We read with interest the recently published update to an algorithm for the early recognition and treatment of meningococcal disease in children.1 Of note there is a change to the recommended trigger point for tracheal intubation. The previously recommended trigger point has moved from after 40 ml/kg of fluid resuscitation in the face of persistent shock to after 60 ml/kg of fluid resuscitation. This is following consideration of the work of Carcillo et al who recommend that up to 200 ml/kg (average 40–60 ml/kg) of fluid resuscitation may be required in the first hour of resuscitation in septic shock.2 This is based on level II evidence. Although early intubation in fluid refractory septic shock is desirable, the trigger for tracheal intubation should not be based solely on the volume of resuscitation fluid administered; the trigger should be based on clinical need. Indeed, Carcillo et al recommend that the decision to intubate and ventilate in septic shock should be based on the presence of the clinical findings of increased work of breathing, hypoventilation, impaired mental status or the presence of a moribund state. The current algorithm as published may result in patients being intubated unnecessarily; as this is not without considerable risk in this cohort of patients, this presents a significant patient safety issue.
The time course over which fluid is administered is also very important: 60 ml/kg given over minutes will precipitate a very different physiological response to 60 ml/kg given over several hours. The optimal time course of rapid volume expansion is within the first hour of resuscitation; however, this time course is often delayed. The resultant redistribution of fluid over time may negate the need for tracheal intubation in some cases and this should be reflected in the algorithm.
If we examine the adult data of Rivers et al looking at early goal‐directed therapy in septic shock, we find that early and generous fluid resuscitation reduced the number of shocked patients who required tracheal intubation and ventilation.3 If these data are extrapolated to the paediatric population they suggest that early, aggressive fluid resuscitation may reverse the progression of septic shock and circumvent the need for tracheal intubation.
This algorithm has contributed to more effective resuscitation of patients with meningococcal septicaemia and septic shock in general. However, without more robust evidence we believe that the indication for tracheal intubation in septic shock should be based on clinical criteria and not the volume of fluid infused during initial resuscitation.
Footnotes
Competing interests: None.
References
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