Confidence level of pediatric trainees in management of shock states

Table 1 Clinical case scenarios and outcomes studied

Case	Scenario description	Clinical questions	Key clinical features	Expected interventions	Outcomes studied
1	A 5 yr-old girl is brought into the emergency department with fever, diarrhea and vomiting. She is drowsy and does not answer questions appropriately. Her vitals are as follows: Temp 38.4 °C, HR 168/min, RR 36/min, BP 90/45 (MAP 60) mmHg. She seems dehydrated with dry mucous membranes, is warm, flushed and has flash capillary refill. You diagnose septic shock and after getting two good IV lines for access, begin rapid fluid administration. You give her 60 mL/kg crystalloids over a period of 60 min, and one dose of antibiotics. At the end of this time, her vitals are as follows: Temp 38.4 °C, HR 165/min, RR 32/min, BP 96/40 (MAP 59) mmHg, capillary refill unchanged. What would be your next plan of action?	What would be your next plan of action (1) Do nothing at this point; (2) give an additional 20 mL/kg fluid bolus; (3) start a vasoactive medication; (4) need additional data to decide- please specify; (5) Other What factors were used for decision making? HR/BP/Cap refill/Response to fluid/other (specify) How confident are you in decision on a scale of 0 (not confident at all) to 4 (sure of decision)	Severe shock with altered mental status Ongoing shock with HR and MAP not at threshold levels per ACCM-PALS guidelines	Continue resuscitation with either fluid or vasoactive administration evaluate lactate, mixed venous saturations	Rationale in choosing fluid vs vasoactive, or vice versa Rationale for withholding resuscitation Confidence level in decision-making
2	You are caring for a 4 yr old in the PICU with severe septic shock due to lobar pneumonia. His first night of admission he received 60 mL/kg of crystalloids and 20 mL/kg of 5% albumin. When you see him this morning, he is barely arousable and has a cap refill time of 5 s. You insert an internal jugular line and a radial arterial line. His vitals at this time are as follows: Temp 37.5 °C, HR 152/min, RR 35/min, BP 100/45 (MAP 63) mmHg. His CVP is 8 mmHg. You obtain a blood gas from the A-line, and his lactate is 4.5 mmol/L. You decide to intubate to reduce oxygen consumption related to work of breathing. Despite adequate sedation, he persists to have tachycardia; vitals after intubation are as follows: Temp 37.5 °C, HR 168/min, BP 110/40 (MAP 63) mmHg, CVP 10 mmHg, cap refill time 5 s. You immediately have to escalate to very high ventilator settings with pressure control of 34 and PEEP of 10 to achieve acceptable oxygenation and ventilation. What would your next intervention be?	What would be your next plan of action (1) Do nothing at this point; (2) give an additional 20 mL/kg fluid bolus; (3) start a vasoactive medication; (4) need additional data to decide- please specify; (5) Other What factors were used for decision making? HR/BP/CVP/Cap refill/Response to fluid/other (specify) How confident are you in decision on a scale of 0 (not confident at all) to 4 (sure of decision)	Worsening hemodynamics after initiation of positive pressure ventilation	Resuscitate shock with fluid or vasoactives	Recognition of decrease in preload caused by initiating of positive pressure ventilation Interpretation of CVP in conjunction with higher intrathoracic pressures
3	While rotating through the Hematology Oncology unit, you are called to the bedside of a 12-yr old receiving maintenance chemotherapy for AML. She has developed a temperature of 39.3 °C. On exam she has a HR of 160/min, RR 32/min, BP 110/40 (MAP 63) mmHg, and cap refill of 3 s. She is known to have anthracycline-induced cardiomyopathy. You palpate her abdomen and notice that her liver is 3-4 cm, similar to earlier, she has no murmur or gallop, and a CVP transduced through her broviac is 6 mmHg. In the last 4 h, her urine output has reduced from 1.5 mL/kg·h to 0.3 mL/kg·h. You decide to cautiously give her a 10 mL/kg fluid bolus over half an hour to see the response. At the end of the bolus, her HR is now 154/min, BP is 106/46 (MAP 66) mmHg, CVP has increased to 8 mmHg. What would your next step be?	What would be your next plan of action (1) Do nothing at this point; (2) give an additional fluid bolus; (3) start a vasoactive medication; (4) need additional data to decide- please specify; (5) Other What factors were used for decision making? HR/BP/Cap refill/Response to fluid/other (specify) How confident are you in decision on a scale of 0 (not confident at all) to 4 (sure of decision)	Known cardiomyopathy with onset of shock Low CVP and absence of hepatomegaly Good response to fluid bolus	Continue fluid resuscitation	Rationale for halting or slowing resuscitation
4	You are caring for a 6 yr old girl admitted to the PICU after anaphylactic shock from a bee sting. She has required a lot of fluid in the 4 h since admission-a total of 60 mL/kg, and is currently on dopamine at 7 mg/kg per minute. She has a urine output of 1 mL/kg per hour. She is on 2 L NC, and her vitals are as follows: Temp 36.8 °C, HR 115/min, RR 16/min, BP 95/65 (MAP 75) mmHg, with flushed extremities and cap refill of 2 s. You insert an internal jugular line and when you transduce it, you get a CVP of 3 mmHg. What would you do next?	What would be your next plan of action (1) Do nothing- continue maintenance fluids; (2) give an additional 20 mL/kg fluid bolus; (3) increase vasoactive medication; (4) need additional data to decide- please specify; (5) other What factors were used for decision making? HR/BP/Cap refill/Response to fluid/other (specify) How confident are you in decision on a scale of 0 (not confident at all) to 4 (sure of decision)	Vital signs not suggestive of shock Incidentally transduced CVP level of 3 mmHg	Do not continue any further resuscitation	Percentage continuing fluid resuscitation based on isolated CVP value

ACCM: American college of critical care medicine; PALS: Pediatric advanced life support; MAP: Mean arterial pressure; CVP: Central venous pressure.

Table 2 Demographics of respondents

Demographics of respondents	n (%)
Total respondents	539 (100)
Medical students	37 (7)
Residents	393 (73)
Fellows	97 (18)
Attending physicians	12 (2)
Level of training- residents	3671 (100)
PGY-1	120 (33)
PGY-2	110 (30)
PGY-3	121 (33)
PGY-4	16 (4)
No response	26
Level of training- fellows	901 (100)
PGY-4	25 (28)
PGY-5	32 (35)
PGY-6	29 (32)
PGY-7	4 (4)
No response	7
Pediatric fellows’ specialty (97)
Pediatric critical care medicine 25 (26)
Pediatric emergency medicine 22 (23)
Neonatology 14 (14)
Pediatric hospital medicine 5 (5)
Pediatric cardiology 4 (4)
Other 27 (28)

¹Total number of respondents to this question from all survey takers.

Table 3 Responses to clinical scenarios

Scenario	Fluid bolus	Vasoactive	No further intervention/ need more data/other	Factors cited as important for decision-making	Percentage with low confidence
1-septic shock s/p 60 mL/kg fluid	38%	47%	15%	Capillary refill, response to fluid	36%
2-hemodynamic instability s/p initiation of positive pressure ventilation	20%	60%	20%	CVP, lactate	65%
3-shock with comorbid cardiomyopathy	39%	15%	46%	HR, BP	64%
4-anaphylaxis with resolved shock	29%	20%	51%	CVP	61%

s/p: Status post; CVP: Central venous pressure; HR: Heart rate; BP: Blood pressure.

Table 4 Preferences of non-experts vs experts

Scenario	Role	Bolus (% of total)	Vasoactive (% of total)	Other (% of total)	P value
1-septic shock with ongoing losses	Non-experts1 (n = 438) Experts1 (n = 52)	40	47	13	0.02
		25	50	25
2-worsening hemodynamics after intubation	Non-experts (n = 438) Experts (n = 52)	21	59	20	0.08
		11	73	16
3-shock in a child known to have cardiomyopathy	Non-experts (n = 438) Experts (n = 52)	39	15	46	0.77
		42	17	41
4-recovering anaphylactic shock with low CVP	Non-experts (n = 438) Experts (n = 52)	29	21	50	0.01
		25	8	67

¹Experts: Fellows in pediatric critical care, pediatric emergency medicine, and pediatric hospital medicine; Non-experts: All other respondents.