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Three Part Question

In [paediatric patients with severe sepsis or toxic shock syndrome], does [commencing intravenous immunoglobulin in the resus room] [improve mortality or morbidity?]

Clinical Scenario

10 month old girl seen in PICU, approx 12 hours after developing toxic shock syndrome secondary to a thigh myositis. Had been resusitated agressively in resus before transfer to PICU with fluids, antibiotics and commenced on inotropes. It was decided to give her IVIG. throughout the day the patient improved clinically, I noticed her ABG had dramatically improved, and she required less inotropic support. I wondered whether her dramatic improvement could have been sooner if we had administered IVIG in resus.

Search Strategy

MEDLINE 1.[exp immunoglobulins, intravenous]
2. [exp sepsis]
3.combine [1+2]
4. limit to age group infant or child, preschool or child or adolescent
5. [exp resuscitation]
6. combine [4+5].
7. [exp shock, septic] limit to age group infant or child, preschool or adolescent
8. combine [1+7} limit to age group
9. [exp resuscitation]
10. combine [8+9]
11. combine [1+2+9]
used medline

Search Outcome

7 papers found, 2 discarded because relevant to ARDS and trauma

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Turgeon, Alexis et al February 2007 UK	Critically ill ADULT patients with sepsis	Meta-analysis to evaluate the effect of IVIG on adult patients in ICU with severe sepsis.	No evidence currently available to evaluate the benefits of commencing IVIG in resus on paediatric patients with severe sepsis or toxic shock syndrome.		Meta-analysis relates to adult data, in ICU.

Comment(s)

Robust meta-analysis looked at 20 randomised control trials. IVIG was shown to improve survival, however acknowledged that developments in the management of severe sepsis lead to needing a further larger study.

Clinical Bottom Line

There is no evidence currently that commencing IVIG for paediatric patients in resus would improve the outcome. A large, multi-centre randomised controlled trial would be needed to evaluate the benefits. There is evidence that commencing IVIG in adult patients improves outcomes in ICU.

References

1. Turgeon et al. Meta-analysis : intravenous immunoglobulin in critically ill adult patients with sepsis. Annals of Internal Medicine Feb 2007, vol 146 no. 3; p193-203