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reversal was titrated to central venous pressure (CVP) and ScvO2 or
hypotension/shock index reversal. Pediatric studies have also demonstrated
improved survival with timely fluid resuscitation, and continuous monitoring of
ScvO2 . Recent data from New York State demonstrated that completion of a 1hour bundle of blood cultures, broad-spectrum antibiotics, and a 20-mL/kg IV
fluid bolus was associated with a lower risk-adjusted odds of hospital mortality in
children with sepsis and septic shock (aOR 0.59, 95% CI 0.38–0.93). There is
increasing interest in definitively answering questions about both appropriate
volume and type of crystalloid fluid resuscitation in pediatric sepsis, and several
ongoing clinical trials are attempting to answer these questions.

Global Considerations
The efficacy of fluid resuscitation in pediatric sepsis has been questioned in the
FEAST trial which demonstrated increased mortality in children with septic
shock who received rapid and large-volume fluid resuscitation. Several concerns
have been raised that these findings were specific to the local host population
with a high prevalence of malaria, severe anemia, and low availability of critical
care interventions, and also that the definition of shock may differ between this
study and others. However, this study was a robust trial, and certainly raises the
possibility that caution should be taken with fluid resuscitation in certain
populations of children with sepsis, especially those with severe anemia and
malnutrition.

American College of Critical Care Medicine and Surviving
Sepsis Campaign Recommendations
Based on available data, current sepsis guidelines recommend antibiotic
administration within 1 hour of recognition of septic shock, as well as prompt
fluid resuscitation in adults and children. In addition, timely sepsis care has been
identified as a quality metric at many pediatric institutions in the United States.
Several pediatric institutions have successfully implemented protocol-based
sepsis care and have demonstrated associated improvements in the delivery of
timely sepsis care. These improvements have been associated with reduced ICU

and hospital length of stay and lower hospital mortality. However, although there
is clear data outlining poor outcomes with long (>3-hour) antibiotic delays in
pediatric sepsis, the importance of the 1-hour cut-point has not been firmly
established.

Quality Metrics in Pediatric Sepsis