Baca Jurnal ERIA

Fluid Overload in Children with

Severe Sepsis and Septic Shock

Abdi Dwiyanto Putra Samosir

Supervisor:

Dr. dr. Idham Jaya Ganda, Sp.A(K)

Dr. dr. St. Aizah Lawang, Sp.A(K)
 ABSTRACT
• Fluid therapy is one pillar of the treatment of septic shock,
however, a hydric≥10% of the weight or Fluid Overload (FO>10%)
is associated with poor hospital outcomes. The present study aims
to determine the FO in patients with septic shock, and its main
associations in terms of mortality and morbidity. An observational
and descriptive study was conducted in 49 hospitalized children
with septic shock in the PICU of the Manuel Ascencio Villarroel
Children’s Hospital (MAVCH);
• The patients were divided into two groups according to the
FO>10% (22 patients) and<10% (18 patients), for their descriptive
analysis we included comparison of means and calculation of the
OR. Regarding the water requirements, we observed that the
group with FO>10% a mean of 5681ml; while in the group with
ISCH<10% the mean was 3297.8ml (p=0.19) during first 72 hours,
showing greater overload with the administration of colloids and
blood products (p=0.02, p=0.004).
 ABSTRACT

• Regarding hospital outcomes, was found morbidity associated

with FO>10% (respiratory dysfunction, vasopressor
requirement and renal replacement therapy); The length of
hospitalization and FO were not different in groups (p=0.60),
but there was higher mortality of patients with FO>10%
(p=0.01, OR: 5.57 IC95% 1.4-21.8).
• Fluids therapy of in the patient with septic shock constitutes
one of the first-line hemodynamic treatments, however in
limited resources settings, overload should be avoided,
mainly due to associated morbidity during the first 72 hours.
INTRODUCTION
The incidence of severe sepsis
and septic shock varies between
20 and 30% in most pediatric
intensive care units (PICU) and is
one of the leading causes of
mortality

One of the pillars of septic shock

treatment is fluid therapy to
increase systolic volume and,
thus, the patient's cardiac output
as an initial resuscitation measure.

The present study sought to

determine the FO in patients with
septic shock admitted to the PICU of
the Manuel Ascencio Villarroel
Children's Hospital (MAVCH), and its
main associations based on
mortality and hospital stay.
 METHODS
An observational and descriptive study was
conducted in 49 children hospitalized with septic
shock in the MAVCH PICU, using a randomized
sampling of all admissions,

The FO was established according to the

following formula: Fluid overload index=((total of
liquids administrated - total of eliminated liquid) /
body weight of entry x 100),

In the statistical analysis, version 23.0 of the

SPSS Statistics® program was used. For the
qualitative variables with the Chi square test and
the Mann-Whitney U test.
RESULTS
DISCUSSION
• The mechanisms by which the increase in FO
influence the prognosis of patients with septic
shock are still under debate, it is considered that
a positive accumulated fluid balance is
associated with the development of systemic
hypoperfusion, tissue edema, respiratory and
renal system failure
• The observed results suggest that an FO>10%
is associated with a high probability of mortality,
very similar to studies conducted (by Naveda E. Omar and
collaborators)
 CONCLUTION

• We conclude that the judicious

administration of liquids (crystalloids,
colloids and blood products) in patients
with severe sepsis and septic shock is one
of the most useful and first-line
hemodynamic treatments; but, if
administered liberally, they could produce
a water overload with the aforementioned
complications
 Telaah Kritis Jurnal berbasis
evidens Untuk Menilai VIA
(Validity, Important, Aplicability)

Fluid Overload in Children with

Severe Sepsis and Septic Shock

Copana Raul, Diaz Willmer

 TELAAH KRITIS JURNAL (TELAAH KRITIS UMUM)
HAL YANG
NO CHECK LIST PENILAIAN YA TIDAK
DINILAI
1 Judul a. Tidak terlalu panjang atau tidak terlalu pendek v  
Makalah b. Menggambarkan isi utama penelitian v
c. Cukup menarik v
d. Tanpa singkatan, selain yang baku v   

 
2 Abstrak a. Abstrak terstruktur v
b. Mencakup komponen IMRAC (Introduction,
methods, Results, Conclussion) v
c. Secara keseluruhan abstrak informatif v
d. Tanpa singkatan, selain yang baku v
e. Kurang dari 250 kata   v (274) 

3 Kata a. Ringkas terdiri dari 2 – 3 paragraf v

pengantar b. Paragraf pertama mengemukakan alasan v
dilakukannya penelitian
c. Paragraf berikut menyatakan hipotesis atau v
tujuan penelitian
d. Didukung oleh pustaka yang kuat & relevan v
e. Kurang dari 1 halaman v
 TELAAH KRITIS JURNAL (TELAAH KRITIS UMUM)
HAL YANG
NO CHECK LIST PENILAIAN YA TIDAK
DINILAI
4 Metode a. Disebutkan design, tempat dan waktu penelitian v
b. Disebutkan populasi sumber (populasi v
terjangkau)
c. Dijelaskan kriteria pemilihan subyek (inklusi & v
eksklusi)
d. Disebutkan cara pemilihan subjek (teknik v
sampling)
e. Disebutkan perkiraan besar sampel & alasannya v
f. Perkiraan besar sampel dihitung dengan rumus v
yang sesuai
g. Observasi, pengukuran serta intervensi dirinci v
sehingga orang lain dapat mengulanginya
h. Ditulis rujukan bila teknik pengukuran tidak dirinci v
i. Pengkuran dilakukan secara tersamar v v
j. Definisi iistilah & variable penting dikemukakan v
k. Ethical clearance diperoleh v
l. Disebutkan rencana analisis, batas kemaknaan &
power penelitian  
 TELAAH KRITIS JURNAL (TELAAH KRITIS UMUM)
HAL YANG
NO CHECK LIST PENILAIAN YA TIDAK
DINILAI
5. Hasil a. Disertakan tabel karakteristik subjek penelitian v  
b. Karakteristik subjek yang penting (data awal) v
dibandingkan kesetaraannya
c. Dilakukan uji hipotesis(statistik) untuk v
kesetaraannya
d. Disebutkan jumlah subjek yang diteliti v
e. Dijelaskan subyek yang dropout dengan v
alasannya  
f. Ketepatan numerik dinyatakan dengan benar v
g. Penulisan tabel dilakukan dengan tepat v
h. Semua hasil di dalam tabel disebutkan dalam v
naskah
i. Semua outcome yang penting disebutkan dalam v
hasil
j. Subyek yang drop out diikutkan dalam analisis v
k. Analisis dilakukan dengan uji statistik yang sesuai v
l. Ditulis hasil ujistatistik, derajat kebebasan v
(degree of freedom), dan nilai p
m. Disertakan interval kepercayaan v
n. Dalam hasil disertakan komentar & pendapat v
 TELAAH KRITIS JURNAL (TELAAH KRITIS UMUM)

HAL YANG
NO CHECK LIST PENILAIAN YA TIDAK
DINILAI
6. Diskusi a. Semua hal yang relevan dibahas v  
b. Tidak sering diulang hal yang dikemukakan v
pada hasil
c. Dibahas keterbatasan penelitian, dan v 
dampaknya terhadap hasil
d. Disebutkan penyimpangan protokol, dan v
dampaknya terhadap hasil
e. Diskusi dihubungkan dengan pertanyaan v
penelitian
f. Dibahas hubungan hasil dengan teori/hasil v
penelitian terdahulu
g. Dibahas hubungan hasil dengan praktek klinis v
h. Efek samping dikemukakan dan dibahas v
i. Disebutkan hasil tambahan selama v
diobservasi
j. Disertakan simpulan utama penelitian v
k. Simpulan didasarkan pada data penelitian v
l. Disebutkan generalisasi hasil penelitian v
v
m. Disertakan saran penelitian selanjutnya
TELAAH KRITIS JURNAL (TELAAH KRITIS KHUSUS)

• VALIDITY UNTUK MENILAI KESAHIHAN STUDI :

1. Apakah definisi awal penelitian jelas? Ya, jelas
2. Apakah desain penelitian jelas? Ya, Observational and
Descriptive
3. Apakah identifikasi kelompok pembanding jelas ? Ya, Anak-
anak dengan sepsis berat dan syok sepsis yang di rawat di
PICU
4. Apakah outcome dinilai dengan kriteria obyektif? Ya,
5. Overall study lengkap

• KESIMPULAN: PENELITIAN INI VALID

 IMPORTANT- MENENTUKAN
PENTINGNYA STUDI INI DI RSWS
• Apakah hasil penelitian dengan uji statistic dan nilai P? Ya,
From ringer lactate, an average of 381.4ml in patients with FO>10% group,
and 161ml in patients with FO<10%, in relation to FO there is no statistically
significant difference between both crystalloid solutions (p=0.28).
• Seberapa besarkah hasil efektivitas terapi dengan OR dan
CI 95%?
Mortality in the FO>10% group was 75% vs. 25% in the FO<10% group
(p=0.01 and an OR: 5.57 95% CI 1.4-21.8).
• KESIMPULAN :
We conclude that the judicious administration of liquids (crystalloids,
colloids and blood products) in patients with severe sepsis and septic shock
is one of the most useful and first-line hemodynamic treatments; but, if
administered liberally, they could produce a water overload with the
aforementioned complications,
 APLICABILITY
1.Apakah pasien kita serupa dengan subyek
penelitian? Ya
• 2. Apakah bukti klinis ini mempengaruhi
pencegahan pasien ? Ya,
• KESIMPULAN: Pemberian cairan pada
pasien sepsis berat dan syok septik adalah
salah satu yang bermanfaat namun harus
disesuaikan dengan kebutuhan dasar agar
tidak terjadi kelebihan cairan yang dapat
menyebabkan komplikasi yang berat
 Level of evidence dan
Recommendation Grades:
Level of evidence
Level 1: Systematic review/meta- Recommendation Grades
analysis. Grade A : Strongly recommended
Level 2: At least 1 randomized because the scientific basis is strong.
controlled trial (RCT). Grade B : Recommended because there
Level 3: A non-RCT. is some scientific basis.
Level 4: An analytical epidemiologic Grade C1 : Recommended despite having
study (cohort study or case-control study) only a weak scientific basis.
or single-arm intervention study (no Grade C2 : Not recommended because
controls). there is only a weak scientific basis.
Level 5: A descriptive study(case report Grade D: Not recommended because
or case series). scientific evidence shows
Level 6: Opinion of an expert treatment to be ineffective or
committee or an individual expert, which is harmful.
not based on patient data.
HASIL TELAAH KRITIS JURNAL :
• Level of evidence: A descriptive study(case report or
case series).
• Recommendation Grades: B because there is some
scientific basis.

• KESIMPULAN:
Fluid Overload in Children with Severe Sepsis
and Septic Shock
. ( level of evidence 5, derajat rekomendasi B)
TERIMAKASIH