101
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Desmond FA, Namachivayam S. Does near-infrared spectroscopy play a role in paediatric intensive care? BJA Educ 2016. [DOI: 10.1093/bjaed/mkv053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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102
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Abstract
OBJECTIVES In this review, we discuss hemodynamic monitoring modalities, including their application, the interpretation of data, limitations, and impact on outcomes. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS One of the tenets of critical care medicine is to ensure adequate tissue oxygenation. This assessment must be timely and accurate to optimize outcomes. The clinical assessment of cardiac function, cardiac output, and tissue oxygenation based on the physical examination and standard hemodynamic variables, although an indispensable part of this exercise, has significant limitations. The use of adjunctive hemodynamic monitoring modalities provides a much more objective, accurate, and timely assessment of the patient's hemodynamic profile and is invaluable for assessing the patient's clinical status, clinical trajectory, and response to interventions.
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103
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Garzotto F, Ostermann M, Martín-Langerwerf D, Sánchez-Sánchez M, Teng J, Robert R, Marinho A, Herrera-Gutierrez ME, Mao HJ, Benavente D, Kipnis E, Lorenzin A, Marcelli D, Tetta C, Ronco C. The Dose Response Multicentre Investigation on Fluid Assessment (DoReMIFA) in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:196. [PMID: 27334608 PMCID: PMC4918119 DOI: 10.1186/s13054-016-1355-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/19/2016] [Indexed: 01/09/2023]
Abstract
Background The previously published “Dose Response Multicentre International Collaborative Initiative (DoReMi)” study concluded that the high mortality of critically ill patients with acute kidney injury (AKI) was unlikely to be related to an inadequate dose of renal replacement therapy (RRT) and other factors were contributing. This follow-up study aimed to investigate the impact of daily fluid balance and fluid accumulation on mortality of critically ill patients without AKI (N-AKI), with AKI (AKI) and with AKI on RRT (AKI-RRT) receiving an adequate dose of RRT. Methods We prospectively enrolled all consecutive patients admitted to 21 intensive care units (ICUs) from nine countries and collected baseline characteristics, comorbidities, severity of illness, presence of sepsis, daily physiologic parameters and fluid intake-output, AKI stage, need for RRT and survival status. Daily fluid balance was computed and fluid overload (FO) was defined as percentage of admission body weight (BW). Maximum fluid overload (MFO) was the peak value of FO. Results We analysed 1734 patients. A total of 991 (57 %) had N-AKI, 560 (32 %) had AKI but did not have RRT and 183 (11 %) had AKI-RRT. ICU mortality was 22.3 % in AKI patients and 5.6 % in those without AKI (p < 0.0001). Progressive fluid accumulation was seen in all three groups. Maximum fluid accumulation occurred on day 2 in N-AKI patients (2.8 % of BW), on day 3 in AKI patients not receiving RRT (4.3 % of BW) and on day 5 in AKI-RRT patients (7.9 % of BW). The main findings were: (1) the odds ratio (OR) for hospital mortality increased by 1.075 (95 % confidence interval 1.055–1.095) with every 1 % increase of MFO. When adjusting for severity of illness and AKI status, the OR changed to 1.044. This phenomenon was a continuum and independent of thresholds as previously reported. (2) Multivariate analysis confirmed that the speed of fluid accumulation was independently associated with ICU mortality. (3) Fluid accumulation increased significantly in the 3-day period prior to the diagnosis of AKI and peaked 3 days later. Conclusions In critically ill patients, the severity and speed of fluid accumulation are independent risk factors for ICU mortality. Fluid balance abnormality precedes and follows the diagnosis of AKI. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1355-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Garzotto
- Department of Nephrology Dialysis and Transplantation, San Bortolo Hospital, 37 Via Rodolfi, 36100, Vicenza, Italy. .,International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, 37 Via Rodolfi, 36100, Vicenza, Italy.
| | - M Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - D Martín-Langerwerf
- Servicio de Medicina Intensiva, Hospital Universitario del Vinalopo, Calle Tonico Sansano Mora, 14, 03283, Elche, Spain
| | - M Sánchez-Sánchez
- Intensive Care, Hospital Universitario La Paz/Carlos III. IdiPAZ, Paseo Castellana 261, 28046, Madrid, Spain
| | - J Teng
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, 180 Fenglin Road, 200032, Shanghai, China
| | - R Robert
- Medical Intensive Care, University of Poitiers; CHU Poitiers, 2, rue de la Milétrie, Poitiers, 86021, France
| | - A Marinho
- Intensive Care Service, St Antonio Hospital - Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - M E Herrera-Gutierrez
- Intensive Care Unit, General University Hospital, Avd Carlos Haya s/n, Malaga, 29010, Spain
| | - H J Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, 210029, Nanjing, Jiangsu, China
| | - D Benavente
- Department of Nephrology, Clinica Las Condes, Estoril 450, Las Condes, 7591283, Santiago, Chile
| | - E Kipnis
- Department of Anesthesiology and Critical Care, University Hospital, EA 7366, Lille, 59000, France
| | - A Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, 37 Via Rodolfi, 36100, Vicenza, Italy
| | - D Marcelli
- Fresenius Medical Care, Else-Kröner-Straße 1, 61352 Bad, Homburg, Germany
| | - C Tetta
- Fresenius Medical Care, Else-Kröner-Straße 1, 61352 Bad, Homburg, Germany
| | - C Ronco
- Department of Nephrology Dialysis and Transplantation, San Bortolo Hospital, 37 Via Rodolfi, 36100, Vicenza, Italy.,International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, 37 Via Rodolfi, 36100, Vicenza, Italy
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The authors reply. Pediatr Crit Care Med 2016; 17:582. [PMID: 27261658 DOI: 10.1097/pcc.0000000000000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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105
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Pedro TDCS, Morcillo AM, Baracat ECE. Etiology and prognostic factors of sepsis among children and adolescents admitted to the intensive care unit. Rev Bras Ter Intensiva 2016; 27:240-6. [PMID: 26465245 PMCID: PMC4592118 DOI: 10.5935/0103-507x.20150044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 07/25/2015] [Indexed: 12/20/2022] Open
Abstract
Objective To determine the etiology and clinical disease progression variables of sepsis
associated with the prognosis of patients admitted to a pediatric intensive care
unit. Methods Prospective and retrospective case series. Data were collected from the medical
records of patients diagnosed with sepsis who were admitted to the pediatric
intensive care unit of a general hospital from January 2011 to December 2013.
Bacteria were identified in blood and fluid cultures. Age, sex, vaccination
schedule, comorbidities, prior antibiotic use, clinical data on admission, and
complications during disease progression were compared in the survival and death
groups at a 5% significance level. Results A total of 115 patients, with a mean age of 30.5 months, were included in the
study. Bacterial etiology was identified in 40 patients. Altered peripheral
perfusion on admission and diagnosis of severe sepsis were associated with
complications. A greater number of complications occurred in the group of patients
older than 36 months (p = 0.003; odds ratio = 4.94). The presence of complications
during hospitalization was associated with death (odds ratio = 27.7). The main
etiological agents were Gram-negative bacteria (15/40), Staphylococcus
aureus (11/40) and Neisseria meningitidis (5/40). Conclusion Gram-negative bacteria and Staphylococcus aureus predominated in
the etiology of sepsis among children and adolescents admitted to an intensive
care unit. The severity of sepsis and the presence of altered peripheral perfusion
on admission were associated with complications. Moreover, the presence of
complications was a factor associated with death.
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Affiliation(s)
- Taís da Costa São Pedro
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - André Moreno Morcillo
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Emílio Carlos Elias Baracat
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, BR
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106
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Brissaud O, Botte A, Cambonie G, Dauger S, de Saint Blanquat L, Durand P, Gournay V, Guillet E, Laux D, Leclerc F, Mauriat P, Boulain T, Kuteifan K. Experts' recommendations for the management of cardiogenic shock in children. Ann Intensive Care 2016; 6:14. [PMID: 26879087 PMCID: PMC4754230 DOI: 10.1186/s13613-016-0111-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/26/2016] [Indexed: 12/13/2022] Open
Abstract
Cardiogenic shock which corresponds to an acute state of circulatory failure due to impairment of myocardial contractility is a very rare disease in children, even more than in adults. To date, no international recommendations regarding its management in critically ill children are available. An experts’ recommendations in adult population have recently been made (Levy et al. Ann Intensive Care 5(1):52, 2015; Levy et al. Ann Intensive Care 5(1):26, 2015). We present herein recommendations for the management of cardiogenic shock in children, developed with the grading of recommendations’ assessment, development, and evaluation system by an expert group of the Groupe Francophone de Réanimation et Urgences Pédiatriques (French Group for Pediatric Intensive Care and Emergencies). The recommendations cover four major fields of application such as: recognition of early signs of shock and the patient pathway, management principles and therapeutic goals, monitoring hemodynamic and biological variables, and circulatory support (indications, techniques, organization, and transfer criteria). Major principle care for children with cardiogenic shock is primarily based on clinical and echocardiographic assessment. There are few drugs reported as effective in childhood in the medical literature. The use of circulatory support should be facilitated in terms of organization and reflected in the centers that support these children. Children with cardiogenic shock are vulnerable and should be followed regularly by intensivist cardiologists and pediatricians. The experts emphasize the multidisciplinary nature of management of children with cardiogenic shock and the importance of effective communication between emergency medical assistance teams (SAMU), mobile pediatric emergency units (SMUR), pediatric emergency departments, pediatric cardiology and cardiac surgery departments, and pediatric intensive care units.
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Affiliation(s)
- Olivier Brissaud
- Unité de Réanimation Pédiatrique et Néonatale, Hôpital des Enfants, CHU Pellegrin Enfants, Place Amélie Raba Léon, 33000, Bordeaux, France.
| | - Astrid Botte
- Unité de Réanimation Pédiatrique, Faculté de Médecine, Université de Lille Nord de France, Hôpital Jeanne de Flandre CHU de Lille, 54, Avenue Eugène Avinée, 59037, Lille Cedex, France
| | - Gilles Cambonie
- Département de Pédiatrie Néonatale et Réanimations, Pôle Hospitalo-Universitaire Femme-Mère-Enfant, Hôpital Arnaud-de-Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, 371, Avenue du Doyen-Gaston-Giraud, 34295, Montpellier Cedex 5, France
| | - Stéphane Dauger
- Réanimation et Surveillance Continue Pédiatriques, Pôle de Pédiatrie Médicale, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité, 48, Boulevard Sérurier, 75019, Paris, France
| | - Laure de Saint Blanquat
- Service de Réanimation, CHU Necker-Enfants-Malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France
| | - Philippe Durand
- Réanimation Pédiatrique, AP-HP, CHU Kremlin Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Véronique Gournay
- Service de Cardiologie Pédiatrique, CHU de Nantes, 44093, Nantes Cedex, France
| | - Elodie Guillet
- Unité de Réanimation Pédiatrique et Néonatale, Hôpital des Enfants, CHU Pellegrin Enfants, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - Daniela Laux
- Pôle des Cardiopathies Congénitales, Centre Chirurgical Marie Lannelongue, 133, Avenue de la Résistance, 92350, Le Plessis-Robinson, France
| | - Francis Leclerc
- Unité de Réanimation Pédiatrique, Faculté de Médecine, Université de Lille Nord de France, Hôpital Jeanne de Flandre CHU de Lille, 54, Avenue Eugène Avinée, 59037, Lille Cedex, France
| | - Philippe Mauriat
- Service de Cardiologie Pédiatrique et Congénitale, Hôpital Haut-Lévèque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac Cedex, France
| | - Thierry Boulain
- Service de Réanimation Polyvalente, Hôpital de La Source, Centre Hospitalier Régional Orléans, 45067, Orléans, France
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale, Hôpital Émile-Muller, 68070, Mulhouse, France
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107
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Abstract
OBJECTIVES Nonspecific clinical symptoms frequently lead to suspicion of bacterial infection in critically ill children. Clinicians send bacterial cultures for suspected infection and begin an empiric course of antibiotics while microbiology results are pending. We investigated whether the biomarker procalcitonin could be useful to predict confirmed bacterial infection in critically ill children in the PICU, before culture results are available. DESIGN Prospective, blinded single-center study. SETTING Tertiary PICU and cardiothoracic ICU. PATIENTS There were one hundred forty-four patients with suspected bacterial infections that had bacterial cultures sent by clinicians. INTERVENTIONS Procalcitonin samples were obtained at three time intervals: as close to the time of the initial culture as possible (up to 12 hr after) and 24 and 72 hours after the initial culture. Patients were stratified into clinical outcome groups based on microbiology results and clinical symptoms using Centers for Disease Control and Prevention criteria. These assignments were blinded to procalcitonin levels. Primary outcome was the presence of culture-proven bacterial infection. MEASUREMENTS AND MAIN RESULTS There was a statistically significant difference in initial and subsequent median procalcitonin values between patients with confirmed bacterial infections and patients with low suspicion of bacterial infection (p < 0.02). However, there was extremely high variability in procalcitonin values among all groups. Procalcitonin had only a fair ability to predict bacterial infection, with area under the curve of receiver operating characteristic plots ranging between 0.63 and 0.71. When using serial procalcitonin values to predict bacterial infection, positive likelihood ratios were near 1 and negative likelihood ratios were between 0.3 and 0.4. CONCLUSIONS Procalcitonin levels were higher in children with documented confirmed bacterial infection as compared with those with low suspicion of infection. However, neither single nor serial procalcitonin measurements were able to predict the presence or absence of confirmed bacterial infection with enough certainty to be clinically useful as to recommend initiating or withholding antibiotics.
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108
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Wheeler DS. Is the "golden age" of the "golden hour" in sepsis over? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:447. [PMID: 26712155 PMCID: PMC4699349 DOI: 10.1186/s13054-015-1167-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The so-called “golden hour” of trauma resuscitation has been applied to a number of disease conditions in the intensive care unit (ICU) setting. For example, the “golden hour” as applied to the treatment of critically children and adults with severe sepsis and septic shock is based upon early recognition, early administration of antibiotics, and early reversal of the shock state. However, several clinical studies published over the last decade have called into question this time-honored approach and suggest that overly aggressive fluid resuscitation may cause more harm than good. Perhaps we are finally leaving the “Golden Age” of the “golden hour” and entering a new age in which we are able to use a more personalized approach to fluid management for patients with severe sepsis/septic shock.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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109
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Mortality and other outcomes in relation to first hour fluid resuscitation rate: A systematic review. Indian Pediatr 2015; 52:965-72. [DOI: 10.1007/s13312-015-0754-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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110
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Iyer PU. Management Issues in Intensive Care Units for Infants and Children with Heart Disease. Indian J Pediatr 2015; 82:1164-71. [PMID: 26542311 DOI: 10.1007/s12098-015-1914-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/10/2015] [Indexed: 12/01/2022]
Abstract
Admission of infants and children with cardiac disease to the neonatal (NICU) and pediatric ICU (PICU) is ever increasing in India (30-50 % of all admissions). The commonest indication for admission to the NICU or PICU is acute deterioration of cardiac disease. This includes: acute heart failure, hypercyanotic spells, arrhythmias, pericardial tamponade and sick cardiac neonates who need urgent intervention. Other increasingly frequent indications for ICU admission include heart failure with concomitant chest infection and impending respiratory failure and, severe cyanotic heart disease with various stroke syndromes. It is thus essential that a pediatrician be comfortable with the ICU management of such children and that low cost ICU modalities be utilized in order to reach out to as many children as feasible. It is heartening that there is renewed interest in inexpensive therapies like noninvasive ventilation and therapeutic hypothermia.
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Affiliation(s)
- Parvathi U Iyer
- Department of Pediatric Cardiac Intensive Care, Fortis Escorts Heart Institute, New Delhi, 110025, India.
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111
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Balamuth F, Alpern ER, Grundmeier RW, Chilutti M, Weiss SL, Fitzgerald JC, Hayes K, Bilker W, Lautenbach E. Comparison of Two Sepsis Recognition Methods in a Pediatric Emergency Department. Acad Emerg Med 2015; 22:1298-306. [PMID: 26474032 PMCID: PMC4639443 DOI: 10.1111/acem.12814] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The objective was to compare the effectiveness of physician judgment and an electronic algorithmic alert to identify pediatric patients with severe sepsis/septic shock in a pediatric emergency department (ED). METHODS This was an observational cohort study of patients older than 56 days with fever or hypothermia. All patients were evaluated for potential sepsis in real time by the ED clinical team. An electronic algorithmic alert was retrospectively applied to identify patients with potential sepsis independent of physician judgment. The primary outcome was the proportion of patients correctly identified with severe sepsis/septic shock defined by consensus criteria. Test characteristics were determined and receiver operating characteristic (ROC) curves were compared. RESULTS Of 19,524 eligible patient visits, 88 patients developed consensus-confirmed severe sepsis or septic shock. Physician judgment identified 159 and the algorithmic alert identified 3,301 patients with potential sepsis. Physician judgment had sensitivity of 72.7% (95% confidence interval [CI] = 72.1% to 73.4%) and specificity of 99.5% (95% CI = 99.4% to 99.6%); the algorithmic alert had sensitivity of 92.1% (95% CI = 91.7% to 92.4%) and specificity of 83.4% (95% CI = 82.9% to 83.9%) for severe sepsis/septic shock. There was no significant difference in the area under the ROC curve for physician judgment (0.86, 95% CI = 0.81 to 0.91) or the algorithm (0.88, 95% CI = 0.85 to 0.91; p = 0.54). A combination method using either positive physician judgment or an algorithmic alert improved sensitivity to 96.6% and specificity to 83.3%. A sequential approach, in which positive identification by the algorithmic alert was then confirmed by physician judgment, achieved 68.2% sensitivity and 99.6% specificity. Positive and negative predictive values for physician judgment versus algorithmic alert were 40.3% versus 2.5% and 99.88% versus 99.96%, respectively. CONCLUSIONS The electronic algorithmic alert was more sensitive but less specific than physician judgment for recognition of pediatric severe sepsis and septic shock. These findings can help to guide institutions in selecting pediatric sepsis recognition methods based on institutional needs and priorities.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Robert W Grundmeier
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Marianne Chilutti
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott L Weiss
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie C Fitzgerald
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katie Hayes
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Warren Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ebbing Lautenbach
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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112
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Janssens U. [Early goal-directed therapy for septic shock : Systematic review and meta-analysis]. Med Klin Intensivmed Notfmed 2015; 111:551-5. [PMID: 26507496 DOI: 10.1007/s00063-015-0108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 10/22/2022]
Affiliation(s)
- U Janssens
- Klinik für Innere Medizin, Sankt Antonius Hospital, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
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113
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Kessler DO, Walsh B, Whitfill T, Dudas RA, Gangadharan S, Gawel M, Brown L, Auerbach M. Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments: A Multicenter, Cross-Sectional Observational In Situ Simulation Study. J Emerg Med 2015; 50:403-15.e1-3. [PMID: 26499775 DOI: 10.1016/j.jemermed.2015.08.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/14/2015] [Accepted: 08/08/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of $4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described. OBJECTIVES We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance. METHODS This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance. RESULTS We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43-84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01-1.88). CONCLUSIONS Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.
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Affiliation(s)
- David O Kessler
- Department of Pediatrics, Columbia University Medical Center, New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, New York
| | - Barbara Walsh
- Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Robert A Dudas
- Department of Pediatrics, Johns Hopkins University, St. Petersburg, Florida
| | - Sandeep Gangadharan
- Department of Pediatrics, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Marcie Gawel
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Linda Brown
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Marc Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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114
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Frazier WJ, Muszynski JA. Fluid Resuscitation in Pediatric Sepsis: Lack of Data Versus Lack of Equipoise. Pediatr Crit Care Med 2015; 16:789-90. [PMID: 26427816 PMCID: PMC4603290 DOI: 10.1097/pcc.0000000000000531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- W. Joshua Frazier
- Department of Pediatrics, Division of Critical Care
Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer A. Muszynski
- Department of Pediatrics, Division of Critical Care
Medicine, The Ohio State University College of Medicine, Columbus, OH,Center for Clinical and Translational Research, The
Research Institute at Nationwide Children's Hospital, Columbus, OH
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115
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Abstract
OBJECTIVES To review systematically data from randomized and nonrandomized studies of fluid bolus therapy in hospitalized children with septic shock. DATA SOURCES Medline, EMBASE, and Cochrane Central Register of Controlled Trials. STUDY SELECTION We searched for randomized controlled studies of fluid bolus therapy in children with severe sepsis. We identified retrospective, prospective, and observational studies. We excluded studies of severe sepsis/septic shock due to a specific microbiological etiology, neonatal studies, and studies where advanced supportive therapies were unavailable. DATA EXTRACTION Two authors screened articles for inclusion. DATA SYNTHESIS We identified and analyzed three randomized controlled trials and eight nonrandomized studies. Heterogeneity precluded meta-analysis. Two single-center Indian studies and one Brazilian study assessed three different fluid bolus therapy regimens in small cohorts with different populations, physiological triggers, and physiological and clinical outcomes. No randomized controlled trials compared fluid bolus therapy with alternative interventions, such as vasopressors. The nonrandomized studies were heterogeneous in populations, methodology, and outcome measures. No observed physiological differences were identified based on volume of fluid bolus therapy. CONCLUSIONS There are only limited data to support the use of fluid bolus therapy in hospitalized children. Prospective observational data and randomized controlled trials are urgently needed to evaluate this therapy in resource rich settings.
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Weiss SL, Fitzgerald JC, Maffei FA, Kane JM, Rodriguez-Nunez A, Hsing DD, Franzon D, Kee SY, Bush JL, Roy JA, Thomas NJ, Nadkarni VM. Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study. Crit Care 2015; 19:325. [PMID: 26373923 PMCID: PMC4572676 DOI: 10.1186/s13054-015-1055-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Consensus criteria for pediatric severe sepsis have standardized enrollment for research studies. However, the extent to which critically ill children identified by consensus criteria reflect physician diagnosis of severe sepsis, which underlies external validity for pediatric sepsis research, is not known. We sought to determine the agreement between physician diagnosis and consensus criteria to identify pediatric patients with severe sepsis across a network of international pediatric intensive care units (PICUs). METHODS We conducted a point prevalence study involving 128 PICUs in 26 countries across 6 continents. Over the course of 5 study days, 6925 PICU patients <18 years of age were screened, and 706 with severe sepsis defined either by physician diagnosis or on the basis of 2005 International Pediatric Sepsis Consensus Conference consensus criteria were enrolled. The primary endpoint was agreement of pediatric severe sepsis between physician diagnosis and consensus criteria as measured using Cohen's κ. Secondary endpoints included characteristics and clinical outcomes for patients identified using physician diagnosis versus consensus criteria. RESULTS Of the 706 patients, 301 (42.6%) met both definitions. The inter-rater agreement (κ ± SE) between physician diagnosis and consensus criteria was 0.57 ± 0.02. Of the 438 patients with a physician's diagnosis of severe sepsis, only 69% (301 of 438) would have been eligible to participate in a clinical trial of pediatric severe sepsis that enrolled patients based on consensus criteria. Patients with physician-diagnosed severe sepsis who did not meet consensus criteria were younger and had lower severity of illness and lower PICU mortality than those meeting consensus criteria or both definitions. After controlling for age, severity of illness, number of comorbid conditions, and treatment in developed versus resource-limited regions, patients identified with severe sepsis by physician diagnosis alone or by consensus criteria alone did not have PICU mortality significantly different from that of patients identified by both physician diagnosis and consensus criteria. CONCLUSIONS Physician diagnosis of pediatric severe sepsis achieved only moderate agreement with consensus criteria, with physicians diagnosing severe sepsis more broadly. Consequently, the results of a research study based on consensus criteria may have limited generalizability to nearly one-third of PICU patients diagnosed with severe sepsis.
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Affiliation(s)
- Scott L Weiss
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Frank A Maffei
- Division of Pediatric Critical Care, Janet Weis Children's Hospital at Geisinger Health System, Danville, PA, USA.
| | - Jason M Kane
- Department of Pediatrics, Section of Critical Care, University of Chicago Medicine, Comer Children's Hospital, Chicago, IL, USA.
| | - Antonio Rodriguez-Nunez
- Division of Pediatric Emergency and Critical Care, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain.
| | - Deyin D Hsing
- Division of Pediatric Critical Care Medicine, New York Presbyterian Hospital, Weill Cornell Medical School, New York, NY, USA.
| | - Deborah Franzon
- Division of Critical Care Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA.
| | - Sze Ying Kee
- Department of Pediatric Pulmonology, University Malaya Medical Centre, University of Malaya, Kuala Lumpur, Malaysia.
| | - Jenny L Bush
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jason A Roy
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA, USA.
| | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, Delaney A, Harrison DA, Holdgate A, Howe B, Huang DT, Iwashyna T, Kellum JA, Peake SL, Pike F, Reade MC, Rowan KM, Singer M, Webb SAR, Weissfeld LA, Yealy DM, Young JD. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med 2015; 41:1549-60. [PMID: 25952825 DOI: 10.1007/s00134-015-3822-1] [Citation(s) in RCA: 256] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/10/2015] [Indexed: 01/06/2023]
Abstract
PURPOSE To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. METHODS Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. RESULTS From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33]. CONCLUSION EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.
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Affiliation(s)
- D C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Weiss SL, Fitzgerald JC, Pappachan J, Wheeler D, Jaramillo-Bustamante JC, Salloo A, Singhi SC, Erickson S, Roy JA, Bush JL, Nadkarni VM, Thomas NJ. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med 2015; 191:1147-57. [PMID: 25734408 DOI: 10.1164/rccm.201412-2323oc] [Citation(s) in RCA: 578] [Impact Index Per Article: 64.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RATIONALE Limited data exist about the international burden of severe sepsis in critically ill children. OBJECTIVES To characterize the global prevalence, therapies, and outcomes of severe sepsis in pediatric intensive care units to better inform interventional trials. METHODS A point prevalence study was conducted on 5 days throughout 2013-2014 at 128 sites in 26 countries. Patients younger than 18 years of age with severe sepsis as defined by consensus criteria were included. Outcomes were severe sepsis point prevalence, therapies used, new or progressive multiorgan dysfunction, ventilator- and vasoactive-free days at Day 28, functional status, and mortality. MEASUREMENTS AND MAIN RESULTS Of 6,925 patients screened, 569 had severe sepsis (prevalence, 8.2%; 95% confidence interval, 7.6-8.9%). The patients' median age was 3.0 (interquartile range [IQR], 0.7-11.0) years. The most frequent sites of infection were respiratory (40%) and bloodstream (19%). Common therapies included mechanical ventilation (74% of patients), vasoactive infusions (55%), and corticosteroids (45%). Hospital mortality was 25% and did not differ by age or between developed and resource-limited countries. Median ventilator-free days were 16 (IQR, 0-25), and vasoactive-free days were 23 (IQR, 12-28). Sixty-seven percent of patients had multiorgan dysfunction at sepsis recognition, with 30% subsequently developing new or progressive multiorgan dysfunction. Among survivors, 17% developed at least moderate disability. Sample sizes needed to detect a 5-10% absolute risk reduction in outcomes within interventional trials are estimated between 165 and 1,471 [corrected] patients per group. CONCLUSIONS Pediatric severe sepsis remains a burdensome public health problem, with prevalence, morbidity, and mortality rates similar to those reported in critically ill adult populations. International clinical trials targeting children with severe sepsis are warranted.
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Affiliation(s)
- Scott L Weiss
- 1 Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, and
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Thompson GC, Macias CG. Recognition and Management of Sepsis in Children: Practice Patterns in the Emergency Department. J Emerg Med 2015; 49:391-9. [PMID: 26093939 DOI: 10.1016/j.jemermed.2015.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/16/2015] [Accepted: 03/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pediatric sepsis remains a leading cause of morbidity and mortality. Understanding current practice patterns and challenges is essential to inform future research and education strategies. OBJECTIVE Our aim was to describe the practice patterns of pediatric emergency physicians (PEPs) in the recognition and management of sepsis in children and to identify perceived priorities for future research and education. METHODS We conducted a cross-sectional, internet-based survey of members of the American Academy of Pediatrics, Section on Emergency Medicine and Pediatric Emergency Research Canada. The survey was internally derived, externally validated, and distributed using a modified Dillman methodology. Rank scores (RS) were calculated for responses using Likert-assigned frequency values. RESULTS Tachycardia, mental-status changes, and abnormal temperature (RS = 83.7, 80.6, and 79.6) were the highest ranked clinical measures for diagnosing sepsis; white blood cell count, lactate, and band count (RS = 73.5, 70.9, and 69.1) were the highest ranked laboratory investigations. The resuscitation fluid of choice (85.5%) was normal saline. Dopamine was the first-line vasoactive medication (VAM) for cold (57.1%) and warm (42.2%) shock with epinephrine (18.5%) and norepinephrine (25.1%) as second-line VAMs (cold and warm, respectively). Steroid administration increased with complexity of presentation (all-comers 3.8%, VAM-resistant shock 54.5%, chronic steroid users 72.0%). Local ED-specific clinical pathways, national emergency department (ED)-specific guidelines, and identification of clinical biomarkers were described as future priorities. CONCLUSIONS While practice variability exists among clinicians, PEPs continue to rely heavily on clinical metrics for recognizing sepsis. Improved recognition through clinical biomarkers and standardization of care were perceived as priorities. Our results provide a strong framework to guide future research and education strategies in pediatric sepsis.
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Affiliation(s)
- Graham C Thompson
- Department of Pediatrics, Alberta Children's Hospital/University of Calgary, Calgary, Alberta, Canada
| | - Charles G Macias
- Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
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Abstract
PURPOSE OF REVIEW To discuss the tradeoff between permissive anemia and administering red blood cell transfusion to children in pediatric ICUs. RECENT FINDINGS Postsurgical mortality in adults increases abruptly if their nadir hemoglobin level falls below 5 g/dl. Patients with sepsis, even those in septic shock, and patients with upper gastrointestinal bleeding do not require red blood cell (RBC) transfusion if their hemoglobin level is above 7 g/dl. SUMMARY Anemia is common in critically ill children and is well tolerated most of the time. RBC transfusion is required in cases of hemorrhagic shock and in children with a hemoglobin level below 5 g/dl. Children with sepsis, including septic shock, those with a severe upper gastrointestinal bleeding and all stable critically ill children, including noncyanotic cardiac children older than 28 days, do not require an RBC transfusion if their hemoglobin level is above 7 g/dl. Transfusion threshold in children with univentricular physiology and in critically ill children with a hemoglobin level between 5 and 7 g/dl remains to be determined.
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Timing of death in children referred for intensive care with severe sepsis: implications for interventional studies. Pediatr Crit Care Med 2015; 16:410-7. [PMID: 25739013 DOI: 10.1097/pcc.0000000000000385] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Early deaths in pediatric sepsis may limit the impact of therapies that can only be provided on PICUs. By introducing selection and survivorship biases, these very early deaths may also undermine the results of trials that employ standard consent procedures. We hypothesized that: 1) the majority of deaths in children with severe sepsis occur very early, within 24 hours of referral to PICU; and 2) a significant proportion of deaths occur before PICU admission. DESIGN, SETTING, AND PATIENTS We studied consecutive referrals of newborns through to 16 years of age, between 2005 and 2011 to the Children's Acute Transport Service, the North Thames regional pediatric intensive care transport service, with a working diagnosis of "sepsis," "severe sepsis," "meningococcal sepsis," or "septic shock." INTERVENTIONS The primary outcome measure was the proportion of deaths within 24 hours of referral. Survival distributions of previously healthy children were compared with those with significant comorbidities. MEASUREMENTS AND MAIN RESULTS Thirteen thousand four hundred and nine referrals were made to Children's Acute Transport Service, of whom 703 (5%) met inclusion criteria. Data on survival to 1 year were available in 627 of 703 patients (89%). One hundred thirty children (130/627; 21%; 95% CI, 18-24%) died in the first year. A higher proportion of children with comorbidity cases (46/85, 54%, 44-64) died compared with previously healthy cases (84/542; 16%; 13-19; p < 0.0005, Fisher exact test). Seventy-one deaths occurred within 24 hours of PICU referral (71/130, 55%, 46-63). The timing of death differed with comorbidity. Similar proportions of children survived to 24 hours (previously healthy children 90% vs children with comorbidity 83%, p = 0.06). However, deaths after 24 hours were infrequent among previously healthy cases (28/84 deaths, 33%, 24-44%) compared with children with comorbidity cases (31/46 deaths, 66%, 53-79%) (p < 0.001, Fisher exact test). CONCLUSIONS This majority of deaths among children referred for pediatric intensive care with for severe sepsis occur within 24 hours. This has important implications for future clinical trials and quality improvement initiatives aimed at improving sepsis outcomes.
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Monitoring of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S86-101. [PMID: 26035368 DOI: 10.1097/pcc.0000000000000436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To critically review the potential role of monitoring technologies in the management of pediatric acute respiratory distress syndrome, and specifically regarding monitoring of the general condition, respiratory system mechanics, severity scoring parameters, imaging, hemodynamic status, and specific weaning considerations. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The monitoring subgroup comprised two experts. When published data were lacking a modified Delphi approach, emphasizing strong professional agreement was used. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 21 of which related to monitoring of a child with pediatric acute respiratory distress syndrome. All 21 recommendations had agreement, with 19 (90%) reaching strong agreement. CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations related to monitoring children with pediatric acute respiratory distress syndrome. These include interpreting monitored values such as tidal volume using predicted body weight, monitoring tidal volume at the end of the endotracheal tube in small children, and continuous monitoring of exhaled carbon dioxide in intubated children with pediatric acute respiratory distress syndrome, among others. These recommendations for monitoring in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
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Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S73-85. [PMID: 26035367 DOI: 10.1097/pcc.0000000000000435] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies. CONCLUSIONS The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
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Campagne « survivre au sepsis chez l’enfant ». ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0543-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Can inferior vena cava saturations be used instead of ScvO2 in children with septic shock? Intensive Care Med 2015; 41:1141-2. [PMID: 25851392 DOI: 10.1007/s00134-015-3783-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
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McCulloch MI. Acute Kidney Injury (AKI): Current Thoughts and Controversies in Pediatrics. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-014-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Investigation of the status of interhospital transport of critically ill pediatric patients. World J Pediatr 2015; 11:67-73. [PMID: 25822701 DOI: 10.1007/s12519-015-0004-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 01/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND With the unequal distribution of medical resources in developing countries, critically ill children need to be transferred to tertiary hospitals from primary hospitals with limited resources. Although a large number of critically ill children are transferred each day in China, the standard process of inter-hospital transport is not formulated. METHODS We retrospectively analyzed the data collected during transport. A total number of 9231 patients (≤14 years) who had been transferred to the Hunan Children's Hospital by a specialized team from primary hospitals from January 1, 2009 to June 30, 2012 were included in the study. RESULTS Nearly half of the critically ill children were neonates (48.72%) and two thirds of the children were suffering from respiratory, neurological and cardiac diseases. Multivariate adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using unconditional logistic regression. Mobilization time in non-working hours was longer than the working hours (OR=1.186, 95% CI=1.059-1.329). Our study showed that mobilization time for neonates was shorter than that for older children (OR=0.801, 95% CI=0.692-0.928). The mobilization time of referral cases was shorter in areas within a radius of 50 km than in those within a radius of over 250 km (OR=0.427, 95% CI=0.350-0.521). Referred patients in summer needed a significantly shorter mobilization time than in winter (OR=0.705, 95% CI=0.616-0.806). CONCLUSION Standardized processes and guidelines for inter-hospital transport would be essential to ensure effective transport of patients and reduce the mobilization activation time.
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Tweddell JS, Ghanayem NS, Hoffman GM. All this monitoring…what's necessary, what's not? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:81-90. [PMID: 24725722 DOI: 10.1053/j.pcsu.2014.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The goal of perioperative monitoring is to aid the clinician in optimizing care to achieve the best possible survival with the lowest possible morbidity. Ideally, we would like to have monitoring that can rapidly and accurately identify perturbations in circulatory well-being that would permit timely intervention and allow for restoration before the patient is damaged. The evidence to support the use of our standard monitoring strategies (continuous electrocardiography, blood pressure, central venous pressure, oxygen saturation and capnography) is based on expert opinion, case series, or at best observational studies. While these monitoring parameters will identify life-threatening events, they provide no direct information concerning the oxygen economy of the patient. Nevertheless, they are mandated by professional societies representing specialists in cardiac disease, critical care, and anesthesiology. Additional non-routine monitoring strategies that provide data concerning the body's oxygen economy, such as venous saturation monitoring and near infrared spectroscopy, have shown promise in prospective observational studies in managing these complex groups of patients. Ideally, high-level evidence would be required before adopting these newer strategies, but in the absence of new funding sources and the challenges of the wide variation in practice patterns between centers, this seems unlikely. The evidence supporting the current standard perioperative monitoring strategies will be reviewed. In addition, evidence supporting non-routine monitoring strategies will be reviewed and their potential for added benefit assessed.
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Affiliation(s)
- James S Tweddell
- Herma Heart Center, Milwaukee, WI; Children's Hospital of Wisconsin, Milwaukee, WI; Department of Surgery, Division of Cardiothoracic Surgery, Milwaukee, WI.
| | - Nancy S Ghanayem
- Herma Heart Center, Milwaukee, WI; Children's Hospital of Wisconsin, Milwaukee, WI; Department of Pediatrics, Section of Critical Care, Milwaukee, WI
| | - George M Hoffman
- Herma Heart Center, Milwaukee, WI; Children's Hospital of Wisconsin, Milwaukee, WI; Department of Anesthesiology, The Medical College of Wisconsin, Milwaukee, WI
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Schlapbach LJ, Straney L, Alexander J, MacLaren G, Festa M, Schibler A, Slater A. Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, 2002-13: a multicentre retrospective cohort study. THE LANCET. INFECTIOUS DISEASES 2014; 15:46-54. [PMID: 25471555 DOI: 10.1016/s1473-3099(14)71003-5] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Severe infections kill more than 4·5 million children every year. Population-based data for severe infections in children requiring admission to intensive care units (ICUs) are scarce. We assessed changes in incidence and mortality of severe infections in critically ill children in Australia and New Zealand. METHODS We did a retrospective multicentre cohort study of children requiring intensive care in Australia and New Zealand between 2002 and 2013, with data from the Australian and New Zealand Paediatric Intensive Care Registry. We included children younger than 16 years with invasive infection, sepsis, or septic shock. We assessed incidence and mortality in the ICU for 2002-07 versus 2008-13. FINDINGS During the study period, 97 127 children were admitted to ICUs, 11 574 (11·9%) had severe infections, including 6688 (6·9%) with invasive infections, 2847 (2·9%) with sepsis, and 2039 (2·1%) with septic shock. Age-standardised incidence increased each year by an average of 0·56 cases per 100 000 children (95% CI 0·41-0·71) for invasive infections, 0·09 cases per 100 000 children (0·00-0·17) for sepsis, and 0·08 cases per 100 000 children (0·04-0·12) for septic shock. 260 (3·9%) of 6688 patients with invasive infection died, 159 (5·6%) of 2847 with sepsis died, and 346 (17·0%) of 2039 with septic shock died, compared with 2893 (3·0%) of all paediatric ICU admissions. Children admitted with invasive infections, sepsis, and septic shock accounted for 765 (26·4%) of 2893 paediatric deaths in ICUs. Comparing 2008-13 with 2002-07, risk-adjusted mortality decreased significantly for invasive infections (odds ratio 0·72, 95% CI 0·56-0·94; p=0·016), and for sepsis (0·66, 0·47-0·93; p=0·016), but not significantly for septic shock (0·79, 0·61-1·01; p=0·065). INTERPRETATION Severe infections remain a major cause of mortality in paediatric ICUs, representing a major public health problem. Future studies should focus on patients with the highest risk of poor outcome, and assess the effectiveness of present sepsis interventions in children. FUNDING National Medical Health and Research Council, Australian Resuscitation Outcomes Consortium, Centre of Research Excellence (1029983).
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Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Mater Children's Hospital, Brisbane, QLD, Australia; Children's Critical Care Services, Gold Coast University Hospital, Southport, QLD, Australia.
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Janet Alexander
- Australian and New Zealand Paediatric Intensive Care Registry, CORE, Royal Children's Hospital Brisbane, Herston, QLD, Australia
| | - Graeme MacLaren
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, VIC, Australia; Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, NSW, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Mater Children's Hospital, Brisbane, QLD, Australia
| | - Anthony Slater
- Paediatric Intensive Care Unit, Royal Children's Hospital Brisbane, Herston, QLD, Australia
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Abstract
OBJECTIVE To determine the prevalence, treatment, and outcomes of sepsis at regional hospitals in Huai'an, Jiangsu, China. DESIGN Prospective data registry using a descriptive clinical epidemiologic approach through a collaborative network. SETTING Pediatric departments in 11 regional city and county referral hospitals serving 843,000 children (exclusive of neonates). SUBJECTS All admissions (n = 27,836) of patients from 28 days to 15 years old from September 1, 2010, to August 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,530 patients met the 2005 international consensus definition of sepsis, corresponding to an estimated incidence of 181/100,000 children, with 80% under 5 years old, and in 10% (153), severe sepsis or septic shock developed. The overall case fatality rate for sepsis was 3.5% (53/1,530) or 34.6% (53/153) in those in whom severe sepsis or septic shock developed. Treatment varied widely and in many instances did not conform to international guidelines as reflected by inadequate use of antibiotics, corticosteroids, vasoactive agents, and inotropes. CONCLUSIONS We first report the prevalence and outcome of pediatric sepsis based on a regional hospital network in China. The diverse treatment approaches and practice at low-level clinics suggest the need for clinical implementation of internationally recognized strategy to improve the care standard in resource-limited regional hospitals.
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Goldstein S, Bagshaw S, Cecconi M, Okusa M, Wang H, Kellum J, Mythen M, Shaw A. Pharmacological management of fluid overload. Br J Anaesth 2014; 113:756-63. [DOI: 10.1093/bja/aeu299] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Monitoring central venous saturation: where do we go from this point in pediatrics? Pediatr Crit Care Med 2014; 15:686. [PMID: 25186330 DOI: 10.1097/pcc.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.
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137
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Du Pont-Thibodeau G, Joyal JS, Lacroix J. Management of neonatal sepsis in term newborns. F1000PRIME REPORTS 2014; 6:67. [PMID: 25165566 PMCID: PMC4126544 DOI: 10.12703/p6-67] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neonatal sepsis is a common and deadly disease. It is broadly defined as a systemic inflammatory response, occurring in the first four weeks of life, as a result of a suspected or proven infection. Yet, more reliable and consistently applied diagnostic criteria would help improve our knowledge of the disease epidemiology. Several therapeutic attempts to control systemic inflammation in sepsis were unsuccessful. Immediate empirical administration of broad-spectrum anti-microbials, aggressive fluid resuscitation, and vaso-active or inotropic support (or both) are the mainstays of the therapeutic management of neonatal sepsis.
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Affiliation(s)
- Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal and Sainte-Justine Hospital3175 Cote Sainte-Catherine, MontrealCanada H3T1C5
| | - Jean-Sébastien Joyal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal and Sainte-Justine Hospital3175 Cote Sainte-Catherine, MontrealCanada H3T1C5
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal and Sainte-Justine Hospital3175 Cote Sainte-Catherine, MontrealCanada H3T1C5
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Du Pont-Thibodeau G, Harrington K, Lacroix J. Anemia and red blood cell transfusion in critically ill cardiac patients. Ann Intensive Care 2014; 4:16. [PMID: 25024880 PMCID: PMC4085735 DOI: 10.1186/2110-5820-4-16] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/07/2014] [Indexed: 12/19/2022] Open
Abstract
Anemia and red blood cell (RBC) transfusion occur frequently in hospitalized patients with cardiac disease. In this narrative review, we report the epidemiology of anemia and RBC transfusion in hospitalized adults and children (excluding premature neonates) with cardiac disease, and on the outcome of anemic and transfused cardiac patients. Both anemia and RBC transfusion are common in cardiac patients, and both are associated with mortality. RBC transfusion is the only way to rapidly treat severe anemia, but is not completely safe. In addition to hemoglobin (Hb) concentration, the determinant(s) that should drive a practitioner to prescribe a RBC transfusion to cardiac patients are currently unclear. In stable acyanotic cardiac patients, Hb level above 70 g/L in children and above 70 to 80 g/L in adults appears safe. In cyanotic children, Hb level above 90 g/L appears safe. The appropriate threshold Hb level for unstable cardiac patients and for children younger than 28 days is unknown. The optimal transfusion strategy in cardiac patients is not well characterized. The threshold at which the risk of anemia outweighs the risk of transfusion is not known. More studies are needed to determine when RBC transfusion is indicated in hospitalized patients with cardiac disease.
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Affiliation(s)
| | - Karen Harrington
- Sainte-Justine Hospital, Room 3431, 3175 Côte Sainte-Catherine, Montreal, QC H3T 1C5, Canada
| | - Jacques Lacroix
- Sainte-Justine Hospital, Room 3431, 3175 Côte Sainte-Catherine, Montreal, QC H3T 1C5, Canada
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140
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Alqahtani MF, Marsillio LE, Rozenfeld RA. A Review of Biomarkers and Physiomarkers in Pediatric Sepsis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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141
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Friedman ML, Bone MF. Management of Pediatric Septic Shock in the Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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142
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Crisanti L, Genualdi L, Mahoney K, Derrington S, Sorce L. Refractory Septic Shock in a 17 Year Old Female With Fever, Neutropenia, and Severe Abdominal Pain: The First 24 Hours. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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143
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Chong SL, Ong GYK, Venkataraman A, Chan YH. The Golden Hours in Paediatric Septic Shock—Current Updates and Recommendations. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2014. [DOI: 10.47102/annals-acadmedsg.v43n5p267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Paediatric sepsis is a global health problem. It is the leading cause of mortality in infants and children worldwide. Appropriate and timely initial management in the first hours, often termed as the “golden hours”, has great impact on survival. The aim of this paper is to summarise the current literature and updates on the initial management of paediatric sepsis. Materials and Methods: A comprehensive literature search was performed via PubMed using the search terms: ‘sepsis’, ‘septic shock’, ‘paediatric’ and ‘early goal-directed therapy’. Original and review articles were identified and selected based on relevance to this review. Results: Early recognition, prompt fluid resuscitation and timely administration of antibiotics remain key in the resuscitation of the septic child. Use of steroids and tight glycaemic control in this setting remain controversial. Conclusion: The use of early goal-directed therapy has had significant impact on patient outcomes and protocolised resuscitation of children in septic shock is recommended.
Key words: Child, Early goal-directed therapy, Emergency, Sepsis
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Affiliation(s)
| | - Gene YK Ong
- KK Women’s and Children’s Hospital, Singapore
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144
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Early goal-directed therapy in pediatric septic shock: comparison of outcomes "with" and "without" intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*. Pediatr Crit Care Med 2014; 15:e157-67. [PMID: 24583504 DOI: 10.1097/pcc.0000000000000073] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the effect of intermittent central venous oxygen saturation monitoring (ScvO(2)) on critical outcomes in children with septic shock, as continuous monitoring may not be feasible in most resource-restricted settings. DESIGN Prospective cohort study. SETTING PICU of a tertiary care teaching hospital. PATIENTS Consecutive children younger than 17 years with fluid refractory septic shock admitted to our ICU from November 2010 to October 2012 were included. INTERVENTIONS Enrolled children were subjected to subclavian/internal jugular catheter insertion. Those in whom it was successful formed the "exposed" group (ScvO(2) group), whereas the rest constituted the control group (no ScvO(2) group). In the former group, intermittent ScvO(2) monitoring at 1, 3, and 6 hours was used to guide resuscitation, whereas in the latter, only clinical variables were used. MEASUREMENTS AND MAIN RESULTS The major outcomes were in-hospital mortality and achievement of therapeutic goals within first 6 hours. One hundred twenty children were enrolled in the study-63 in the ScvO(2) group and 57 in the no ScvO(2) group. Baseline characteristics including the organ dysfunction and mortality risk scores were comparable between the groups. Children in the ScvO(2) group had significantly lower in-hospital mortality (33.3% vs 54%; relative risk, 0.61; 95% CI, 0.4, 0.93; number needed to treat, 5; 95% CI, 3, 27). A greater proportion of children in exposed group achieved therapeutic endpoints in first 6 hours (43% vs 23%, p = 0.02) and during entire ICU stay (71% vs 51%, p = 0.02). The mean number of dysfunctional organs was also significantly lesser in ScvO(2) group in comparison with no ScvO(2) group (2 vs 3, p < 0.001). CONCLUSION Early goal-directed therapy using intermittent ScvO(2) monitoring seemed to reduce the mortality rates and improved organ dysfunction in children with septic shock as compared with those without such monitoring.
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A beneficial role of central venous oxygen saturation-targeted septic shock management in children: follow the pediatric story, not only the adult story*. Pediatr Crit Care Med 2014; 15:380-2. [PMID: 24801424 DOI: 10.1097/pcc.0000000000000096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Samransamruajkit R, Uppala R, Pongsanon K, Deelodejanawong J, Sritippayawan S, Prapphal N. Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP. Indian J Crit Care Med 2014; 18:70-6. [PMID: 24678148 PMCID: PMC3943130 DOI: 10.4103/0972-5229.126075] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear. PURPOSE To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children. MATERIALS AND METHODS Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded. RESULTS A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 μg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%. CONCLUSIONS A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.
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Affiliation(s)
- Rujipat Samransamruajkit
- Department of Pediatrics, Division of Pediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rattapon Uppala
- Department of Pediatrics, Division of Pediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Khemmachart Pongsanon
- Department of Pediatrics, Division of Pediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jitladda Deelodejanawong
- Department of Pediatrics, Division of Pediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suchada Sritippayawan
- Department of Pediatrics, Division of Pediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nuanchan Prapphal
- Department of Pediatrics, Division of Pediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Kissoon N. Sepsis guideline implementation: benefits, pitfalls and possible solutions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:207. [PMID: 25028802 PMCID: PMC4055980 DOI: 10.1186/cc13774] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Post-ICU admission fluid balance and pediatric septic shock outcomes: a risk-stratified analysis. Crit Care Med 2014; 42:397-403. [PMID: 24145842 DOI: 10.1097/ccm.0b013e3182a64607] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Observed associations between fluid balance and septic shock outcomes are likely confounded by initial mortality risk. We conducted a risk-stratified analysis of the association between post-ICU admission fluid balance and pediatric septic shock outcomes. DESIGN Retrospective analysis of an ongoing multicenter pediatric septic shock clinical and biological database. SETTING Seventeen PICUs in the United States. PATIENTS Three hundred and seventeen children with septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We stratified subjects into three mortality risk categories (low, intermediate, and high) using a validated biomarker-based stratification tool. Within each category, we assessed three fluid balance variables: total fluid intake/kg/d during the first 24 hours, percent positive fluid balance during the first 24 hours, and cumulative percent positive fluid balance up to 7 days. We used logistic regression to estimate the effect of fluid balance on the odds of 28-day mortality, and on complicated course, which we defined as either death within 28 days or persistence of two or more organ failures at 7 days. There were 40 deaths, and 91 subjects had a complicated course. Increased cumulative percent positive fluid balance was associated with mortality in the low-risk cohort (n = 204; odds ratio, 1.035; 95% CI, 1.004-1.066) but not in the intermediate- and high-risk cohorts. No other associations with mortality were observed. Fluid intake, percent positive fluid balance in the first 24 hours, and cumulative percent positive fluid balance were all associated with increased odds of a complicated course in the low-risk cohort but not in the intermediate- and high-risk cohorts. CONCLUSIONS When stratified for mortality risk, increased fluid intake and positive fluid balance after ICU admission are associated with worse outcomes in pediatric septic shock patients with a low initial mortality risk but not in patients at moderate or high mortality risk.
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Abstract
PURPOSE OF REVIEW To review recent studies and information on the relationship between fluid administration and kidney function in critically ill patients. RECENT FINDINGS There is little evidence from large multicenter trials to direct fluid therapy in patients at risk of acute kidney injury (AKI). Evidence of benefit for fluid administration from single center studies of fluid resuscitation to hemodynamic goals needs to be weighed against evidence of harm associated with fluid overload in large observational studies. The composition of intravenous fluid may affect the risk of AKI. Even latest-generation hydroxyethyl starches increase the risk of severe AKI in general and septic ICU patients. Isotonic saline has been associated with greater incidence of AKI in comparison to buffered crystalloids. Experimentally, infusion of saline results in reduction in renal perfusion in comparison to buffered solutions. SUMMARY Clinicians need to weigh the balance between adequate resuscitation of cardiac output and avoidance of fluid overload. Protocolized resuscitation to hemodynamic goals may help achieve these conflicting goals at least in the early phases of critical illness. In critically ill patients with, or at risk of, AKI, clinicians should avoid starch and, possibly, saline solutions.
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Abstract
PURPOSE OF REVIEW We discuss the formulation of a prescription for intravenous (i.v.) fluid therapy (a 'volume prescription') for critically ill patients: pros/cons of different fluid types; accurate dosing; and qualitative and quantitative toxicities. Updated physiologic concepts are invoked and results of recent major clinical trials on i.v. fluid therapy in the acutely ill are interpreted. RECENT FINDINGS Context is vital and any fluid can be harmful if dosed incorrectly. When contrasting 'crystalloid versus colloid', differences in efficacy are modest, but differences in safety are significant. Differences in chloride load and strong ion difference appear to be clinically important. Quantitative toxicity is mitigated when dosing is based on dynamic parameters that predict volume responsiveness. Qualitative toxicity for colloids (even with newer hydroxyethyl starch 130/0.4 solutions) and isotonic saline remain a concern. SUMMARY Similar to any drug used in acutely ill patients, clinicians ordering a volume prescription must recognize that context is crucial. Physiologically balanced crystalloids may be the 'default' fluid for acutely ill patients, and the role for colloids is unclear. Optimal dosing involves assessment of volume responsiveness.
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