with septic shock.

Data sources: We performed a PubMed.gov search using the criteria "Fluid Bolus" and "Children" and "Septic Shock," which yielded 29 references.

Study selection: One trial compared different durations of fluid boluses in pediatric septic shock and was therefore selected for critical appraisal. (Sankar J, Ismail J, Sankar MJ, et al: Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children with Septic Shock: A Randomized Controlled Trial. Pediatr Crit Care Med 2017; 18:e435-e445.) DATA EXTRACTION:: This trial compared the effectiveness of 20 mL/kg fluid boluses, in children with septic shock, given over 15-20 versus 5-10 minutes in terms of need for invasive ventilation and/or increase in oxygenation index by 5 from baseline at 6 and 24 hours post initial fluid resuscitation. The relative risk of the primary outcome was 0.62 (p = 0.04; 95% CI, 0.39-0.99) at 6 hours and 0.63 (p = 0.02; 95% CI, 0.42-0.93) at 24 hours.

Data synthesis: Fragility Index calculations for the primary outcomes of this trial were 1 and 2. Therefore, only one and two children would have needed different outcomes to have given nonsignificant p values greater than 0.05. Analysis of the results did not support the early stopping of this trial at the interim period.

Conclusions: The article reviewed does not support a change in practice to a longer duration of fluid bolus. The "push" technique for titration of fluid boluses in pediatric septic shock should continue to be the method of choice. Critical Care trials using binary outcomes as endpoints should publish Fragility Index results to aid interpretation and generate stronger conclusions.