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Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA 2019; 321:654-664. [PMID: 30772908 PMCID: PMC6439620 DOI: 10.1001/jama.2019.0071] [Citation(s) in RCA: 416] [Impact Index Per Article: 83.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. OBJECTIVE To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. INTERVENTIONS Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. RESULTS Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. CONCLUSIONS AND RELEVANCE Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03078712.
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Affiliation(s)
- Glenn Hernández
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Gustavo A. Ospina-Tascón
- Fundación Valle del Lili, Universidad ICESI, Department of Intensive Care Medicine, Cali, Colombia
| | - Lucas Petri Damiani
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Arnaldo Dubin
- Sanatorio Otamendi, Buenos Aires, Argentina
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Javier Hurtado
- Intensive Care Unit, Hospital Español–ASSE, Montevideo, Uruguay
- Department of Pathophysiology, School of Medicine Universidad de la República, Montevideo, Uruguay
| | - Gilberto Friedman
- Post-Graduation Program in Pneumological Sciences, Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ricardo Castro
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Leyla Alegría
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hopital Bicetre, Hopitaux Universitaires Paris–Sud, Paris, France
- Assistance Publique Hôpitaux de Paris, Université Paris–Sud, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Manuel Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Escuela de Medicina, Universidad Internacional del Ecuador, Quito
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Paula Fernández
- Unidad de Pacientes Críticos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Diego Barahona
- Unidad de Cuidados Intensivos, Hospital General Docente de Calderón, Universidad Central del Ecuador, Quito
| | - Vladimir Granda-Luna
- Unidad de Cuidados Intensivos, Hospital San Francisco, Pontificia Universidad Católica de Quito, Quito, Ecuador
| | - Alexandre Biasi Cavalcanti
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jan Bakker
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, New York
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
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Blaxter LL, Morris DE, Crowe JA, Henry C, Hill S, Sharkey D, Vyas H, Hayes-Gill BR. An automated quasi-continuous capillary refill timing device. Physiol Meas 2015; 37:83-99. [PMID: 26642080 PMCID: PMC4770525 DOI: 10.1088/0967-3334/37/1/83] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Capillary refill time (CRT) is a simple means of cardiovascular assessment which is widely used in clinical care. Currently, CRT is measured through manual assessment of the time taken for skin tone to return to normal colour following blanching of the skin surface. There is evidence to suggest that manually assessed CRT is subject to bias from ambient light conditions, a lack of standardisation of both blanching time and manually applied pressure, subjectiveness of return to normal colour, and variability in the manual assessment of time. We present a novel automated system for CRT measurement, incorporating three components: a non-invasive adhesive sensor incorporating a pneumatic actuator, a diffuse multi-wavelength reflectance measurement device, and a temperature sensor; a battery operated datalogger unit containing a self contained pneumatic supply; and PC based data analysis software for the extraction of refill time, patient skin surface temperature, and sensor signal quality. Through standardisation of the test, it is hoped that some of the shortcomings of manual CRT can be overcome. In addition, an automated system will facilitate easier integration of CRT into electronic record keeping and clinical monitoring or scoring systems, as well as reducing demands on clinicians. Summary analysis of volunteer (n = 30) automated CRT datasets are presented, from 15 healthy adults and 15 healthy children (aged from 5 to 15 years), as their arms were cooled from ambient temperature to 5°C. A more detailed analysis of two typical datasets is also presented, demonstrating that the response of automated CRT to cooling matches that of previously published studies.
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Affiliation(s)
- L L Blaxter
- Electrical Systems & Optics Research Division, Faculty of Engineering, University of Nottingham, University Park, Nottingham NG7 2RD, UK
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Fleming S, Gill P, Jones C, Taylor JA, Van den Bruel A, Heneghan C, Roberts N, Thompson M. The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0138155. [PMID: 26375953 PMCID: PMC4573516 DOI: 10.1371/journal.pone.0138155] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/25/2015] [Indexed: 11/18/2022] Open
Abstract
Importance Capillary refill time (CRT) is widely recommended as part of the routine assessment of unwell children. Objective To determine the diagnostic value of capillary refill time for a range of serious outcomes in children. Methods We searched Medline, Embase and CINAHL from inception to June 2014. We included studies that measured both capillary refill time and a relevant clinical outcome such as mortality, dehydration, meningitis, or other serious illnesses in children aged up to 18 years of age. We screened 1,265 references, of which 24 papers were included in this review. Where sufficient studies were available, we conducted meta-analysis and constructed hierarchical summary ROC curves. Results Meta-analysis on the relationship between capillary refill time and mortality resulted in sensitivity of 34.6% (95% CI 23.9 to 47.1%), specificity 92.3% (88.6 to 94.8%), positive likelihood ratio 4.49 (3.06 to 6.57), and negative likelihood ratio 0.71 (0.60 to 0.84). Studies of children attending Emergency Departments with vomiting and diarrhea showed that capillary refill time had specificity of 89 to 94% for identifying 5% dehydration, but sensitivity ranged from 0 to 94%. This level of heterogeneity precluded formal meta-analysis of this outcome. Meta-analysis was not possible for other outcomes due to insufficient data, but we found consistently high specificity for a range of outcomes including meningitis, sepsis, admission to hospital, hypoxia, severity of illness and dengue. Conclusions Our results show that capillary refill time is a specific sign, indicating that it can be used as a “red-flag”: children with prolonged capillary refill time have a four-fold risk of dying compared to children with normal capillary refill time. The low sensitivity means that a normal capillary refill time should not reassure clinicians.
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Affiliation(s)
- Susannah Fleming
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
- * E-mail:
| | - Peter Gill
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - James A. Taylor
- Child Health Institute, University of Washington, Seattle, Washington, United States of America
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, United States of America
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Affiliation(s)
- David King
- Academic Unit of Child Health, Sheffield Children's Hospital, Sheffield, UK
| | - Robert Morton
- Academic Unit of Child Health, Sheffield Children's Hospital, Sheffield, UK
| | - Cliff Bevan
- Paediatric Intensive Care Unit, Sheffield Children's Hospital, Sheffield, UK
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Pruvost I, Dubos F, Chazard E, Hue V, Duhamel A, Martinot A. The value of body weight measurement to assess dehydration in children. PLoS One 2013; 8:e55063. [PMID: 23383058 PMCID: PMC3558475 DOI: 10.1371/journal.pone.0055063] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 12/21/2012] [Indexed: 11/18/2022] Open
Abstract
Dehydration secondary to gastroenteritis is one of the most common reasons for office visits and hospital admissions. The indicator most commonly used to estimate dehydration status is acute weight loss. Post-illness weight gain is considered as the gold-standard to determine the true level of dehydration and is widely used to estimate weight loss in research. To determine the value of post-illness weight gain as a gold standard for acute dehydration, we conducted a prospective cohort study in which 293 children, aged 1 month to 2 years, with acute diarrhea were followed for 7 days during a 3-year period. The main outcome measures were an accurate pre-illness weight (if available within 8 days before the diarrhea), post-illness weight, and theoretical weight (predicted from the child's individual growth chart). Post-illness weight was measured for 231 (79%) and both theoretical and post-illness weights were obtained for 111 (39%). Only 62 (21%) had an accurate pre-illness weight. The correlation between post-illness and theoretical weight was excellent (0.978), but bootstrapped linear regression analysis showed that post-illness weight underestimated theoretical weight by 0.48 kg (95% CI: 0.06-0.79, p<0.02). The mean difference in the fluid deficit calculated was 4.0% of body weight (95% CI: 3.2-4.7, p<0.0001). Theoretical weight overestimated accurate pre-illness weight by 0.21 kg (95% CI: 0.08-0.34, p = 0.002). Post-illness weight underestimated pre-illness weight by 0.19 kg (95% CI: 0.03-0.36, p = 0.02). The prevalence of 5% dehydration according to post-illness weight (21%) was significantly lower than the prevalence estimated by either theoretical weight (60%) or clinical assessment (66%, p<0.0001).These data suggest that post-illness weight is of little value as a gold standard to determine the true level of dehydration. The performance of dehydration signs or scales determined by using post-illness weight as a gold standard has to be reconsidered.
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Affiliation(s)
- Isabelle Pruvost
- Univ Lille Nord de France, UDSL, Lille, France
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
| | - François Dubos
- Univ Lille Nord de France, UDSL, Lille, France
- EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
| | | | - Valérie Hue
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
| | - Alain Duhamel
- Univ Lille Nord de France, UDSL, Lille, France
- EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
- Department of Biostatistics, CHU Lille, Lille, France
| | - Alain Martinot
- Univ Lille Nord de France, UDSL, Lille, France
- EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
- * E-mail:
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6
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van den Berg J, Berger MY. Guidelines on acute gastroenteritis in children: a critical appraisal of their quality and applicability in primary care. BMC FAMILY PRACTICE 2011; 12:134. [PMID: 22136388 PMCID: PMC3331832 DOI: 10.1186/1471-2296-12-134] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 12/02/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Reasons for poor guideline adherence in acute gastroenteritis (AGE) in children in high-income countries are unclear, but may be due to inconsistency between guideline recommendations, lack of evidence, and lack of generalizability of the recommendations to general practice. The aim of this study was to assess the quality of international guidelines on AGE in children and investigate the generalizability of the recommendations to general practice. METHODS Guidelines were retrieved from websites of professional medical organisations and websites of institutes involved in guideline development. In addition, a systematic search of the literature was performed. Articles were selected if they were a guideline, consensus statement or care protocol. RESULTS Eight guidelines met the inclusion criteria, the quality of the guidelines varied. 242 recommendations on diagnosis and management were found, of which 138 (57%) were based on evidence.There is a large variety in the classification of symptoms to different categories of dehydration. No signs are generalizable to general practice.It is consistently recommended to use hypo-osmolar ORS, however, the recommendations on ORS-dosage are not evidence based and are inconsistent. One of 14 evidence based recommendations on therapy of AGE is based on outpatient research and is therefore generalizable to general practice. CONCLUSIONS The present study shows considerable variation in the quality of guidelines on AGE in children, as well as inconsistencies between the recommendations. It remains unclear how to asses the extent of dehydration and determine the preferred treatment or referral of a young child with AGE presenting in general practice.
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Affiliation(s)
- José van den Berg
- Department of General Practice, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
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Top APC, Tasker RC, Ince C. The microcirculation of the critically ill pediatric patient. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:213. [PMID: 21457503 PMCID: PMC3219409 DOI: 10.1186/cc9995] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Anke P C Top
- Pediatric Intensive Care Unit, Cambridge University NHS Foundation Trust Hospital, Box 7, Hills Road, Cambridge, CB2 0QQ, UK.
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Honarmand A, Safavi M. Prediction of arterial blood gas values from arterialized earlobe blood gas values in patients treated with mechanical ventilation. Indian J Crit Care Med 2010; 12:96-101. [PMID: 19742254 PMCID: PMC2738313 DOI: 10.4103/0972-5229.43677] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background/Objective: Arterial blood gas (ABG) analysis is useful in evaluation of the clinical condition of critically ill patients; however, arterial puncture or insertion of an arterial catheter may sometimes be difficult and cause many complications. Arterialized ear lobe blood samples have been described as adequate to gauge gas exchange in acute and chronically ill pediatric patients. Purpose: This study evaluates whether pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), base excess (BE), and bicarbonate (HCO3) values of arterialized earlobe blood samples could accurately predict their arterial blood gas analogs for adult patients treated by mechanical ventilation in an intensive care unit (ICU). Setting: A prospective descriptive study Methods: Sixty-seven patients who were admitted to ICU and treated with mechanical ventilation were included in this study. Blood samples were drawn simultaneously from the radial artery and arterialized earlobe of each patient. Results: Regression equations and mean percentage-difference equations were derived to predict arterial pH, PCO2, PO2, BE, and HCO3-values from their earlobe analogs. pH, PCO2, BE, and HCO3 all significantly correlated in ABG and earlobe values. In spite of a highly significant correlation, the limits of agreement between the two methods were wide for PO2. Regression equations for prediction of pH, PCO2, BE, and HCO3- values were: arterial pH (pHa) = 1.81+ 0.76 × earlobe pH (pHe) [r = 0.791, P < 0.001]; PaCO2 = 1.224+ 1.058 × earlobePCO2 (PeCO2) [r = 0.956, P < 0.001]; arterial BE (BEa) = 1.14+ 0.95 × earlobe BE (BEe) [r= 0.894, P < 0.001], and arterial HCO3- (HCO3-a) = 1.41+ earlobe HCO3(HCO3-e) [r = 0.874, P < 0.001]. The predicted ABG values from the mean percentage-difference equations were derived as follows: pHa = pHe × 1.001; PaCO2 = PeCO2 × 0.33; BEa = BEe × 0.57; and HCO3-a = HCO3-e × 1.06. Conclusions: Arterialized earlobe blood gas can accurately predict the ABG values of pH, PCO2, BE, and HCO3- for patients who do not require regular continuous blood pressure measurements and close monitoring of arterial PO2 measurements.
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Affiliation(s)
- Azim Honarmand
- Department of Anaesthesiology and Intensive Care, Isfahan University of Medical Sciences, Isfahan, Iran.
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Abstract
Dehydration in infant under the age of one year, even more under six months old, due to viral diarrhoea in most cases, is particularly risky. Management of dehydration consists in rehydrating and maintaining nutritional needs. The key to choosing the right treatment is to assess dehydration gravity according to weight loss, expressed in percentages of body weight before dehydration, which can be tough or impossible to obtain. So, clinical signs like impairment of general aspect, lengthening of cutaneous recoloration time, persistent cutaneous crease, hollow eyes, mucous membranes dryness or tear lack, with tachycardia, arterial pressure and diuresis, can help in diagnosing dehydration gravity. Treatment is based on correcting extracellular area deficit. In severe cases, it is possible to treat with 20 ml/kg of isotonic cristalloide solute intravenously (dehydration greater than 10%). In all other cases, the technique mostly used is oral rehydration, aimed for correcting hydrical deficit in four hours, which has proved to be efficient, secure and fast. It consists in using rehydration solutes fitting specific criteria. Using them precociously allows most efficient prevention of acute forms.
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Affiliation(s)
- P Hubert
- Service de réanimation pédiatrique et de néonatologie, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
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10
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Shavit I, Brant R, Nijssen-Jordan C, Galbraith R, Johnson DW. A novel imaging technique to measure capillary-refill time: improving diagnostic accuracy for dehydration in young children with gastroenteritis. Pediatrics 2006; 118:2402-8. [PMID: 17142525 DOI: 10.1542/peds.2006-1108] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Assessment of dehydration in young children currently depends on clinical judgment, which is relatively inaccurate. By using digital videography, we developed a way to assess capillary-refill time more objectively. OBJECTIVE Our goal was to determine whether digitally measured capillary-refill time assesses the presence of significant dehydration (> or = 5%) in young children with gastroenteritis more accurately than conventional capillary refill and overall clinical assessment. METHODS We prospectively enrolled children with gastroenteritis, 1 month to 5 years of age, who were evaluated in a tertiary-care pediatric emergency department and judged by a triage nurse to be at least mildly dehydrated. Before any treatment, we measured the weight and digitally measured capillary-refill time of these children. Pediatric emergency physicians determined capillary-refill time by using conventional methods and degree of dehydration by overall clinical assessment by using a 7-point Likert scale. Postillness weight gain was used to estimate fluid deficit; beginning 48 hours after assessment, children were reweighed every 24 hours until 2 sequential weights differed by no more than 2%. We compared the accuracy of digitally measured capillary-refill time with conventional capillary refill and overall clinical assessment by determining sensitivities, specificities, likelihood ratios, and area under the receiver operator characteristic curves. RESULTS A total of 83 patients were enrolled and had complete follow-up; 13 of these patients had significant dehydration (> or = 5% of body weight). The area under the receiver operator characteristic curves for digitally measured capillary-refill time and overall clinical assessment relative to fluid deficit (< 5% vs > or = 5%) were 0.99 and 0.88, respectively. Positive likelihood ratios were 11.7 for digitally measured capillary-refill time, 4.5 for conventional capillary refill, and 4.1 for overall clinical assessment. CONCLUSIONS Results of this prospective cohort study suggest that digitally measured capillary-refill time more accurately predicts significant dehydration (> or = 5%) in young children with gastroenteritis than overall clinical assessment.
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Affiliation(s)
- Itai Shavit
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
AIMS To ascertain from paediatricians and child psychiatrists their views regarding the aetiology, assessment, and diagnosis of attentional difficulties in children, and the prescribing of stimulant medication for such difficulties. METHODS Using a questionnaire devised by the authors, 465 paediatricians and 444 child psychiatrists were surveyed. RESULTS The overall response rate was 73%. Some 94% of child psychiatrists and 29% of paediatricians routinely dealt with attentional difficulties. Views on aetiology, classification, and diagnosis were varied. More than 60% of both groups were prepared to prescribe stimulant medication without a formal diagnosis being made. Comorbid conduct disorder and the views of other professionals and of parents have an impact on practice. CONCLUSIONS This survey demonstrates that there is a range of approaches to attentional difficulties by both paediatricians and child psychiatrists.
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Affiliation(s)
- I McKenzie
- Glen Acre House Child and Family Service, 21 Acre House Avenue, Lindley, Huddersfield HD3 3BB, UK
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12
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Abstract
AIMS To determine whether delayed capillary refill time (>3 seconds) is a useful prognostic indicator in Kenyan children admitted to hospital. METHODS A total of 4160 children admitted to Kilifi District Hospital with malaria, malarial anaemia, acute respiratory tract infection (ARI), severe anaemia (haemoglobin <50 g/l), gastroenteritis, malnutrition, meningitis, or septicaemia were studied. RESULTS Overall, delayed capillary refill time (dCRT), present in 346/4160 (8%) of the children, was significantly more common in fatal cases (44/189, 23%) than survivors (7.5%), and had useful prognostic value. In children admitted with malaria, gastroenteritis, or malnutrition, likelihood ratio tests suggested that dCRT was useful in identifying high risk groups for mortality, but its prognostic value in anaemia, ARI, and sepsis was unclear due to low case fatality or limited numbers. The severity features of impaired consciousness and deep breathing were significantly associated both with the presence of dCRT and fatal outcome. In children, with either of these severity features, a less stringent value of dCRT(>2 s) identified 50% of children with hypotension (systolic BP <2SD) and 40% of those requiring volume resuscitation (for metabolic acidosis). CONCLUSIONS Although CRT is a simple bedside test, which may be used in resource poor settings as a guide to the circulatory status, dCRT should not be relied on in the absence of other features of severity. In non-severe disease, the additional presence of hypoxia, a moderately raised creatinine (>80 micromol/l), or a raised white cell count should prompt the need for fluid expansion.
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Affiliation(s)
- A Pamba
- Centre for Geographic Medicine Research, Coast, KEMRI/Wellcome Trust Unit, PO Box 230, Kilifi, Kenya
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Yildizdaş D, Yapicioğlu H, Yilmaz HL, Sertdemir Y. Correlation of simultaneously obtained capillary, venous, and arterial blood gases of patients in a paediatric intensive care unit. Arch Dis Child 2004; 89:176-80. [PMID: 14736638 PMCID: PMC1719810 DOI: 10.1136/adc.2002.016261] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To investigate the correlation of pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), base excess (BE), and bicarbonate (HCO3) between arterial (ABG), venous (VBG), and capillary (CBG) blood gases. METHODS Patients admitted to the paediatric intensive care unit (PICU) in Cukurova University between August 2000 and February 2002 were enrolled. RESULTS A total of 116 simultaneous venous, arterial, and capillary blood samples were obtained from 116 patients (mean age 56.91 months, range 15 days to 160 months). Eight (7%) were neonates. Sixty six (57%) were males. pH, PCO2, BE, and HCO3 were all significantly correlated in ABG, VBG, and CBG. Correlation in PO2 was also significant, but less so. Correlation between pH, PCO2, PO2, BE, and HCO3 was similar in the presence of hypothermia, hyperthermia, and prolonged capillary refilling time. In hypotension, correlation in PO2 between VBG and CBG was similar but disappeared in ABG-VBG and ABG-CBG. CONCLUSIONS There is a significant correlation in pH, PCO2, PO2, BE, and HCO3 among ABG, VBG, and CBG values, except for a poor correlation in PO2 in the presence of hypotension. Capillary and venous blood gas measurements may be useful alternatives to arterial samples for patients who do not require regular continuous blood pressure recordings and close monitoring of PaO2. We do not recommend CBG and VBG for determining PO2 of ABG.
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Affiliation(s)
- D Yildizdaş
- Cukurova University, Faculty of Medicine, Department of Pediatrics, Pediatric Intensive Care Unit, 01330, Adana, Turkey.
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Assadi F, Copelovitch L. Simplified treatment strategies to fluid therapy in diarrhea. Pediatr Nephrol 2003; 18:1152-6. [PMID: 14523638 DOI: 10.1007/s00467-003-1303-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2003] [Revised: 07/25/2003] [Accepted: 07/29/2003] [Indexed: 11/24/2022]
Abstract
Dehydration resulting from diarrhea remains an important cause of morbidity and mortality among infants and children worldwide. Although it is well established that rapid and generous intravenous restoration of extracellular fluid, followed by oral rehydration therapy (ORT) should be used in children with severe dehydration, physicians continue to be reluctant to use such therapy. Applying the principle of body fluid physiology to the current treatment of dehydration, we developed a simple and yet effective treatment strategy to fluid therapy for children with diarrheal dehydration using commercially manufactured solutions. Children with mild-to-moderate dehydration are best treated with ORT using commercially available oral solutions containing 45-75 mEq/l of Na(+). Children who have clinical evidence of severe dehydration should receive intravenous fluids, 60-100 ml/kg of 0.9% saline in the first 2-4 h to restore circulation. Oliguric patients with severe acidosis should receive a physiological dose of bicarbonate to correct blood pH level to 7.25. Once circulation is restored, the ORT should be given in small quantities to replace losses of water and Na(+) over 6-8 h. Age-appropriate diet should be started as soon as tolerated. Those who cannot tolerate ORT should receive intravenous rehydration for the remainder of the deficit and maintenance. Addition of 20 mEq/l K(+) to rehydration solutions permits repair of cellular K(+ )deficits without risk of hyperkalemia. The amount of Na(+) given to replace maintenance and deficit fluids varies with the forms of dehydration. Isonatremic dehydration is best treated with 5% dextrose in 0.45% saline containing 20 mEq/l KCl over 24 h. Hyponatremic dehydration is best treated with 0.9% saline and 0.45% saline alternately in a 1:1 ratio in 5% dextrose containing 20 mEq/l KCl over 24 h. Hypernatremic dehydration is best treated with 5% dextrose in 0.2% saline containing 20 mEq/l KCl over 2-3 days to avoid cerebral edema. Maintenance hydration is best treated with 5% dextrose in 0.2% saline containing 20 mEq/l KCl. Ideal commercial intravenous maintenance and deficit solutions have yet to appear.
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Affiliation(s)
- Farahnak Assadi
- Department of Pediatrics, Rush University Medical College, Chicago, Illinois 60612, USA.
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Abstract
Systolic cardiac function results from the interaction of four interdependent factors: heart rate, preload, contractility, and afterload. Heart rate can be quantified easily at the bedside, while preload estimation has traditionally relied on invasive pressure measurements, both central venous and pulmonary artery wedge. These have significant clinical limitations; however, adult literature has highlighted the superiority of several novel preload measures. Measurement of contractility and afterload is difficult; thus in clinical practice the bedside assessment of cardiac function is represented by cardiac output. A variety of techniques are now available for cardiac output measurement in the paediatric patient. This review summarises cardiac function and cardiac output measurement in terms of methodology, interpretation, and their contribution to the concepts of oxygen delivery and consumption in the critically ill child.
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Affiliation(s)
- S M Tibby
- Department of Paediatric Intensive Care, Guy's Hospital, London SE1 9RT, UK.
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Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001; 85:132-42. [PMID: 11466188 PMCID: PMC1718867 DOI: 10.1136/adc.85.2.132] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home. EVIDENCE A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated. CONSENSUS An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement. RECOMMENDATIONS Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated. VALIDATION The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.
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Affiliation(s)
- K Armon
- Academic Division of Child Health, School of Human Development, University of Nottingham, Nottingham NG7 2UH, UK.
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17
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Tibby SM, Hatherill M, Murdoch IA. Capillary refill and core-peripheral temperature gap as indicators of haemodynamic status in paediatric intensive care patients. Arch Dis Child 1999; 80:163-6. [PMID: 10325733 PMCID: PMC1717816 DOI: 10.1136/adc.80.2.163] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Capillary refill time is an important diagnostic adjunct in the acute resuscitation phase of the shocked child. This study assesses its relation to commonly measured haemodynamic parameters in the postresuscitation phase when the child has reached the intensive care unit, and compares this with core-peripheral temperature gap. METHODS Ninety standardised measurements of capillary refill time were made on 55 patients, who were divided into postcardiac surgery (n = 27), and general (n = 28), most of whom had septic shock (n = 24). A normal capillary refill time was defined as < or = 2 seconds. Measured haemodynamic variables included: cardiac index, central venous pressure, systemic vascular resistance index, stroke volume index (SVI), and blood lactate. Seventy measurements were made on patients while being treated with inotropes or vasodilators. RESULTS Capillary refill time and temperature gap both correlated poorly with all haemodynamic variables among post-cardiac surgery children. For general patients, capillary refill time was related to SVI and lactate; temperature gap correlated poorly with all variables. General patients with a prolonged capillary refill time had a lower median SVI (28 v 38 ml/m2) but not a higher lactate (1.7 v 1.1 mmol/l). A capillary refill time of > or = 6 seconds had the best predictive value for a reduced SVI. CONCLUSION Among ventilated, general intensive care patients, capillary refill time is related weakly to blood lactate and SVI. A normal value for capillary refill time of < or = 2 seconds has little predictive value and might be too conservative for this population; septic shock.
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Affiliation(s)
- S M Tibby
- Department of Paediatric Intensive Care, Guy's Hospital, London, UK
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Murphy MS. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch Dis Child 1998; 79:279-84. [PMID: 9875030 PMCID: PMC1717684 DOI: 10.1136/adc.79.3.279] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M S Murphy
- Institute of Child Health, Birmingham, UK
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Strozik KS, Pieper CH, Roller J. Capillary refilling time in newborn babies: normal values. Arch Dis Child Fetal Neonatal Ed 1997; 76:F193-6. [PMID: 9175951 PMCID: PMC1720653 DOI: 10.1136/fn.76.3.f193] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To assess the normal values of capillary refilling time (CRT) in healthy newborn babies; to assess the effect of different nursery containers (incubator, radiant warmer, crib), phototherapy, birthweight, gestational age, size for gestational age and sex on CRT; to compare CRT at different body sites as well as to assess the variation between observers. METHODS Healthy neonates (n = 469) of different gestational ages and different sizes for gestational age, were studied 1 to 7 days after birth. CRT was measured in four of the most suitable sites-namely, midpoints of the sternum and the forehead, the palm of the hand and the plantar surface of the heel (defined as chest, head, palm and heel, respectively). The applied pressing time was 5 seconds. CRT was measured with a manual stopwatch. RESULTS Only the chest and the head distribution curves followed the Gaussian curve. The mean values and standard deviation of CRT in all tested nursery containers, including phototherapy for the chest, ranged from 1.82 (0.34) seconds to 2.01 (0.423) seconds, and for the head from 1.59 (0.36) seconds to 1.83 (0.31) seconds. The mean value of chest CRT was always longer than the head CRT for all parameters. Significant differences were found between different nursery containers, receivers, and non-receivers of phototherapy and between observers. No difference was found between sex, birthweight, gestational age and size for gestational age. CONCLUSIONS The upper limit of normal for neonatal CRT was 3 seconds. Nursery containers, phototherapy, and observers produced significantly different results, but the differences were not clinically important. CRT values of the midpoints of the sternum and the forehead are the most consistent.
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Affiliation(s)
- K S Strozik
- Department of Paediatrics and Child Health, Tygerberg Hospital, University of Stellebhosch, South Africa
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