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Evolution of Acute Kidney Injury and Its Association With Systemic Hemodynamics in Children With Fluid-Refractory Septic Shock. Crit Care Med 2018; 46:e677-e683. [DOI: 10.1097/ccm.0000000000003156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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152
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Abstract
Sepsis is the body's systemic response to infection and is a serious health care concern that affects neonatal, pediatric, and adult populations worldwide. Severe sepsis (sepsis that has progressed to cellular dysfunction and organ damage or evidence of hypoperfusion) and septic shock (sepsis with persistent hypotension despite adequate fluid resuscitation) are still associated with high mortality rates despite improvements in the management of infectious processes. The cellular processes that occur as a result of the inflammatory response in sepsis, including impaired perfusion and microcirculatory coagulation, can lead to organ system dysfunction. Early recognition of sepsis can help prompt treatment to improve patient care. Current pediatric guidelines emphasize early recognition, aggressive fluid resuscitation, and administration of antibiotics within the first hour for a better outcome. The practitioner needs to always be mindful of the possibility of sepsis when examining a patient with potential symptoms. [Pediatr Ann. 2018;47(7):e292-e299.].
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153
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Dabaghi M, Fusch G, Saraei N, Rochow N, Brash JL, Fusch C, Ravi Selvaganapathy P. An artificial placenta type microfluidic blood oxygenator with double-sided gas transfer microchannels and its integration as a neonatal lung assist device. BIOMICROFLUIDICS 2018; 12:044101. [PMID: 30867861 PMCID: PMC6404930 DOI: 10.1063/1.5034791] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/05/2018] [Indexed: 05/22/2023]
Abstract
Preterm neonates suffering from respiratory distress syndrome require assistive support in the form of mechanical ventilation or extracorporeal membrane oxygenation, which may lead to long-term complications or even death. Here, we describe a high performance artificial placenta type microfluidic oxygenator, termed as a double-sided single oxygenator unit (dsSOU), which combines microwire stainless-steel mesh reinforced gas permeable membranes on both sides of a microchannel network, thereby significantly reducing the diffusional resistance to oxygen uptake as compared to the previous single-sided oxygenator designs. The new oxygenator is designed to be operated in a pumpless manner, perfused solely due to the arterio-venous pressure difference in a neonate and oxygenate blood through exposure directly to ambient atmosphere without any air or oxygen pumping. The best performing dsSOUs showed up to ∼343% improvement in oxygen transfer compared to a single-sided SOU (ssSOU) with the same height. Later, the dsSOUs were optimized and integrated to build a lung assist device (LAD) that could support the oxygenation needs for a 1-2 kg neonate under clinically relevant conditions for the artificial placenta, namely, flow rates ranging from 10 to 60 ml/min and a pressure drop of 10-60 mmHg. The LAD provided an oxygen uptake of 0.78-2.86 ml/min, which corresponded to the increase in oxygen saturation from 57 ± 1% to 93%-100%, under pure oxygen environment. This microfluidic lung assist device combines elegant design with new microfabrication methods to develop a pumpless, microfluidic blood oxygenator that is capable of supporting 30% of the oxygen needs of a pre-term neonate.
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Affiliation(s)
| | - Gerhard Fusch
- Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4L7, Canada
| | - Neda Saraei
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario L8S 4L7, Canada
| | - Niels Rochow
- Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4L7, Canada
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154
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Fathi EM, Narchi H, Chedid F. Noninvasive hemodynamic monitoring of septic shock in children. World J Methodol 2018; 8:1-8. [PMID: 29988909 PMCID: PMC6033738 DOI: 10.5662/wjm.v8.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/10/2018] [Accepted: 05/11/2018] [Indexed: 02/06/2023] Open
Abstract
Septic shock in children is associated with high mortality and morbidity. Its management is time-sensitive and must be aggressive and target oriented. The use of clinical assessment alone to differentiate between cold and warm shock and to select the appropriate inotropic and vasoactive medications is fraught with errors. Semi-quantitative and quantitative assessment of the preload, contractility and afterload using non-invasive tools has been suggested, in conjunction with clinical and laboratory assessment, to direct shock management and select between vasopressors, vasodilators and inotropes or a combination of these drugs. This review aims to describe non-invasive tools to assess the hemodynamic status in septic shock including echocardiography, trans-thoracic/trans-esophageal Doppler and electrical cardiometry. As septic shock is a dynamic condition that changes markedly overtime, frequent or continuous measurement of the cardiac output (CO), systemic vascular resistance (SVR) and other hemodynamic parameters using the above-mentioned tools is essential to personalize the treatment and adapt it over time. The different combinations of blood pressure, CO and SVR serve as a pathophysiological framework to manage fluid therapy and titrate inotropic and vasoactive drugs. Near infrared spectroscopy is introduced as a non-invasive method to measure end organ perfusion and assess the response to treatment.
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Affiliation(s)
- Emad Mohamed Fathi
- Department of Critical Care, Al Jalila Children’s Specialty Hospital, Dubai 7662, United Arab Emirates
| | - Hassib Narchi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 17666, United Arab Emirates
| | - Fares Chedid
- Neonatal Intensive Care Unit, Oasis Hospital, Al Ain 1016, United Arab Emirates
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155
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Babaie S, Behzad A, Mohammadpour M, Reisi M. A Comparison between the Bedside Sonographic Measurements of the Inferior Vena Cava Indices and the Central Venous Pressure While Assessing the Decreased Intravascular Volume in Children. Adv Biomed Res 2018; 7:97. [PMID: 30050885 PMCID: PMC6036785 DOI: 10.4103/abr.abr_213_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Hemodynamic monitoring is an essential part in the treatment of critically ill patients. Establishment of intravascular volume and creation of a normal systemic perfusion are the most important part to reduce the risk of organ failure and mortality. This study aimed to determine the correlation between the inferior vena cava (IVC) sonographic indices and the central venous pressure (CVP) to provide a useful guide for noninvasive intravascular volume status assessment in children. Materials and Methods: Target sample of children who were admitted to the pediatric critical care unit and required CVP monitoring were enrolled in this study. The collapsibility index (CI) and IVC/aorta (AO) ratio, from bedside ultrasonography measurement of the IVC, were calculated. Results: Of the 70 participants, 22 patients (31.4%) revealed a CVP of 8 mm/Hg or less and 48 patients (68.6%) revealed a CVP >8 mm/Hg. Fifty-six patients (80%) had an IVC-CI of 0.5 or greater and 17 patients (24.3%) had an IVC/AO of 0.8 or less. IVC-CI index is 45.5% sensitive and 91.7% specific with positive predictive value of 71.4 and negative predictive value of 78.6 to predict CVP <8, and the IVC/AO index is 50.8% sensitive and 87.5% specific with a positive predictive value of 64.7 and a negative predictive value of 79.2 to predict CVP <8. Conclusion: Based on the present finding, the IVC sonographic indices provide a useful guide for noninvasive intravascular volume status assessment in children.
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Affiliation(s)
- Sharareh Babaie
- Department of Pediatrics, Faculty of Medicine, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azita Behzad
- Department of Pediatric Intensive Care Unit, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Department of Pediatric Intensive Care Unit, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Reisi
- Department of Pediatrics, Faculty of Medicine, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
OBJECTIVES To evaluate adherence to the sepsis bundle before and after an educational strategy and its impact on hospital stay. DESIGN A prospective, analytic, before-and-after study of children with severe sepsis and septic shock who presented to the emergency department. SETTING Carried out from January to December 2014 in the emergency department of a quaternary care hospital. PATIENTS Of a total of 19,836 children who presented to the emergency department, 4,383 had an infectious pathology, with 203 of these showing severe sepsis and septic shock (124 pre intervention, and 79 post intervention). INTERVENTIONS The healthcare providers caring for the patients in pediatric emergency received an educational intervention and an update on the bundle concepts proposed in 2010 by the Pediatric Advanced Life Support program of the American Heart Association and adapted by this study's investigators. MEASUREMENTS AND MAIN RESULTS The main cause of sepsis in both groups was respiratory (59 vs 33; p = 0.72), without differences in the Pediatric Index of Mortality 2 score (7.23 vs 8.1; p = 0.23). The postintervention group showed a reduced hospital stay (11.6 vs 7.9 d; p = 0.01), a shorter time before ordering fluid boluses (247 vs 5 min; p = 0.001), the application of the first dose of antibiotic (343 vs 271 min; p = 0.03), and a decreased need for mechanical ventilation (20.1% vs 7.5%; p = 0.01). Postintervention adherence to the complete bundle was 19.2%, compared with the preintervention group, which was 27.7% (p = 0.17). CONCLUSIONS Adherence to a bundle strategy is low following an educational intervention. However, when patients are managed after instruction in guideline recommendations, hospital stay may be significantly reduced.
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157
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A Simulation-Based Quality Improvement Initiative Improves Pediatric Readiness in Community Hospitals. Pediatr Emerg Care 2018; 34:431-435. [PMID: 28719479 DOI: 10.1097/pec.0000000000001233] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The National Pediatric Readiness Project Pediatric Readiness Survey (PRS) measured pediatric readiness in 4149 US emergency departments (EDs) and noted an average score of 69 on a 100-point scale. This readiness score consists of 6 domains: coordination of pediatric patient care (19/100), physician/nurse staffing and training (10/100), quality improvement activities (7/100), patient safety initiatives (14/100), policies and procedures (17/100), and availability of pediatric equipment (33/100). We aimed to assess and improve pediatric emergency readiness scores across Connecticut's hospitals. OBJECTIVE The aim of this study was to compare the National Pediatric Readiness Project readiness score before and after an in situ simulation-based assessment and quality improvement program in Connecticut hospitals. METHODS We leveraged in situ simulations to measure the quality of resuscitative care provided by interprofessional teams to 3 simulated patients (infant septic shock, infant seizure, and child cardiac arrest) presenting to their ED resuscitation bay. Assessments of EDs were made based on a composite quality score that was measured as the sum of 4 distinct domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. After the simulation, a detailed report with scores, comparisons to other EDs, and a gap analysis were provided to sites. Based on this report, a regional children's hospital team worked collaboratively with each ED to develop action items and a timeline for improvements. The National Pediatric Readiness Project PRS scores, the primary outcome of this study, were measured before and after participation. RESULTS Twelve community EDs in Connecticut participated in this project. The PRS scores were assessed before and after the intervention (simulation-based assessment and gap analysis/report-out). The average time between PRS assessments was 21 months. The PRS scores significantly improved 12.9% from the first assessment (mean ± SEM = 64 ± 4.4) to the second assessment (77 ± 4.0, P = 0.022). The PRS score domains also showed improvements in coordination of pediatric patient care (median improvement, 50%), quality improvement activities (median improvement, 79%), patient safety initiatives (mean improvement, 7%), policies and procedures (mean improvement, 17%), and availability of pediatric equipment (mean improvement, 7%). CONCLUSIONS Participation in a simulation-based quality improvement collaborative was associated with improvements in pediatric readiness.
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158
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Abstract
OBJECTIVES Fluid bolus therapy is the initial recommended treatment for acute circulatory failure in sepsis, yet it is unknown whether this has the intended effect of increasing cardiac index. We aimed to describe the effect of fluid bolus therapy on cardiac index in children with sepsis. DESIGN A prospective observational cohort study. SETTING The Emergency Department of The Royal Children's Hospital, Melbourne, VIC, Australia. PATIENTS A convenience sample of children meeting international consensus criteria for sepsis with acute circulatory failure. INTERVENTION Treating clinician decision to administer fluid bolus therapy. MEASUREMENTS AND MAIN RESULTS Transthoracic echocardiography was recorded immediately before, 5 minutes after, and 60 minutes after fluid bolus therapy. Cardiac index was calculated by a pediatric cardiologist blinded to the timing of the echocardiogram. Cardiac index was calculated for 49 fluid boluses in 41 children. The median change in cardiac index 5 minutes after a fluid bolus therapy was +18.0% (interquartile range, 8.6-28.1%) and after 60 minutes was -6.0% (interquartile range, -15.2% to 3.0%) relative to baseline. Thirty-one of 49 fluid boluses (63%) resulted in an increase in cardiac index of greater than 10% at 5 minutes, and these participants were considered fluid responsive. This was sustained in four of 31 (14%) at 60 minutes. No association between change in cardiac index at 5 or 60 minutes and age, baseline mean arterial blood pressure, fluid bolus volume, and prior volume of fluid bolus therapy was found on linear regression. CONCLUSIONS Fluid bolus therapy for pediatric sepsis is associated with a transient increase in cardiac index. Fluid responsiveness is variable and, when present, not sustained. The efficacy of fluid bolus therapy for achieving a sustained increase in cardiac index in children with sepsis is limited.
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159
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Evans JM, Dayal P, Hallam DL, Natale JE, Kodali P, Sauers-Ford HS, Marcin JP. Illness Severity of Children Admitted to the PICU From Referring Emergency Departments. Hosp Pediatr 2018; 8:404-409. [PMID: 29858424 DOI: 10.1542/hpeds.2017-0201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare patient factors and outcomes among children admitted to PICUs from referring versus children's hospital emergency departments (EDs). METHODS Pediatric patients (<19 years old) admitted to PICUs from referring and children's hospital EDs from July 1, 2011 to June 30, 2013. We compared demographic and clinical factors, including severity of illness as measured by a recalibrated Pediatric Index of Mortality, version 2 score. RESULTS Of 80 045 children from 109 PICUs, 35.6% were admitted from referring EDs and 64.4% were admitted from children's hospital EDs. Children from referring EDs had higher illness severity (Pediatric Index of Mortality, version 2-predicted risk of mortality, 3.1% vs 2.2%, P < .001), were more likely to be mechanically ventilated within their first hour in the PICU (28.4% vs 23.4%, P < .001), and had higher observed mortality (3.3% vs 2.1%, P < .001). Once adjusted for illness severity and other confounders in a multivariable logistic regression model, there was no difference in the odds of mortality between children from referring and children's hospital EDs (odds ratio: 0.90; 95% confidence interval: 0.79 to 1.02, P = .09) CONCLUSIONS: Children transferred to PICUs from referring EDs had higher illness severity on arrival compared with children admitted from children's hospital EDs. Variations in patient selection for transfer or pretransfer treatment at referring EDs may contribute to the greater illness severity of transferred children. Referring hospitals may benefit from leveraging existing resources to improve patient stabilization before transfer.
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Affiliation(s)
- Jacqueline M Evans
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Parul Dayal
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Douglas L Hallam
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - JoAnne E Natale
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Pranav Kodali
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Hadley S Sauers-Ford
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - James P Marcin
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
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160
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Duber HC, Hartford EA, Schaefer AM, Johanns CK, Colombara DV, Iriarte E, Palmisano EB, Rios-Zertuche D, Zuniga-Brenes P, Hernández-Prado B, Mokdad AH. Appropriate and timely antibiotic administration for neonatal sepsis in Mesoamérica. BMJ Glob Health 2018; 3:e000650. [PMID: 29862053 PMCID: PMC5969725 DOI: 10.1136/bmjgh-2017-000650] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 01/09/2023] Open
Abstract
Neonatal sepsis is a leading cause of mortality among children under-5 in Latin America. The Salud Mesoamérica Initiative (SMI), a multicountry results-based aid programme, was designed to improve maternal, newborn and child health in impoverished communities in Mesoamérica. This study examines the delivery of timely and appropriate antibiotics for neonatal sepsis among facilities participating in the SMI project. A multifaceted health facility survey was implemented at SMI inception and approximately 18 months later as a follow-up. A random sample of medical records from neonates diagnosed with sepsis was reviewed, and data regarding antibiotic administration were extracted. In this paper, we present the percentage of patients who received timely (within 2 hours) and appropriate antibiotics. Multilevel logistic regression was used to assess for potential facility-level determinants of timely and appropriate antibiotic treatment. Among 821 neonates diagnosed with sepsis in 63 facilities, 61.8% received an appropriate antibiotic regimen, most commonly ampicillin plus an aminoglycoside. Within 2 hours of presentation, 32.3% received any antibiotic and only 26.6% received an appropriate regimen within that time. Antibiotic availability improved over the course of the SMI project, increasing from 27.5% at baseline to 64.0% at follow-up, and it was highly correlated with timely and appropriate antibiotic administration (adjusted OR=5.36, 95% CI 2.85 to 10.08). However, we also found a decline in the percentage of neonates documented to have received appropriate antibiotics (74.4% vs 51.1%). Our study demonstrated early success of the SMI project through improvements in the availability of appropriate antibiotic regimens for neonatal sepsis. At the same time, overall rates of timely and appropriate antibiotic administration remain low, and the next phase of the initiative will need to address other barriers to the provision of life-saving antibiotic treatment for neonatal sepsis.
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Affiliation(s)
- Herbert C Duber
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.,Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Emily A Hartford
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Alexandra M Schaefer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Casey K Johanns
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Danny V Colombara
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Emma Iriarte
- Salud Mesoamérica Initiative/Inter-American Development Bank, Panama City, Panama
| | - Erin B Palmisano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Diego Rios-Zertuche
- Salud Mesoamérica Initiative/Inter-American Development Bank, Panama City, Panama
| | - Paola Zuniga-Brenes
- Salud Mesoamérica Initiative/Inter-American Development Bank, Panama City, Panama
| | | | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
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161
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Amdani SM, Kim HS, Orvedahl A, John AO, Said A, Simpson K. Successful treatment of fulminant neonatal enteroviral myocarditis in monochorionic diamniotic twins with cardiopulmonary support, intravenous immunoglobulin and pocapavir. BMJ Case Rep 2018; 2018:bcr-2017-224133. [PMID: 29776940 DOI: 10.1136/bcr-2017-224133] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Neonatal cardiogenic shock most commonly occurs due to critical congenital heart disease, sepsis, metabolic disorder or arrhythmias. In particular, enterovirus infections are common in the neonatal period, and patients can present with fulminant myocarditis. Early recognition is imperative due to its high morbidity and mortality without prompt and aggressive treatment. We present the successful treatment of fulminant neonatal enteroviral myocarditis in a pair of monochorionic diamniotic twins with cardiopulmonary support, intravenous immunoglobulin and pocapavir, an enteroviral capsid inhibitor. The twins took an almost exact parallel hospital course, including day of extracorporeal membrane oxygenation (ECMO) cannulation, day of ECMO decannulation, improvement of cardiac function, discharge and status at follow-up. While it was difficult to assess the relative contribution of each intervention, our case shows promise in the use of pocapavir for treatment of severe enteroviral infections. Remarkably, both twins demonstrated remarkable recovery within 2 weeks, underscoring that early aggressive cardiopulmonary support, and potentially pocapavir, contributed to their recovery.
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Affiliation(s)
- Shahnawaz M Amdani
- Division of Pediatric Cardiology, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
| | - Hannah S Kim
- Division of Pediatric Cardiology, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
| | - Anthony Orvedahl
- Division of Pediatric Infectious Diseases, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
| | - Audrey Odom John
- Division of Pediatric Infectious Diseases, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ahmed Said
- Division of Pediatric Cardiology, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
| | - Kathleen Simpson
- Division of Pediatric Cardiology, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
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162
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Houston KA, George EC, Maitland K. Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial. Crit Care 2018; 22:119. [PMID: 29728116 PMCID: PMC5936024 DOI: 10.1186/s13054-018-1966-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 01/26/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although the African "Fluid Expansion as Supportive therapy" (FEAST) trial showed fluid resuscitation was harmful in children with severe febrile illness managed in resource-limited hospitals, the most recent evidence reviewed World Health Organization (WHO) guidelines continue to recommend fluid boluses in children with shock according to WHO criteria "WHO shock", arguing that the numbers included in the FEAST trial were too small to provide reasonable certainty. METHODS We re-analysed the FEAST trial results for all international definitions for paediatric shock including hypotensive (or decompensated shock) and the WHO criteria. In addition, we examined the clinical relevance of the WHO criteria to published and unpublished observational studies reporting shock in resource-limited settings. RESULTS We established that hypotension was rare in children with severe febrile illness complicating only 29/3170 trial participants (0.9%). We confirmed that fluid boluses were harmful irrespective of the definitions of shock including the very small number with WHO shock (n = 65). In this subgroup 48% of bolus recipients died at 48 h compared to 20% of the non-bolus control group, an increased absolute risk of 28%, but translating to an increased relative risk of 240% (p = 0.07 (two-sided Fisher's exact test)). Examining studies describing the prevalence of the stringent WHO shock criteria in children presenting to hospital we found this was rare (~ 0.1%) and in these children mortality was very high (41.5-100%). CONCLUSIONS The updated WHO guidelines continue to recommend boluses for a very limited number of children presenting at hospital with the strict definition of WHO shock. Nevertheless, the 3% increased mortality from boluses seen across FEAST trial participants would also include this subgroup of children receiving boluses. Recommendations aiming to differentiate WHO shock from other definitions will invariably lead to "slippage" at the bedside, with the potential of exposing a wider group of children to the harm of fluid-bolus therapy.
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Affiliation(s)
- Kirsty Anne Houston
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, PO Box 230, Kilifi, Kenya
| | - Elizabeth C. George
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London (UCL), 90 High Holborn, 2nd Floor, London, WC1V 6XX UK
| | - Kathryn Maitland
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, PO Box 230, Kilifi, Kenya
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163
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Morparia K, Berg J, Basu S. Confidence level of pediatric trainees in management of shock states. World J Crit Care Med 2018; 7:31-38. [PMID: 29736378 PMCID: PMC5934529 DOI: 10.5492/wjccm.v7.i2.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/12/2018] [Accepted: 04/22/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess overall confidence level of trainees in assessing and treating shock, we sought to improve awareness of recurrent biases in clinical decision-making to help address appropriate educational interventions.
METHODS Pediatric trainees on a national listserv were offered the opportunity to complete an electronic survey anonymously. Four commonly occurring clinical scenarios were presented, and respondents were asked to choose whether or not they would give fluid, rank factors utilized in decision-making, and comment on confidence level in their decision.
RESULTS Pediatric trainees have a very low confidence level for assessment and treatment of shock. Highest confidence level is for initial assessment and treatment of shock involving American College of Critical Care Medicine/Pediatric Advanced Life Support recommendations. Children with preexisting cardiac comorbidities are at high risk of under-resuscitation.
CONCLUSION Pediatric trainees nationwide have low confidence in managing various shock states, and would benefit from guidance and teaching around certain common clinical situations.
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Affiliation(s)
- Kavita Morparia
- Department of Pediatric Critical Care, Children’s Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, NJ 07112, United States
| | - Julie Berg
- Department of Emergency Medicine, Children’s National Health System, Washington, DC 20010, United States
| | - Sonali Basu
- Department of Critical Care Medicine, George Washington University, Children’s National Health System, Washington, DC 20010, United States
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165
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Abstract
OBJECTIVES With continued attention to pediatric sepsis at both the clinical and policy levels, it is important to understand the quality of hospitals in terms of their pediatric sepsis mortality. We sought to develop a method to evaluate hospital pediatric sepsis performance using 30-day risk-adjusted mortality and to assess hospital variation in risk-adjusted sepsis mortality in a large state-wide sample. DESIGN Retrospective cohort study using administrative claims data. SETTINGS Acute care hospitals in the state of Pennsylvania from 2011 to 2013. PATIENTS Patients between the ages of 0-19 years admitted to a hospital with sepsis defined using validated International Classification of Diseases, Ninth revision, Clinical Modification, diagnosis and procedure codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, there were 9,013 pediatric sepsis encounters in 153 hospitals. After excluding repeat visits and hospitals with annual patient volumes too small to reliably assess hospital performance, there were 6,468 unique encounters in 24 hospitals. The overall unadjusted mortality rate was 6.5% (range across all hospitals: 1.5-11.9%). The median number of pediatric sepsis cases per hospital was 67 (range across all hospitals: 30-1,858). A hierarchical logistic regression model for 30-day risk-adjusted mortality controlling for patient age, gender, emergency department admission, infection source, presence of organ dysfunction at admission, and presence of chronic complex conditions showed good discrimination (C-statistic = 0.80) and calibration (slope and intercept of calibration plot: 0.95 and -0.01, respectively). The hospital-specific risk-adjusted mortality rates calculated from this model varied minimally, ranging from 6.0% to 7.4%. CONCLUSIONS Although a risk-adjustment model for 30-day pediatric sepsis mortality had good performance characteristics, the use of risk-adjusted mortality rates as a hospital quality measure in pediatric sepsis is not useful due to the low volume of cases at most hospitals. Novel metrics to evaluate the quality of pediatric sepsis care are needed.
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166
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Martinón-Torres F, Salas A, Rivero-Calle I, Cebey-López M, Pardo-Seco J, Herberg JA, Boeddha NP, Klobassa DS, Secka F, Paulus S, de Groot R, Schlapbach LJ, Driessen GJ, Anderson ST, Emonts M, Zenz W, Carrol ED, Van der Flier M, Levin M. Life-threatening infections in children in Europe (the EUCLIDS Project): a prospective cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:404-414. [PMID: 30169282 DOI: 10.1016/s2352-4642(18)30113-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Sepsis and severe focal infections represent a substantial disease burden in children admitted to hospital. We aimed to understand the burden of disease and outcomes in children with life-threatening bacterial infections in Europe. METHODS The European Union Childhood Life-threatening Infectious Disease Study (EUCLIDS) was a prospective, multicentre, cohort study done in six countries in Europe. Patients aged 1 month to 18 years with sepsis (or suspected sepsis) or severe focal infections, admitted to 98 participating hospitals in the UK, Austria, Germany, Lithuania, Spain, and the Netherlands were prospectively recruited between July 1, 2012, and Dec 31, 2015. To assess disease burden and outcomes, we collected demographic and clinical data using a secured web-based platform and obtained microbiological data using locally available clinical diagnostic procedures. FINDINGS 2844 patients were recruited and included in the analysis. 1512 (53·2%) of 2841 patients were male and median age was 39·1 months (IQR 12·4-93·9). 1229 (43·2%) patients had sepsis and 1615 (56·8%) had severe focal infections. Patients diagnosed with sepsis had a median age of 27·6 months (IQR 9·0-80·2), whereas those diagnosed with severe focal infections had a median age of 46·5 months (15·8-100·4; p<0·0001). Of 2844 patients in the entire cohort, the main clinical syndromes were pneumonia (511 [18·0%] patients), CNS infection (469 [16·5%]), and skin and soft tissue infection (247 [8·7%]). The causal microorganism was identified in 1359 (47·8%) children, with the most prevalent ones being Neisseria meningitidis (in 259 [9·1%] patients), followed by Staphylococcus aureus (in 222 [7·8%]), Streptococcus pneumoniae (in 219 [7·7%]), and group A streptococcus (in 162 [5·7%]). 1070 (37·6%) patients required admission to a paediatric intensive care unit. Of 2469 patients with outcome data, 57 (2·2%) deaths occurred: seven were in patients with severe focal infections and 50 in those with sepsis. INTERPRETATION Mortality in children admitted to hospital for sepsis or severe focal infections is low in Europe. The disease burden is mainly in children younger than 5 years and is largely due to vaccine-preventable meningococcal and pneumococcal infections. Despite the availability and application of clinical procedures for microbiological diagnosis, the causative organism remained unidentified in approximately 50% of patients. FUNDING European Union's Seventh Framework programme.
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Affiliation(s)
- Federico Martinón-Torres
- Pediatrics Department, Translational Pediatrics and Infectious Diseases Section, Santiago de Compostela, Spain; Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain.
| | - Antonio Salas
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain; Unidade de Xenética, Departamento de Anatomía Patolóxica e Ciencias Forenses, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, Galicia, Spain; GenPoB Research Group, Instituto de Investigaciones Sanitarias (IDIS), Hospital Clínico Universitario de Santiago (SERGAS), Galicia, Spain
| | - Irene Rivero-Calle
- Pediatrics Department, Translational Pediatrics and Infectious Diseases Section, Santiago de Compostela, Spain; Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
| | - Miriam Cebey-López
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
| | - Jacobo Pardo-Seco
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
| | | | - Navin P Boeddha
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Daniela S Klobassa
- Medical University of Graz, Department of General Pediatrics, Graz, Austria
| | - Fatou Secka
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - Stephane Paulus
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection and Global Health, Liverpool, UK
| | - Ronald de Groot
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology and Laboratory of Infectious Diseases, Radboud Institute of Molecular Life Sciences, Radboudumc Nijmegen, the Netherlands
| | - Luregn J Schlapbach
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland; Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, QLD, Australia; Paediatric Critical Care Research Group, Mater Research, University of Queensland, Brisbane, QLD, Australia
| | - Gertjan J Driessen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Marieke Emonts
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; Paediatric Infectious Diseases and Immunology Department, Newcastle upon Tyne Hospitals Foundation Trust, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Werner Zenz
- Medical University of Graz, Department of General Pediatrics, Graz, Austria
| | - Enitan D Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection and Global Health, Liverpool, UK
| | - Michiel Van der Flier
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology and Laboratory of Infectious Diseases, Radboud Institute of Molecular Life Sciences, Radboudumc Nijmegen, the Netherlands
| | - Michael Levin
- Section of Paediatrics, Imperial College London, London, UK
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167
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Extracorporeal life support for adults with refractory septic shock. J Thorac Cardiovasc Surg 2018; 156:1104-1109.e1. [PMID: 29753504 DOI: 10.1016/j.jtcvs.2018.03.123] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 03/02/2018] [Accepted: 03/24/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although the use of extracorporeal membrane oxygenation (ECMO) in shock patients is increasing worldwide, studies concerning this treatment for adult septic shock are limited. This study aimed to analyze the outcome of venoarterial ECMO in adult patients with septic shock refractory to conventional treatment. METHODS A total of 71 consecutive patients who presented with septic shock and underwent venoarterial ECMO were reviewed. Clinical parameters were compared between survivors and nonsurvivors. Weaning and survival outcomes of these patients were compared with the control group of 253 patients who received venoarterial ECMO for cardiogenic shock. RESULTS The mean age was 56.0 ± 12.3 years. Of the 71 septic shock patients, 11 (15.5%) were successfully weaned from ECMO after a median of 7.9 [interquartile range (IQR), 6.3-10.2] days, 5 of whom (7.0%) survived to discharge. Pre- and 6 hours post-procedural lactate levels were significantly higher in the nonsurvivors (11.6 [IQR, 7.5-15.0] vs 5.8 [IQR, 4.3-5.9], P = .036; 15.0 [IQR, 11.1-15.0] vs 5.2 [IQR, 4.7-5.4], P = .002). Rates of successful weaning from venoarterial ECMO (15.5% vs 45.5%), and of survival up to hospital discharge (7.0% vs 28.9%) were significantly lower in septic shock than in cardiogenic shock patients (n = 253; P < .001). CONCLUSIONS Outcomes of ECMO in refractory septic shock patients were poor with a very low probability of survival. This finding raises questions concerning the utility of applying ECMO for medically refractory septic shock. Elevated arterial lactate levels pre- and post-ECMO were associated with risk of in-hospital death. Further large-scale studies are needed to validate the results of this study.
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168
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Semmelmann A, Kaltofen H, Loop T. Anesthesia of thoracic surgery in children. Paediatr Anaesth 2018; 28:326-331. [PMID: 29484775 DOI: 10.1111/pan.13350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2018] [Indexed: 02/06/2023]
Abstract
Providing anesthesia in children with thoracic disease is a challenging task. The effects of the underlying disease, the surgical interventions, and preexisting condition of the patient need to be considered when planning perioperative care. The perioperative care for children undergoing thoracic surgery requires specific techniques adapted to the pediatric physiology and anatomy. This review is focused on anesthetic strategies for thoracic surgery with an emphasis on perioperative analgesia including neuraxial techniques.
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Affiliation(s)
- Axel Semmelmann
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center, Freiburg, Germany
| | - Heike Kaltofen
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center, Freiburg, Germany
| | - Torsten Loop
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center, Freiburg, Germany
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169
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Leal YA, Álvarez-Nemegyei J, Lavadores-May AI, Girón-Carrillo JL, Cedillo-Rivera R, Velazquez JR. Cytokine profile as diagnostic and prognostic factor in neonatal sepsis. J Matern Fetal Neonatal Med 2018; 32:2830-2836. [DOI: 10.1080/14767058.2018.1449828] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Yelda A. Leal
- Cancer Population Record of Merida, Medical High Speciality Unit, Mexican Institute of Social Security (IMSS), Merida, Yucatan, Mexico
| | | | - Ana I. Lavadores-May
- Department of Clinical Neonatology, Regional Hospital 1, IMSS. Merida, Yucatan, Mexico
| | | | - Roberto Cedillo-Rivera
- Clinic and Epidemiology Interinstitutional Research Unit, Medicine Faculty, Autonomous University of Yucatan, Merida, Yucatan, Mexico
| | - Juan R. Velazquez
- Allergy and Immunogenetics Department, National Institute of Respiratory Diseases (INER), Mexico City, Mexico
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170
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Long E, Duke T, Oakley E, O'Brien A, Sheridan B, Babl FE. Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis. Emerg Med Australas 2018. [PMID: 29520998 DOI: 10.1111/1742-6723.12948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The intent of fluid bolus therapy (FBT) is to increase cardiac output and tissue perfusion, yet only 50% of septic children are fluid responsive. We evaluated respiratory variation of inferior vena cava (IVC) diameter as a predictor of fluid responsiveness. METHODS A prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Patients were spontaneously ventilating children treated with FBT for sepsis-induced acute circulatory failure. IVC ultrasound was performed prior to FBT. Trans-thoracic echocardiography was performed prior to, 5 and 60 min after FBT. IVC collapsibility index and stroke distance were calculated by a blinded Paediatric Emergency Physician and blinded Paediatric Cardiologist, respectively. RESULTS Thirty-nine fluid boluses were recorded in 33 children, 28/39 (72%) of which met criteria for fluid responsiveness at 5 min, which was sustained in 2/28 (7%) of initial fluid responders at 60 min. Sensitivity and specificity (95% confidence interval) of IVC collapsibility index were 0.44 (0.25-0.65) and 0.33 (0.10-0.65) with an area under the receiver operator characteristics curve (95% confidence interval) of 0.38 (0.23-0.55) at 5 min. Test characteristics 60 min after fluid bolus administration were not meaningful because of the infrequency of sustained fluid responsiveness in this patient group. There was no significant correlation between IVC collapsibility and fluid responsiveness at 5 or 60 min. CONCLUSIONS IVC collapsibility has poor test characteristics for predicting fluid responsiveness in spontaneously ventilating children with sepsis.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ed Oakley
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam O'Brien
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bennett Sheridan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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171
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Kim HS, Cheon DY, Ha SO, Han SJ, Kim HS, Lee SH, Kim SG, Park S. Early changes in coagulation profiles and lactate levels in patients with septic shock undergoing extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:1418-1430. [PMID: 29707291 DOI: 10.21037/jtd.2018.02.28] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background To investigate the impact of coagulation profiles and lactate levels in patients with septic shock undergoing extracorporeal membrane oxygenation (ECMO). Methods A retrospective analysis of coagulation profiles, including disseminated intravascular coagulation (DIC) score, before and during 48 h of ECMO support [on day 0 (pre-ECMO), day 1, and day 2], was conducted in patients with septic shock undergoing ECMO. Results A total of 37 patients were included, and 15 (40.5%) patients survived. The initial DIC scores did not change in either the pre-ECMO overt-DIC (n=15) or non-overt-DIC (n=22) group after ECMO commencement. However, the DIC scores were significantly higher, at all three time-points, in non-survivors than in survivors. Additionally, the lactate levels improved considerably in the pre-ECMO non-overt-DIC group and in survivors during ECMO support, but not in the pre-ECMO overt DIC group or non-survivors. On a multivariate analysis, the pre-ECMO DIC score was significantly associated with hospital death [odds ratio (OR), 3.935; 95% confidence interval (CI), 1.170-13.230]. Receiver operating characteristic (ROC) curves revealed that the combination of pre-ECMO DIC score plus lactate level was the best predictor of hospital death (area under the curve, 0.879; 0.771-0.987); patients with combined scores >9.35 (the optimal cut-off) exhibited a three-fold higher mortality rate than did those with lower scores (81.8% vs. 26.7%, P=0.001). Conclusions During the early period of ECMO support, the coagulation profiles and lactate levels exhibited different trajectories in survivors and non-survivors. Furthermore, the pre-ECMO DIC score plus lactate level was the best predictor of hospital death.
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Affiliation(s)
- Hyoung Soo Kim
- Department of Cardiothoracic Surgery, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Dae Young Cheon
- Department of Internal Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sang Jin Han
- Department of Cardiology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Hyun-Sook Kim
- Department of Cardiology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sun Hee Lee
- Department of Cardiothoracic Surgery, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sung Gyun Kim
- Department of Nephrology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
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172
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Rizk MY, Lapointe A, Lefebvre F, Barrington KJ. Norepinephrine infusion improves haemodynamics in the preterm infants during septic shock. Acta Paediatr 2018; 107:408-413. [PMID: 28992392 DOI: 10.1111/apa.14112] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/13/2017] [Accepted: 10/05/2017] [Indexed: 01/02/2023]
Abstract
AIM This study evaluated the clinical and haemodynamic effects of norepinephrine infusion in preterm infants. METHODS The effects of norepinephrine therapy for refractory hypotension were evaluated in preterm infants between April 2009 and April 2011 at the neonatal intensive care unit of Sainte-Justine Hospital, Montreal, Quebec. Changes in haemodynamics and clinical parameters were analysed eight hours before and eight hours after the start of norepinephrine infusion, and eight hours after its cessation. RESULTS During the study, 30 preterm infants at a mean gestational age of 26.5 ± 2.6 weeks (median: 25.7, 23.4-34) and birthweight of 903 ± 437 g (median 827, 450-2550) received norepinephrine infusion for neonatal septic shock. After eight hours of treatment, mean blood pressure, urine output and FiO2 significantly improved. Eight hours after cessation of norepinephrine infusion, the number of patients treated with other inotropes decreased significantly, 24 patients (80%) had normal mean blood pressure and 27 patients (90%) had normal urine output. CONCLUSION Norepinephrine therapy could be considered to improve blood pressure and urine output during neonatal septic shock in preterm infants. Further studies are needed to prove the efficacy and safety of norepinephrine infusion in neonates.
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Affiliation(s)
- MY Rizk
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
| | - A Lapointe
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
| | - F Lefebvre
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
| | - KJ Barrington
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
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173
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Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, Imaizumi H, Inoue S, Kakihana Y, Kotani J, Kushimoto S, Masuda Y, Matsuda N, Matsushima A, Nakada TA, Nakagawa S, Nunomiya S, Sadahiro T, Shime N, Yatabe T, Hara Y, Hayashida K, Kondo Y, Sumi Y, Yasuda H, Aoyama K, Azuhata T, Doi K, Doi M, Fujimura N, Fuke R, Fukuda T, Goto K, Hasegawa R, Hashimoto S, Hatakeyama J, Hayakawa M, Hifumi T, Higashibeppu N, Hirai K, Hirose T, Ide K, Kaizuka Y, Kan’o T, Kawasaki T, Kuroda H, Matsuda A, Matsumoto S, Nagae M, Onodera M, Ohnuma T, Oshima K, Saito N, Sakamoto S, Sakuraya M, Sasano M, Sato N, Sawamura A, Shimizu K, Shirai K, Takei T, Takeuchi M, Takimoto K, Taniguchi T, Tatsumi H, Tsuruta R, Yama N, Yamakawa K, Yamashita C, Yamashita K, Yoshida T, Tanaka H, Oda S. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). J Intensive Care 2018; 6:7. [PMID: 29435330 PMCID: PMC5797365 DOI: 10.1186/s40560-017-0270-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. METHODS Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. RESULTS A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. CONCLUSIONS Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.
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Affiliation(s)
- Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hitoshi Imaizumi
- Department of Anesthesiology and Critical Care Medicine, Tokyo Medical University School of Medicine, Tokyo, Japan
| | - Shigeaki Inoue
- Department of Emergency and Critical Care Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoyuki Matsuda
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Nakagawa
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Tokyo, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Institute of Biomedical & Health Sciences, Hiroshima University, Higashihiroshima, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kochi, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yutaka Kondo
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Yuka Sumi
- Healthcare New Frontier Promotion Headquarters Office, Kanagawa Prefectural Government, Yokohama, Japan
| | - Hideto Yasuda
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Takeo Azuhata
- Division of Emergency and Critical Care Medicine, Departmen of Acute Medicine, Nihon university school of Medicine, Tokyo, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary’s Hospital, Westminster, UK
| | - Ryota Fuke
- Division of Infectious Diseases and Infection Control, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Tatsuma Fukuda
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Koji Goto
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University, Oita, Japan
| | - Ryuichi Hasegawa
- Department of Emergency and Intensive Care Medicine, Mito Clinical Education and Training Center, Tsukuba University Hospital, Mito Kyodo General Hospital, Mito, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Tsukuba, Japan
| | - Junji Hatakeyama
- Department of Intensive Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Japan
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Katsuki Hirai
- Department of Pediatrics, Kumamoto Red cross Hospital, Kumamoto, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Kentaro Ide
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuo Kaizuka
- Department of Emergency & ICU, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Tomomichi Kan’o
- Department of Emergency & Critical Care Medicine Kitasato University, Tokyo, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children’s Hospital, Shizuoka, Japan
| | - Hiromitsu Kuroda
- Department of Anesthesia, Obihiro Kosei Hospital, Obihiro, Japan
| | - Akihisa Matsuda
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masaharu Nagae
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Mutsuo Onodera
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Tetsu Ohnuma
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, USA
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - So Sakamoto
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Mikio Sasano
- Department of Intensive Care Medicine, Nakagami Hospital, Uruma, Japan
| | - Norio Sato
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Atsushi Sawamura
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Kohei Takimoto
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Naoya Yama
- Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Yoshida
- Intensive Care Unit, Osaka University Hospital, Osaka, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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174
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Abstract
Sepsis, severe sepsis, and septic shock represent a dynamic clinical syndrome involving a systemic inflammatory response, circulatory changes, and end-organ dysfunction from an infection. Early aggressive management to restore perfusion and/or improve hypotension is critical to improving outcomes. Although the basic management principles of early goal-directed therapy for sepsis have not undergone significant changes, there has been a recent shift in recommendations related to the timing and type of inotropic support. The purpose of this article is to review fluid management along with previous and current inotrope recommendations in pediatric sepsis and septic shock.
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175
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Choi YM, Leopold D, Campbell K, Mulligan J, Grudic GZ, Moulton SL. Noninvasive monitoring of physiologic compromise in acute appendicitis: New insight into an old disease. J Pediatr Surg 2018; 53:241-246. [PMID: 29217323 DOI: 10.1016/j.jpedsurg.2017.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Physiologic compromise in children with acute appendicitis has heretofore been difficult to measure. We hypothesized that the Compensatory Reserve Index (CRI), a novel adjunctive cardiovascular status indicator, would be low for children presenting with acute appendicitis in proportion to their physiological compromise, and that CRI would rise with fluid resuscitation and surgical management of their disease. METHODS Ninety-four children diagnosed with acute appendicitis were monitored with a CipherOx CRI™ M1 pulse oximeter (Flashback Technologies Inc., Boulder, CO). For clarity, CRI=1 indicates supine normovolemia, CRI=0 indicates hemodynamic decompensation (systolic blood pressure<80mmHg), and CRI values between 1 and 0 indicate the proportion of volume reserve remaining before collapse. Results are presented as counts with proportion (%), or mean with 95% confidence interval (CI). RESULTS Mean age was 11years old (95% CI: 10-12), and 49 (52%) of the children were male. Fifty-four (57%) had nonperforated appendicitis and 40 (43%) had perforated appendicitis. Mean initial CRI was significantly higher in those with nonperforated appendicitis compared to those with perforated appendicitis (0.57, 95% CI: 0.52-0.63 vs. 0.36, 95% CI: 0.29-0.43; P<0.001). The significant differences in mean CRI values between the two groups remained throughout the course of treatment, but lost its significance at 2h after surgery (0.63, 95% CI: 0.57-0.70 vs. 0.53, 95% CI: 0.46-0.61; P=0.05). CONCLUSION Low CRI values in children with perforated appendicitis are indicative of their lower reserve capacity owing to peritonitis and hypovolemia. CRI offers a real-time, noninvasive adjunctive tool to monitor tolerance to volume loss in children. LEVEL OF EVIDENCE Study of diagnostic test; Level of evidence: Level III.
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Affiliation(s)
- Young Mee Choi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - David Leopold
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Kristen Campbell
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Flashback Technologies, Inc., Boulder, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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176
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[Value of arterial blood lactic acid in the evaluation of disease severity and prognosis in neonatal shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20. [PMID: 29335076 PMCID: PMC7390323 DOI: 10.7499/j.issn.1008-8830.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate the value of blood lactic acid (BLA) as a predictor for the severity and prognosis of neonatal shock. METHODS A total of 326 neonates with shock were enrolled and divided into three groups based on the severity, namely mild group (n=147), moderate group (n=105), and severe group (n=74). BLA level was measured during and early after (about 6 hours later) fluid resuscitation, and lactate clearance rate (LCR) was calculated. The receiver operating characteristic (ROC) curve was applied to evaluate the predictive value of BLA in neonatal shock. RESULTS BLA level was high in all subjects prior to treatment, and was highest in the severe group and lowest in the mild group (P<0.01). BLA level was significantly higher among patients with septic shock than among those with hypovolemic, cardiogenic, and asphyxiating shock (P<0.05). BLA level was significantly reduced in patients in recovery after treatment (P<0.05). Mortality was significantly lower in patients with BLA level ≤4 mmol/L or LCR ≥10% than in those with BLA level >4 mmol/L or LCR <10% (P<0.01). BLA at 11.15 mmol/L had 100% sensitivity and 96.8% specificity in predicting severe shock. BLA at 10.65 mmol/L had 88.9% sensitivity and 74.1% specificity in predicting the prognosis (survival or dead) of newborns with shock. CONCLUSIONS In neonates with shock, arterial BLA level increases as the disease severity increases and is associated with prognosis, so it is a useful predictor of the severity and prognosis of neonatal shock.
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177
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Singh Y, Katheria AC, Vora F. Advances in Diagnosis and Management of Hemodynamic Instability in Neonatal Shock. Front Pediatr 2018; 6:2. [PMID: 29404312 PMCID: PMC5780410 DOI: 10.3389/fped.2018.00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/05/2018] [Indexed: 01/20/2023] Open
Abstract
Shock in newborn infants has unique etiopathologic origins that require careful assessment to direct specific interventions. Early diagnosis is key to successful management. Unlike adults and pediatric patients, shock in newborn infants is often recognized in the uncompensated phase by the presence of hypotension, which may be too late. The routine methods of evaluation used in the adult and pediatric population are often invasive and less feasible. We aim to discuss the pathophysiology in shock in newborn infants, including the transitional changes at birth and unique features that contribute to the challenges in early identification. Special emphasis has been placed on bedside focused echocardiography/focused cardiac ultrasound, which can be used as an additional tool for early, neonatologist driven, ongoing evaluation and management. An approach to goal oriented management of shock has been described and how bed side functional echocardiography can help in making a logical choice of intervention (fluid therapy, inotropic therapy or vasopressor therapy) in infants with shock.
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Affiliation(s)
- Yogen Singh
- Department of Pediatric Cardiology and Neonatal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
| | - Anup C. Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Farha Vora
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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178
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Perdue SM, Poore BJ, Babu AN, Stribling WK. Successful use of extracorporeal membrane oxygenation support in severe septic shock with associated acute cardiomyopathy. J Card Surg 2018; 33:50-52. [PMID: 29314296 DOI: 10.1111/jocs.13508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 24-year-old female presented with sepsis and cardiogenic shock 4 days after vaginal delivery. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) therapy was used for cardiovascular support as a bridge for recovery. The use of VA ECMO in patients with cardiogenic shock secondary to sepsis is reviewed.
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Affiliation(s)
- S Michelle Perdue
- Department of Critical Care, Saint Thomas West Hospital, Nashville, Tennessee
| | - Brian J Poore
- Department of Critical Care, Saint Thomas West Hospital, Nashville, Tennessee
| | - Ashok N Babu
- Department of Cardiovascular Surgery, Saint Thomas West Hospital, Nashville, Tennessee
| | - W Kyle Stribling
- Department of Cardiology, Saint Thomas West Hospital, Nashville, Tennessee
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179
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Piteau S. Update in Pediatric Emergency Medicine: Pediatric Resuscitation, Pediatric Sepsis, Interfacility Transport of the Pediatric Patient, Pain and sedation in the Emergency Department, Pediatric Trauma. UPDATE IN PEDIATRICS 2018. [PMCID: PMC7123355 DOI: 10.1007/978-3-319-58027-2_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Shalea Piteau
- Chief/Medical Director of Pediatrics at Quinte Health Care, Assistant Professor at Queen’s University, Belleville, Ontario Canada
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180
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Obonyo NG, Schlapbach LJ, Fraser JF. Sepsis: Changing Definitions, Unchanging Treatment. Front Pediatr 2018; 6:425. [PMID: 30729101 PMCID: PMC6351458 DOI: 10.3389/fped.2018.00425] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/21/2018] [Indexed: 11/13/2022] Open
Abstract
The recently revised Sepsis-3 definitions were based on criteria that were derived and validated in adult patient databases from high income countries. Both sepsis and septic shock continue to account for a substantial proportion of mortality globally, especially amongst children in low-and-middle income country settings. It is therefore urgent to develop and validate standardized criteria for sepsis that can be applied to pediatric populations in different settings, including in- and outside intensive care, both in high- and low/middle- income countries. This will be a pre-requisite to evaluate the impact of sepsis treatment strategies to improve clinical outcomes.
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Affiliation(s)
- Nchafatso Gikenyi Obonyo
- IDeAL/KEMRI-Wellcome Trust Research Programme, CGMRC, Kilifi, Kenya.,Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
| | - Luregn Jan Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia.,Department of Pediatrics, Inselspital Universitätsspital Bern, Bern, Switzerland.,Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - John Francis Fraser
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
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181
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Sethi SK, Raghunathan V, Shah S, Dhaliwal M, Jha P, Kumar M, Paluri S, Bansal S, Mhanna MJ, Raina R. Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children. Front Pediatr 2018; 6:118. [PMID: 29765932 PMCID: PMC5938374 DOI: 10.3389/fped.2018.00118] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 04/12/2018] [Indexed: 11/20/2022] Open
Abstract
Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission. Design and setting: Prospective study, pediatric intensive care in a tertiary hospital. Duration: June 2013-June 2014. Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded. Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality. Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score (p < 0.05). Fluid overload was associated with longer duration of ventilation (p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80-95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3. Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI.
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Affiliation(s)
- Sidharth K Sethi
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Veena Raghunathan
- Pediatric Intensive Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Shilpi Shah
- Department of Pediatric Nephrology, Akron Children Hospital, Akron, OH, United States
| | - Maninder Dhaliwal
- Pediatric Intensive Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Pranaw Jha
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maneesh Kumar
- Pediatric Intensive Care, Medanta, The Medicity Hospital, Gurgaon, India
| | | | - Shyam Bansal
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maroun J Mhanna
- Department of Pediatrics, Metrohealth Medical Center, Cleveland, OH, United States
| | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children Hospital, Akron, OH, United States
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182
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Sepanski RJ, Godambe SA, Zaritsky AL. Pediatric Vital Sign Distribution Derived From a Multi-Centered Emergency Department Database. Front Pediatr 2018; 6:66. [PMID: 29629363 PMCID: PMC5876311 DOI: 10.3389/fped.2018.00066] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/08/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We hypothesized that current vital sign thresholds used in pediatric emergency department (ED) screening tools do not reflect observed vital signs in this population. We analyzed a large multi-centered database to develop heart rate (HR) and respiratory rate centile rankings and z-scores that could be incorporated into electronic health record ED screening tools and we compared our derived centiles to previously published centiles and Pediatric Advanced Life Support (PALS) vital sign thresholds. METHODS Initial HR and respiratory rate data entered into the Cerner™ electronic health record at 169 participating hospitals' ED over 5 years (2009 through 2013) as part of routine care were analyzed. Analysis was restricted to non-admitted children (0 to <18 years). Centile curves and z-scores were developed using generalized additive models for location, scale, and shape. A split-sample validation using two-thirds of the sample was compared with the remaining one-third. Centile values were compared with results from previous studies and guidelines. RESULTS HR and RR centiles and z-scores were determined from ~1.2 million records. Empirical 95th centiles for HR and respiratory rate were higher than previously published results and both deviated from PALS guideline recommendations. CONCLUSION Heart and respiratory rate centiles derived from a large real-world non-hospitalized ED pediatric population can inform the modification of electronic and paper-based screening tools to stratify children by the degree of deviation from normal for age rather than dichotomizing children into groups having "normal" versus "abnormal" vital signs. Furthermore, these centiles also may be useful in paper-based screening tools and bedside alarm limits for children in areas other than the ED and may establish improved alarm limits for bedside monitors.
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Affiliation(s)
- Robert J Sepanski
- Department of Quality Improvement, Children's Hospital of The King's Daughters, Norfolk, VA, United States
| | - Sandip A Godambe
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, United States
| | - Arno L Zaritsky
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, United States
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183
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van Nassau SC, van Beek RH, Driessen GJ, Hazelzet JA, van Wering HM, Boeddha NP. Translating Sepsis-3 Criteria in Children: Prognostic Accuracy of Age-Adjusted Quick SOFA Score in Children Visiting the Emergency Department With Suspected Bacterial Infection. Front Pediatr 2018; 6:266. [PMID: 30327759 PMCID: PMC6174358 DOI: 10.3389/fped.2018.00266] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Recent attempts to translate Sepsis-3 criteria to children have been restricted to PICU patients and did not target children in emergency departments (ED). We assessed the prognostic accuracy of the age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) and compared the performance to SIRS and the quick Pediatric Logistic Organ Dysfunction-2 score (qPELOD-2). We studied whether the addition of lactate (qSOFA-L) would increase prognostic accuracy. Methods: Non-academic, single-center, retrospective study in children visiting the ED and admitted with suspected bacterial infection between March 2013 and January 2018. We defined suspected bacterial infection as initiation of antibiotic therapy within 24 h after ED entry. Age-adjusted qSOFA, SIRS, qPELOD-2, and qSOFA-L scores were compared by area under the receiver operating characteristics curve (AUROC) analysis. Primary outcome measure was PICU transfer and/or mortality and secondary outcome was prolonged hospital length of stay. Results: We included 864 ED visits [474 (55%) male; median age 2.5 years; IQR 9 months-6 years], of which 18 were transferred to a PICU and 6 ended in death [composite outcome PICU transfer and/or mortality; 23 admissions (2.7%)]. 179 (22.2%) admissions resulted in prolonged hospital length of stay. PICU transfer and/or death was present in 22.5% of visits with qSOFA≥2 (n = 40) compared to 2.0% of visits with qSOFA<2 (n = 444) (p < 0.01). qSOFA tends to be the best predictor of PICU transfer and/or mortality (AUROC 0.72 (95% CI, 0.57-0.86) compared to SIRS [0.64 (95% CI, 0.53-0.74), p = 0.23] and qPELOD-2 [0.60 (95% CI, 0.45-0.76), p = 0.03)]. Prolonged hospital length of stay was poorly predicted by qSOFA (AUROC 0.53, 95% CI 0.46-0.59), SIRS (0.49, 95% CI 0.44-0.54), and qPELOD-2 (0.51, 95%CI 0.45-0.57). qSOFA-L resulted in an AUROC of 0.67 (95% CI, 0.50-0.84) for PICU transfer and/or mortality and an AUROC of 0.56 (95% CI, 0.46-0.67) for prolonged hospital length of stay. Conclusion: The currently proposed bedside risk-stratification tool of Sepsis-3 criteria, qSOFA, shows moderate prognostic accuracy for PICU transfer and/or mortality in children visiting the ED with suspected bacterial infection. The addition of lactate did not improve prognostic accuracy. Future prospective studies in larger ED populations are needed to further determine the utility of the qSOFA score.
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Affiliation(s)
| | - Ron H van Beek
- Department of Pediatrics, Amphia Hospital, Breda, Netherlands
| | - Gertjan J Driessen
- Department of Pediatrics, Juliana Children's Hospital, Haga Teaching Hospital, The Hague, Netherlands
| | - Jan A Hazelzet
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Navin P Boeddha
- Department of Pediatrics, Amphia Hospital, Breda, Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands.,Division of Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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184
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O’Hara CB, Canter RR, Mouncey PR, Carter A, Jones N, Nadel S, Peters MJ, Lyttle MD, Harrison DA, Rowan KM, Inwald D, Woolfall K. A qualitative feasibility study to inform a randomised controlled trial of fluid bolus therapy in septic shock. Arch Dis Child 2018; 103:28-32. [PMID: 28847877 PMCID: PMC5754873 DOI: 10.1136/archdischild-2016-312515] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 06/01/2017] [Accepted: 06/12/2017] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The Fluids in Shock (FiSh) Trial proposes to evaluate whether restrictive fluid bolus therapy (10 mL/kg) is more beneficial than current recommended practice (20 mL/kg) in the resuscitation of children with septic shock in the UK. This qualitative feasibility study aimed to explore acceptability of the FiSh Trial, including research without prior consent (RWPC), potential barriers to recruitment and participant information for a pilot trial. DESIGN Qualitative interview study involving parents of children who had presented to a UK emergency department or been admitted to a paediatric intensive care unit with severe infection in the previous 3 years. PARTICIPANTS Twenty-one parents (seven bereaved) were interviewed 16 (median) months since their child's hospital admission (range: 1-41). RESULTS All parents said they would have provided consent for the use of their child's data in the FiSh Trial. The majority were unfamiliar with RWPC, yet supported its use. Parents were initially concerned about the change from currently recommended treatment, yet were reassured by explanations of the current evidence base, fluid bolus therapy and monitoring procedures. Parents made recommendations about the timing of the research discussion and content of participant information. Bereaved parents stated that recruiters should not discuss research immediately after a child's death, but supported a personalised postal 'opt-out' approach to consent. CONCLUSIONS Findings show that parents whose child has experienced severe infection supported the proposed FiSh Trial, including the use of RWPC. Parents' views informed the development of the pilot trial protocol and site staff training. TRIAL REGISTRATION NUMBER ISRCTN15244462-results.
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Affiliation(s)
- Caitlin B O’Hara
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | | | - Nicola Jones
- Patient and Public Involvement Partner, Watford, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mark J Peters
- Institute of Child Health, University College London, UK and Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK,Emergency Department, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - David Inwald
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kerry Woolfall
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
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185
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Tissot C, Singh Y, Sekarski N. Echocardiographic Evaluation of Ventricular Function-For the Neonatologist and Pediatric Intensivist. Front Pediatr 2018; 6:79. [PMID: 29670871 PMCID: PMC5893826 DOI: 10.3389/fped.2018.00079] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/14/2018] [Indexed: 12/27/2022] Open
Abstract
In the neonatal and pediatric intensive care setting, bedside cardiac ultrasound is often used to assess ventricular dimensions and function. Depending upon the underlying disease process, it is necessary to be able to evaluate the systolic and diastolic function of left and or right ventricles. The systolic function of left ventricle is mostly assessed qualitatively on visual inspection "eye-balling" and quantitatively by measuring circumferential fraction shortening or calculating the ejection fraction by Simpson's planimetry. The assessment of left ventricular diastolic function relies essentially on the mitral valve and pulmonary venous Doppler tracings or tissue Doppler evaluation. The right ventricular particular shape and anatomical position does not permit to use the same parameters for measuring systolic function as is used for the LV. Tricuspid annular plane systolic excursion (TAPSE) and S' velocity on tissue Doppler imaging are more often used for quantitative assessment of right ventricle systolic function. Several parameters proposed to assess right ventricle systolic function such as fractional area change, 3D echocardiography, speckle tracking, and strain rate are being researched and normal values for children are being established. Diastolic function of right ventricle is evaluated by tricuspid valve and hepatic venous Doppler tracings or on tissue Doppler evaluation. The normal values for children are pretty similar to adults while normal values for the neonates, especially preterm infants, may differ significantly from adult population. The normal values for most of the parameters used to assess cardiac function in term neonates and children have now been established.
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Affiliation(s)
- Cécile Tissot
- Centre de Pediatrie, Clinique des Grangettes, Geneva, Switzerland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Nicole Sekarski
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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186
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Goonasekera CDA, Carcillo JA, Deep A. Oxygen Delivery and Oxygen Consumption in Pediatric Fluid Refractory Septic Shock During the First 42 h of Therapy and Their Relationship to 28-Day Outcome. Front Pediatr 2018; 6:314. [PMID: 30406065 PMCID: PMC6206202 DOI: 10.3389/fped.2018.00314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/03/2018] [Indexed: 12/16/2022] Open
Abstract
Background: In septic shock, both oxygen delivery (DO2) and oxygen consumption (VO2) are dysfunctional. The current therapeutic regimens are geared to normalize global oxygen delivery (DO2) to tissues via goal directed therapies but mortality remains high at 10-20%. Methods: We studied cardiac index (CI), systemic vascular resistance index (SVRI), central venous oxygen saturation (ScvO2), central venous pressure (CVP), peripheral oxygen saturation (SpO2), mean blood pressure (MBP), body temperature, blood lactate, base excess and hemoglobin concentration (Hb) in a cohort of children admitted in "fluid-refractory" severe septic shock to pediatric intensive care, over 4.5-years. We calculated their 6 h global oxygen delivery (DO2) and global oxygen consumption (VO2) over the first 42 h and looked at factors associated with VO2/DO2 ratio (i.e., global oxygen extraction, gO2ER) and 28-day mortality. Results: Sixty-two children mean age (SD) 7.19 (5.44) years were studied. Fifty-seven (93%) children were sedated and mechanically ventilated and all received adrenaline or noradrenaline or both and added milrinone in 6 (9.6%). At 28 days, 9 (14.5%) were dead. The global oxygen extraction ratio (gO2ER) was consistently lower amongst the survivors and independently predicted mortality (ROC AUC = 0.75). A lactate level of 4 mmol/l or above, when associated with a concurrent metabolic acidosis predicted mortality with a sensitivity of 100% (95% CI 90.5-100) and a specificity of 67.7% (95% CI 62.2-72.9). A gO2ER of 0.48 or above on admission to the PICU was associated with death with a 66.7% sensitivity (95%CI 29.9-92.5) and 90.5% specificity (95%CI 79.3-96.8). A global O2ER of >0.48 combined with a concurrent blood lactate >4.0 mmol/l at any time within the first 42 h of therapy predicted death with a sensitivity of 63.9% (95% CI, 46.2-79.1) and specificity of 97.8% (95% CI, 95.7-99.0). A radar plot identified MBP-CVP difference, and CI as additional goals of therapy that may offer a survival benefit. Conclusions: Global O2ER of >0.48 with a concurrent blood lactate >4.0 mmol/l in children with metabolic acidosis was an independent factor associated with death in fluid resistant septic shock. Trends of gO2ER seem useful to recognize survivors and non-survivors early in the illness.
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Affiliation(s)
| | - Joseph A Carcillo
- Divison of Pediatric Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital, London, United Kingdom
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187
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EL‐Nawawy AA, Abdelmohsen AM, Hassouna HM. Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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188
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Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, Imaizumi H, Inoue S, Kakihana Y, Kotani J, Kushimoto S, Masuda Y, Matsuda N, Matsushima A, Nakada T, Nakagawa S, Nunomiya S, Sadahiro T, Shime N, Yatabe T, Hara Y, Hayashida K, Kondo Y, Sumi Y, Yasuda H, Aoyama K, Azuhata T, Doi K, Doi M, Fujimura N, Fuke R, Fukuda T, Goto K, Hasegawa R, Hashimoto S, Hatakeyama J, Hayakawa M, Hifumi T, Higashibeppu N, Hirai K, Hirose T, Ide K, Kaizuka Y, Kan'o T, Kawasaki T, Kuroda H, Matsuda A, Matsumoto S, Nagae M, Onodera M, Ohnuma T, Oshima K, Saito N, Sakamoto S, Sakuraya M, Sasano M, Sato N, Sawamura A, Shimizu K, Shirai K, Takei T, Takeuchi M, Takimoto K, Taniguchi T, Tatsumi H, Tsuruta R, Yama N, Yamakawa K, Yamashita C, Yamashita K, Yoshida T, Tanaka H, Oda S. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). Acute Med Surg 2018; 5:3-89. [PMID: 29445505 PMCID: PMC5797842 DOI: 10.1002/ams2.322] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. Methods Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members. Results A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs. Conclusions Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.
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189
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Selewski DT, Goldstein SL. The role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2018; 33:13-24. [PMID: 27900473 DOI: 10.1007/s00467-016-3539-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 01/11/2023]
Abstract
Our understanding of the epidemiology and the impact of acute kidney injury (AKI) and fluid overload on outcomes has improved significantly over the past several decades. Fluid overload occurs commonly in critically ill children with and without associated AKI. Researchers in pediatric AKI have been at the forefront of describing the impact of fluid overload on outcomes in a variety of populations. A full understanding of this topic is important as fluid overload represents a potentially modifiable risk factor and a target for intervention. In this state-of-the-art review, we comprehensively describe the definition of fluid overload, the impact of fluid overload on kidney function, the impact of fluid overload on the diagnosis of AKI, the association of fluid overload with outcomes, the targeted therapy of fluid overload, and the impact of the timing of renal replacement therapy on outcomes.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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190
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John RT, Henricson J, Nilsson GE, Wilhelms D, Anderson CD. Reflectance spectroscopy: to shed new light on the capillary refill test. JOURNAL OF BIOPHOTONICS 2018; 11:e201700043. [PMID: 28544641 DOI: 10.1002/jbio.201700043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/25/2017] [Accepted: 05/09/2017] [Indexed: 06/07/2023]
Abstract
To use Bioengineering methodology is used to achieve, at five anatomical sites, a detailed, quantitative assessment of the return of blood content to the blanched area, during the Capillary Refill (CR) test. An observational, non-randomized, experimental study on 23 healthy subjects (14 females) was performed in our climate controlled skin physiology laboratory. Our main outcome measures were based on the chronological assessment and quantification of red blood cell concentration (RBC) after the release of blanching pressure in the CR test, using Tissue Viability Imaging (TiVi), a digital photographic technique based on polarisation spectroscopy. TiVi enabled collection of detailed data on skin RBC concentration during the CR test. The results were shown as curves with skin blood concentration (TiVi-value) on the y-axis and the time on the x-axis. Quantitative CR responses showed site and temperature variability. We also suggest possible objective endpoint values from the capillary refill curve. Detailed data on skin RBC concentration during the CR test is easily obtained and allows objective determination of end points not possible to achieve by naked eye assessment. These findings have the potential to place the utility of the CR test in a clinical setting in a new light. Picture: Regular photograph and TiVi Image showing CR test and corresponding graph for the CR response.
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Affiliation(s)
- Rani Toll John
- Division of Neuro and Inflammation Science, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University and Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Region Östergötland, 58185, Linköping, Sweden
| | - Joakim Henricson
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Department of Dermatology and Venerology, Heart and Medicine Center, Region Östergötland
| | - Gert E Nilsson
- WheelsBridge AB, Lövsbergsv 13, 589 37 Linköping, Sweden
| | - Daniel Wilhelms
- Division of Drug Research, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Region Östergötland
| | - Chris D Anderson
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Department of Dermatology and Venerology, Heart and Medicine Center, Region Östergötland
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191
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Gelbart B. Fluid Bolus Therapy in Pediatric Sepsis: Current Knowledge and Future Direction. Front Pediatr 2018; 6:308. [PMID: 30410875 PMCID: PMC6209667 DOI: 10.3389/fped.2018.00308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,The University of Melbourne, Melbourne, VIC, Australia
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192
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Yuan WH, Zeng LK, Cai BH, Liu XY, Wang S, Zhao LX, Huang YP, Wang QL, Liu HC. [Value of arterial blood lactic acid in the evaluation of disease severity and prognosis in neonatal shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:17-20. [PMID: 29335076 PMCID: PMC7390323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/25/2017] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To evaluate the value of blood lactic acid (BLA) as a predictor for the severity and prognosis of neonatal shock. METHODS A total of 326 neonates with shock were enrolled and divided into three groups based on the severity, namely mild group (n=147), moderate group (n=105), and severe group (n=74). BLA level was measured during and early after (about 6 hours later) fluid resuscitation, and lactate clearance rate (LCR) was calculated. The receiver operating characteristic (ROC) curve was applied to evaluate the predictive value of BLA in neonatal shock. RESULTS BLA level was high in all subjects prior to treatment, and was highest in the severe group and lowest in the mild group (P<0.01). BLA level was significantly higher among patients with septic shock than among those with hypovolemic, cardiogenic, and asphyxiating shock (P<0.05). BLA level was significantly reduced in patients in recovery after treatment (P<0.05). Mortality was significantly lower in patients with BLA level ≤4 mmol/L or LCR ≥10% than in those with BLA level >4 mmol/L or LCR <10% (P<0.01). BLA at 11.15 mmol/L had 100% sensitivity and 96.8% specificity in predicting severe shock. BLA at 10.65 mmol/L had 88.9% sensitivity and 74.1% specificity in predicting the prognosis (survival or dead) of newborns with shock. CONCLUSIONS In neonates with shock, arterial BLA level increases as the disease severity increases and is associated with prognosis, so it is a useful predictor of the severity and prognosis of neonatal shock.
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Affiliation(s)
- Wen-Hao Yuan
- Department of Neonatology, Wuhan Children's Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China.
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193
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El-Nawawy AA, Abdelmohsen AM, Hassouna HM. Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial. J Pediatr (Rio J) 2018; 94:31-39. [PMID: 28873333 DOI: 10.1016/j.jped.2017.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/05/2017] [Accepted: 01/11/2017] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To evaluate the role of echocardiography in reducing shock reversal time in pediatric septic shock. METHODS A prospective study conducted in the pediatric intensive care unit of a tertiary care teaching hospital from September 2013 to May 2016. Ninety septic shock patients were randomized in a 1:1 ratio for comparing the serial echocardiography-guided therapy in the study group with the standard therapy in the control group regarding clinical course, timely treatment, and outcomes. RESULTS Shock reversal was significantly higher in the study group (89% vs. 67%), with significantly reduced shock reversal time (3.3 vs. 4.5 days). Pediatric intensive care unit stay in the study group was significantly shorter (8±3 vs. 14±10 days). Mortality due to unresolved shock was significantly lower in the study group. Fluid overload was significantly lower in the study group (11% vs. 44%). In the study group, inotropes were used more frequently (89% vs. 67%) and initiated earlier (12[0.5-24] vs. 24[6-72]h) with lower maximum vasopressor inotrope score (120[30-325] vs. 170[80-395]), revealing predominant use of milrinone (62% vs. 22%). CONCLUSION Serial echocardiography provided crucial data for early recognition of septic myocardial dysfunction and hypovolemia that was not apparent on clinical assessment, allowing a timely management and resulting in shock reversal time reduction among children with septic shock.
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Affiliation(s)
- Ahmed A El-Nawawy
- Alexandria University, Faculty of Medicine, Department of Pediatrics, Alexandria, Egypt
| | - Aly M Abdelmohsen
- Alexandria University, Faculty of Medicine, Pediatric Cardiology Unit, Alexandria, Egypt
| | - Hadir M Hassouna
- Alexandria University, Faculty of Medicine, Department of Pediatrics, Alexandria, Egypt.
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194
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A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned. Pediatr Qual Saf 2017; 3:e051. [PMID: 30229187 PMCID: PMC6132697 DOI: 10.1097/pq9.0000000000000051] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 11/16/2017] [Indexed: 01/20/2023] Open
Abstract
Background: Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis. Methods: Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement. Results: Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality. Conclusions: A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a “time zero” for measuring the timeliness of treatment.
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195
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Sepsis bei Kindern. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0416-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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196
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Cattermole GN, Leung PYM, Ho GYL, Lau PWS, Chan CPY, Chan SSW, Smith BE, Graham CA, Rainer TH. The normal ranges of cardiovascular parameters measured using the ultrasonic cardiac output monitor. Physiol Rep 2017; 5:5/6/e13195. [PMID: 28320891 PMCID: PMC5371563 DOI: 10.14814/phy2.13195] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 01/30/2017] [Accepted: 02/14/2017] [Indexed: 11/24/2022] Open
Abstract
The ultrasonic cardiac output monitor (USCOM) is a noninvasive transcutaneous continuous wave Doppler method for assessing hemodynamics. There are no published reference ranges for normal values in adults (aged 18-60 years) for this device. This study aimed to (1) measure cardiovascular indices using USCOM in healthy adults aged 18-60 years; (2) combine these data with those for healthy children (aged 0-12), adolescents (aged 12-18), and the elderly (aged over 60) from our previously published studies in order to present normal ranges for all ages, and (3) establish normal ranges of USCOM-derived variables according to both weight and age. This was a population-based cross-sectional observational study of healthy Chinese subjects aged 0.5-89 years in Hong Kong. USCOM scans were performed on all subjects, to produce measurements including stroke volume, cardiac output, and systemic vascular resistance. Data from previously published studies (children, adolescents, and the elderly) were included. Normal ranges were defined as lying between the 2.5th and 97.5th percentiles. A total of 2218 subjects were studied (mean age = 16.4, range = 0.5-89; 52% male). From previous studies, 1197 children (aged 0-12, 55% male), 590 adolescents (aged 12-18, 49% male), and 77 elderly (aged 60-89, 55% male) were included. New data were collected from 354 adults aged 18-60 (47% male). Normal ranges are presented according to age and weight. We present comprehensive normal ranges for hemodynamic parameters obtained with USCOM in healthy subjects of all ages from infancy to the elderly.
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Affiliation(s)
- Giles N Cattermole
- Emergency Department, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - P Y Mia Leung
- Department of Medicine, Austin/Northern Health, Melbourne, Australia
| | - Grace Y L Ho
- Department of Medicine, Western Health, Melbourne, Australia
| | - Peach W S Lau
- Accident and Emergency Department, Queen Elizabeth Hospital, Hong Kong SAR
| | - Cangel P Y Chan
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR
| | - Stewart S W Chan
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR
| | - Brendan E Smith
- School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia.,Intensive Care Unit, Bathurst Base Hospital, Bathurst, New South Wales, Australia
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR
| | - Timothy H Rainer
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR.,University Hospital of Wales, Heath Park, Heath, Cardiff, U.K
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197
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High Levels of Morbidity and Mortality Among Pediatric Hematopoietic Cell Transplant Recipients With Severe Sepsis: Insights From the Sepsis PRevalence, OUtcomes, and Therapies International Point Prevalence Study. Pediatr Crit Care Med 2017; 18:1114-1125. [PMID: 28926489 PMCID: PMC7339740 DOI: 10.1097/pcc.0000000000001338] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Pediatric severe sepsis is a major cause of morbidity and mortality worldwide, and hematopoietic cell transplant patients represent a high-risk population. We assessed the epidemiology of severe sepsis in hematopoietic cell transplant patients, describing patient outcomes compared with children with no history of hematopoietic cell transplant. DESIGN Secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study, comparing demographics, sepsis etiology, illness severity, organ dysfunction, and sepsis-related treatments in patients with and without hematopoietic cell transplant. The primary outcome was hospital mortality. Multivariable logistic regression models were used to determine adjusted differences in mortality. SETTING International; 128 PICUs in 26 countries. PATIENTS Pediatric patients with severe sepsis prospectively identified over a 1-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In patients with severe sepsis, 37/567 (6.5%) had a history of hematopoietic cell transplant. Compared with patients without hematopoietic cell transplant, hematopoietic cell transplant patients had significantly higher hospital mortality (68% vs 23%; p < 0.001). Hematopoietic cell transplant patients were more likely to have hospital acquired sepsis and had more preexisting renal and hepatic dysfunction than non-hematopoietic cell transplant patients with severe sepsis. History of hematopoietic cell transplant, renal replacement therapy, admission from inpatient floor, and number of organ dysfunctions at severe sepsis recognition were independently associated with hospital mortality in multivariable analysis; hematopoietic cell transplant conferred the highest odds of mortality (odds ratio, 4.00; 95% CI, 1.78-8.98). In secondary analysis of hematopoietic cell transplant patients compared with other immunocompromised patients with severe sepsis, history of hematopoietic cell transplant remained independently associated with hospital mortality (odds ratio, 3.03; 95% CI, 1.11-8.27). CONCLUSIONS In an international study of pediatric severe sepsis, history of hematopoietic cell transplant is associated with a four-fold increased odds of hospital mortality after adjustment for potential measured confounders. Hematopoietic cell transplant patients more often originated from within the hospital compared to children with severe sepsis without hematopoietic cell transplant, possibly providing an earlier opportunity for sepsis recognition and intervention in this high-risk population.
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198
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Selewski DT, Askenazi DJ, Bridges BC, Cooper DS, Fleming GM, Paden ML, Verway M, Sahay R, King E, Zappitelli M. The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study. Pediatr Crit Care Med 2017; 18:1126-1135. [PMID: 28937504 PMCID: PMC5716912 DOI: 10.1097/pcc.0000000000001349] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation in children treated with extracorporeal membrane oxygenation. DESIGN Retrospective cohort study. SETTING Six tertiary children's hospital ICUs. PATIENTS Seven hundred fifty-six children younger than 18 years old treated with extracorporeal membrane oxygenation for greater than or equal to 24 hours from January 1, 2007, to December 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall survival to extracorporeal membrane oxygenation decannulation and hospital discharge was 74.9% (n = 566) and 57.7% (n = 436), respectively. Median fluid overload at extracorporeal membrane oxygenation initiation was 8.8% (interquartile range, 0.3-19.2), and it differed between hospital survivors and non survival, though not between extracorporeal membrane oxygenation survivors and non survivors. Median peak fluid overload on extracorporeal membrane oxygenation was 30.9% (interquartile range, 15.4-54.8). During extracorporeal membrane oxygenation, 84.8% had a peak fluid overload greater than or equal to 10%; 67.2% of patients had a peak fluid overload of greater than or equal to 20% and 29% of patients had a peak fluid overload of greater than or equal to 50%. The median peak fluid overload was lower in patients who survived on extracorporeal membrane oxygenation (27.2% vs 44.4%; p < 0.0001) and survived to hospital discharge (24.8% vs 43.3%; p < 0.0001). After adjusting for acute kidney injury, pH at extracorporeal membrane oxygenation initiation, nonrenal complications, extracorporeal membrane oxygenation mode, support type, center and patient age, the degree of fluid overload at extracorporeal membrane oxygenation initiation (p = 0.05), and the peak fluid overload on extracorporeal membrane oxygenation (p < 0.0001) predicted duration of extracorporeal membrane oxygenation in survivors. Multivariable analysis showed that peak fluid overload on extracorporeal membrane oxygenation (adjusted odds ratio, 1.09; 95% CI, 1.04-1.15) predicted mortality on extracorporeal membrane oxygenation; fluid overload at extracorporeal membrane oxygenation initiation (adjusted odds ratio, 1.13; 95% CI, 1.05-1.22) and peak fluid overload (adjusted odds ratio, 1.18; 95% CI, 1.12-1.24) both predicted hospital morality. CONCLUSIONS Fluid overload occurs commonly and is independently associated with adverse outcomes including increased mortality and increased duration of extracorporeal membrane oxygenation in a broad pediatric extracorporeal membrane oxygenation population. These results suggest that fluid overload is a potential target for intervention to improve outcomes in children on extracorporeal membrane oxygenation.
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Affiliation(s)
- David T Selewski
- Department of Pediatrics & Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Mark Verway
- Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada
| | - Rashmi Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael Zappitelli
- Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada
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Hansmann A, Morrow BM, Lang HJ. Review of supplemental oxygen and respiratory support for paediatric emergency care in sub-Saharan Africa. Afr J Emerg Med 2017; 7:S10-S19. [PMID: 30505669 PMCID: PMC6246869 DOI: 10.1016/j.afjem.2017.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION In African countries, respiratory infections and severe sepsis are common causes of respiratory failure and mortality in children under five years of age. Mortality and morbidity in these children could be reduced with adequate respiratory support in the emergency care setting. The purpose of this review is to describe management priorities in the emergency care of critically ill children presenting with respiratory problems. Basic and advanced respiratory support measures are described for implementation according to available resources, work load and skill-levels. METHODS We did a focused search of respiratory support for critically ill children in resource-limited settings over the past ten years, using the search tools PubMed and Google Scholar, the latest WHO guidelines, international 'Advanced Paediatric Life Support' guidelines and paediatric critical care textbooks. RESULTS The implementation of triage and rapid recognition of respiratory distress and hypoxia with pulse oximetry is important to correctly identify critically ill children with increased risk of mortality in all health facilities in resource constrained settings. Basic, effective airway management and respiratory support are essential elements of emergency care. Correct provision of supplemental oxygen is safe and its application alone can significantly improve the outcome of critically ill children. Non-invasive ventilatory support is cost-effective and feasible, with the potential to improve emergency care packages for children with respiratory failure and other organ dysfunctions. Non-invasive ventilation is particularly important in severely under-resourced regions unable to provide intubation and invasive mechanical ventilation support. Malnutrition and HIV-infection are important co-morbid conditions, associated with increased mortality in children with respiratory dysfunction. DISCUSSION A multi-disciplinary approach is required to optimise emergency care for critically ill children in low-resource settings. In this context, it is important to consider aspects of training of staff, technical support and pragmatic research.
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Affiliation(s)
- Andreas Hansmann
- Universitätsklinikum Bonn, Zentrum für Kinderheilkunde and, Queen Elizabeth Central Hospital Blantyre, Department of Paediatrics, Germany
| | - Brenda May Morrow
- University of Cape Town, Department of Paediatrics and Child Health, South Africa
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Basic Hemodynamic Monitoring Using Ultrasound or Electrical Cardiometry During Transportation of Neonates and Infants. Pediatr Crit Care Med 2017; 18:e488-e493. [PMID: 28800001 DOI: 10.1097/pcc.0000000000001298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Electrical cardiometry and heart ultrasound might allow hemodynamic evaluation during transportation of critically ill patients. Our aims were 1) to test feasibility of stroke volume monitoring using electrical cardiometry or ultrasound during transportation and 2) to investigate if transportation impacts on electrical cardiometry and ultrasound reliability. DESIGN Prospective, pragmatic, feasibility cohort study. SETTING Mobile ICUs specialized for neonatal and pediatric transportation. PATIENTS Thirty hemodynamically stable neonates and infants. INTERVENTIONS Patients enrolled underwent paired stroke volume measurements (180 before/after and 180 during the transfer) by electrical cardiometry (SVEC) and ultrasound (SVUS). MEASUREMENTS AND MAIN RESULTS No problems or malfunctioning occurred neither with electrical cardiometry nor with ultrasound. Ultrasound lasted on average 90 (10) seconds, while 45 (15) seconds were needed to instigate electrical cardiometry monitoring. Coefficient of variation was higher for SVUS (before/after: 0.57; during: 0.66) than for SVEC (before/after: 0.38; during: 0.36). Correlations between SVEC and SVUS before/after and during the transfer were r equal to 0.57 and r equal to 0.8, respectively (p always < 0.001). Bland-Altman analysis showed that stroke volume tends to be higher if measured by electrical cardiometry. SVEC measured before (5.5 [2.4] mL), during (5.4 [2.4] mL), and after the transfer (5.4 [2.3] mL) are similar (p = 0.955); same applies for SVUS before (2.6 [1.5] mL), during (2.4 [2] mL), and after (2.9 [2] mL) the transfer (p = 0.268). CONCLUSIONS Basic hemodynamic monitoring is feasible during pediatric and neonatal transportation both with electrical cardiometry and ultrasound. These two techniques show comparable reliability, although stroke volume was higher if measured by electrical cardiometry. The transportation itself does not affect the reliability of stroke volume measurements.
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