Published online May 4, 2018. doi: 10.5492/wjccm.v7.i2.31
Peer-review started: February 7, 2018
First decision: March 7, 2018
Revised: March 12, 2018
Accepted: April 22, 2018
Article in press: April 22, 2018
Published online: May 4, 2018
Pediatric trainees are often the first responders at the bedside for evaluation and ongoing management of children presenting with various shock states, yet there is little data on how they navigate through these decisions or how confident they feel in making these decisions. We conducted a survey of pediatric trainees all over the United States. Our study is the first study to survey in the literature studying fluid administration practices of trainees.
The motivation for performing this research was to uncover common situations where pediatric trainees faced a significant decisional conflict when treating shock. We also aimed to uncover some common situations where under-resuscitation was common and to highlight cognitive biases and fallacies of trainees while assessing and treating children with shock.
One of the study objectives was to assess level of adherence and confidence level with American College of Critical Care Medicine (ACCM) guidelines which are universally followed in the United States for treatment of septic shock. Additionally, we wanted to assess degree of reliance on central venous pressure, resuscitation in children with ongoing cardiac comorbidity. We also sought to discover if there were significant differences in treatment practices of more advanced level trainees such as pediatric critical care, hospital medicine and emergency medicine fellows. All these objectives were realized, and can help in training and supporting pediatric residents for management of shock.
We conducted a nationwide survey of all pediatric trainees in the United States. This included residents at all levels of training, and fellows training in one of the subspecialties of pediatrics. The survey was voluntary and anonymous. Statistics were primarily descriptive, and SPSS was used for performing additional statistical testing.
We found that pediatric trainees across all levels of training faced a high degree of uncertainty and lack of confidence while they were making decisions regarding fluid administration in children presenting with shock. ACCM guidelines are frequently cited, yet blood pressure goals cited in the ACCM guidelines are often not met, nor is a suboptimal blood pressure recognized. Children with coexisting cardiac comorbidities may be prone to severe under-resuscitation for fear of cardiac failure causing pulmonary edema. Fever is an important confounding factor often delaying recognition of shock. This study sheds light on these important observations, and further prospective observational studies are warranted which study decision-making of trainees.
This study is the first study on how trainees in pediatrics make decisions for treatment of shock. It is vital that shock be recognized and treated rapidly, yet there are no studies looking at how confident trainees feel in their judgment. This study points to a very low level of confidence when treating shock, and some common situations which should be highlighted to trainees while caring for patients or in simulated scenarios.
Pediatric trainees should be supported adequately and provided focused teaching related to treatment of shock states in children. Children with malignancy and cardiac comorbidity who present with septic shock are a uniquely vulnerable population prone to under-resuscitation and should be managed by expert physicians. Central venous pressure should be interpreted with caution and not used in isolation without entire clinical picture.