Changes in shock management and vasoactive therapy after transition to a closed intensivist model in a pediatric intensive care unit.

BACKGROUND

The organizational structure of pediatric intensive care units (PICUs) varies widely, and the degree of intensivist involvement may influence decision-making in shock management. However, the impact of transitioning from an open to a closed intensivist-led ICU model on shock management and vasoactive therapy patterns has not been thoroughly evaluated.

OBJECTIVES

To evaluate how stepwise increases in intensivist decision-making authority influence hemodynamic management strategies and vasoactive therapy patterns in critically ill children

METHODS

We conducted a retrospective study of patients who received vasoactive support in a tertiary PICU between March 2022 and February 2025. Patients were grouped into three phases reflecting increasing intensivist authority according to time period: pre-intensivist (open ICU), passive-intensivist (semi-closed ICU), and active-intensivist (closed ICU). We compared vasoactive-inotropic score (VIS), agent selection, and hemodynamic support strategies across phases.

RESULTS

A total of 80 patients and 239 vasoactive therapy episodes were analyzed. Initial and peak VIS were significantly lower in the active-intensivist phase compared with the pre- and passive-intensivist phases (p = 0.002 and p = 0.012, respectively). Use of dobutamine, epinephrine, and norepinephrine decreased significantly, while bedside inferior vena cava ultrasound assessment and fluid and colloid resuscitation increased across phases. Multivariable regression confirmed that the active-intensivist phase independently predicted lower initial VIS, adjusting for severity. Mortality and length of stay did not differ significantly.

CONCLUSIONS

Transitioning to a closed intensivist-led ICU model was associated with more physiology-driven shock management and reduced catecholamine exposure, suggesting that organizational structure may influence therapeutic behavior in pediatric critical care.