1
|
Zieg J, Narla D, Gonsorcikova L, Raina R. Fluid management in children with volume depletion. Pediatr Nephrol 2024; 39:423-434. [PMID: 37452205 DOI: 10.1007/s00467-023-06080-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
Volume depletion is a common condition and a frequent cause of hospitalization in children. Proper assessment of the patient includes a detailed history and a thorough physical examination. Biochemical tests may be useful in selected cases. Understanding the pathophysiology of fluid balance is necessary for appropriate management. A clinical dehydration scale assessing more physical findings may help to determine dehydration severity. Most dehydrated children can be treated orally; however, intravenous therapy may be indicated in patients with severe volume depletion, in those who have failed oral therapy, or in children with altered consciousness or significant metabolic abnormalities. Proper management consists of restoring circulatory volume and electrolyte balance. In this paper, we review clinical aspects, diagnosis, and management of children with volume depletion.
Collapse
Affiliation(s)
- Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Deepti Narla
- Department of Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA
| | - Lucie Gonsorcikova
- Department of Pediatrics, First Faculty of Medicine, Charles University in Prague and Thomayer University Hospital, Prague, Czech Republic
| | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA.
- Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| |
Collapse
|
2
|
Abstract
OBJECTIVES To describe the characteristics, hemodynamic, and physiologic changes after 4% albumin fluid boluses in critically ill children. DESIGN Retrospective observational study. SETTING Single-center PICU. PATIENTS Children in a cardiac and general PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between January 2017 and May 2019, there were 1,003 fluid boluses of 4% albumin during 420 of 5,731 admissions (7.8%), most commonly in children with congenital/acquired heart disease (71.2%) and sepsis (7.9%). The median fluid bolus dose was 10 mL/kg (interquartile range, 5.8-14.6 mL/kg), and its duration 30 minutes (interquartile range, 14.0-40.0 min; n = 223). After the fluid bolus, a significant change in mean arterial pressure (2.3 mm Hg [5.1%], 2.7 mm Hg [5.8%], 2.9 mm Hg [6.1%], and 3.8 mm Hg [8.0%] at 1, 2, 3, and 4 hr, respectively [p ≤ 0.001]) only occurred in children less than or equal to 12 months old. A mean arterial pressure response, defined by an increase greater than or equal to 10% from baseline, occurred in 290 of 887 patients (33%) with maximal response at 1 hour. Hypotension at baseline predicted the magnitude of mean arterial pressure increase at 60 (coefficient 24.3 [95% CI, 0.79-7.87]; p = 0.04) and 120 minutes (coefficient 26.1 [95% CI, 2.75-48.2]; p = 0.02). There were no biochemical or hematocrit changes within 4 hours of the fluid bolus. Urine output for the entire cohort was 2 mL/kg/hr at baseline and did not change with the fluid bolus. CONCLUSIONS Fluid boluses of 4% albumin were common and predominantly in children with cardiac disease and sepsis with a median dose of 10 mL/kg given over half an hour. Such treatment was associated with significant hemodynamic changes only in children less than 12 months old, and we failed to identify an association with urine output.
Collapse
|
3
|
Lipton M, Mahajan R, Kavanagh C, Shen C, Batal I, Dogra S, Jain NG, Lin F, Uy NS. AKI in COVID-19-Associated Multisystem Inflammatory Syndrome in Children (MIS-C). KIDNEY360 2021; 2:611-618. [PMID: 35373052 PMCID: PMC8791329 DOI: 10.34067/kid.0005372020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/01/2021] [Indexed: 02/04/2023]
Abstract
Background Multisystem inflammatory syndrome in children (MIS-C) is a recently identified entity in association with COVID-19. AKI has been widely reported in patients with primary COVID-19 infection. However, there is a paucity of literature regarding renal injury in MIS-C. We aim to characterize AKI in MIS-C in this cohort identified at a major children's hospital in New York City during the COVID-19 pandemic. Methods We conducted a retrospective cohort study of children 0-20 years old admitted to Morgan Stanley Children's Hospital (MSCH) between April 18th and September 23rd, 2020. Patients were included if they met criteria for MIS-C on the basis of CDC guidelines. All patients were evaluated for the presence of AKI, and AKI was staged according to KDIGO criteria. Results Of the 57 children who met inclusion criteria, 46% (26 of 57) were found to have AKI. The majority of patients (58%; 15 of 26) were classified as KDIGO stage 1. AKI was present upon admission in 70% of those identified. All patients had resolution of AKI at discharge, with 61% achieving recovery by day 2. One patient required dialysis. When compared with those without renal injury, the AKI cohort was older (P<0.001) and had higher median peak values of CRP (P<0.001), IL-6 (P=0.02), ferritin (P<0.001), and procalcitonin (P=0.02). More patients with AKI had left ventricular systolic dysfunction (P<0.001) and lymphopenia (P=0.01) when compared with those without AKI. No differences in body mass index or sex were found. Conclusions Although children with MIS-C may develop AKI, our study suggests that most experience mild disease, swift resolution, and promising outcome. Older age, increased inflammation, and left ventricular systolic dysfunction may be risk factors. Our study highlights the substantial differences in epidemiology and outcomes between AKI associated with pediatric MIS-C versus primary COVID-19 infection.
Collapse
Affiliation(s)
- Marissa Lipton
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Ruchi Mahajan
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Catherine Kavanagh
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Carol Shen
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Samriti Dogra
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Namrata G Jain
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Fangming Lin
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Natalie S Uy
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| |
Collapse
|
4
|
Gokhale S, Gokhale S. Transfusing maternal blood to her newborn baby-irrespective of ABO mismatch. J Matern Fetal Neonatal Med 2019; 33:1593-1606. [PMID: 30686061 DOI: 10.1080/14767058.2018.1525355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Though blood transfusions are the common procedures in pediatric patients, transfusion reactions are rare in children. Though in adults, uncross-matched ABO group-specific blood is used in emergencies, there are no such reports in neonates and children. There are stray case reports about transfusing maternal blood for her baby and maternal blood is de facto compatible regardless of an ABO mismatchObjective: Confirming our previous hypothesis that maternal blood is compatible with her baby's blood; and maternal blood can be used for transfusion in her newborn baby irrespective of ABO match/ mismatch.Design: Prospective interventional study.Setting and Participants: Fifty-one mother-baby pairs were recruited attending Pediatric Unit of our Community Hospital from 15 July 2013 to 13 July 2015. After obtaining consent from the parents, all the required lab tests were done. Since all lab reports were favourable; these babies qualified for transfusion of maternal blood.Interventions: Fifty-one sick newborns were transfused fresh whole maternal blood as a part of treatment; irrespective of mother-baby ABO match or mismatch.Results: All babies tolerated maternal blood well and showed significant and rapid improvement. Minimum period of observation was from a minimum of 32 to a maximum of 56 months. All the babies showed good growth and development.Conclusion: By observing a particular protocol and procedural techniques, mother's blood may be used for transfusion in her own baby in neonatal period, irrespective of ABO mismatch.Significance: This is probably the largest series in world literature of 51 newborns being transfused maternal blood either ABO match or mismatch.
Collapse
Affiliation(s)
- Sanjay Gokhale
- Department of Pediatrics, Rajhans Hospital, Mumbai, India
| | - Sankalp Gokhale
- Department of Neurology [Medicine], Duke University, Durham, NC, USA
| |
Collapse
|
5
|
Katheria A, Mercer J, Brown M, Rich W, Baker K, Harbert MJ, Pierce B, Hassen K, Finer N. Umbilical cord milking at birth for term newborns with acidosis: neonatal outcomes. J Perinatol 2018; 38:240-244. [PMID: 29234144 DOI: 10.1038/s41372-017-0011-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/20/2017] [Accepted: 10/26/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if umbilical cord milking is detrimental in compromised term/near-term infants. STUDY DESIGN A retrospective analysis of infants with abnormal cord gases (cord arterial or venous pH of ≤ 7.1 or base deficit > -12). We collected maternal risk factors, cord management, birth, and neonatal outcomes during hospitalization. RESULT We found 157 infants who met the criteria for abnormal cord gases. Thirty-six of those had umbilical cord milking at delivery. There was no significant difference in neonatal outcomes, but fewer infants in the cord milking group needed resuscitation (38 vs. 56%, p = 0.07) and ongoing respiratory support (19 vs. 31%, p = 0.16) compared to the immediate clamping group. CONCLUSIONS While not significant, infants who received cord milking at birth needed less resuscitation and ongoing respiratory support. This study suggests that umbilical cord milking appears to be a safe therapy when acidosis is present and when resuscitation is needed.
Collapse
Affiliation(s)
- Anup Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
| | - Judith Mercer
- University of Rhode Island, Kingston, RI, USA.,Women and Infants Hospital and Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Melissa Brown
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Wade Rich
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Katie Baker
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - M J Harbert
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Brianna Pierce
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Kasim Hassen
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Neil Finer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| |
Collapse
|
6
|
Levitt DG, Levitt MD. Human serum albumin homeostasis: a new look at the roles of synthesis, catabolism, renal and gastrointestinal excretion, and the clinical value of serum albumin measurements. Int J Gen Med 2016; 9:229-55. [PMID: 27486341 PMCID: PMC4956071 DOI: 10.2147/ijgm.s102819] [Citation(s) in RCA: 379] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Serum albumin concentration (CP) is a remarkably strong prognostic indicator of morbidity and mortality in both sick and seemingly healthy subjects. Surprisingly, the specifics of the pathophysiology underlying the relationship between CP and ill-health are poorly understood. This review provides a summary that is not previously available in the literature, concerning how synthesis, catabolism, and renal and gastrointestinal clearance of albumin interact to bring about albumin homeostasis, with a focus on the clinical factors that influence this homeostasis. In normal humans, the albumin turnover time of about 25 days reflects a liver albumin synthesis rate of about 10.5 g/day balanced by renal (≈6%), gastrointestinal (≈10%), and catabolic (≈84%) clearances. The acute development of hypoalbuminemia with sepsis or trauma results from increased albumin capillary permeability leading to redistribution of albumin from the vascular to interstitial space. The best understood mechanism of chronic hypoalbuminemia is the decreased albumin synthesis observed in liver disease. Decreased albumin production also accounts for hypoalbuminemia observed with a low-protein and normal caloric diet. However, a calorie- and protein-deficient diet does not reduce albumin synthesis and is not associated with hypoalbuminemia, and CP is not a useful marker of malnutrition. In most disease states other than liver disease, albumin synthesis is normal or increased, and hypoalbuminemia reflects an enhanced rate of albumin turnover resulting either from an increased rate of catabolism (a poorly understood phenomenon) or enhanced loss of albumin into the urine (nephrosis) or intestine (protein-losing enteropathy). The latter may occur with subtle intestinal pathology and hence may be more prevalent than commonly appreciated. Clinically, reduced CP appears to be a result rather than a cause of ill-health, and therapy designed to increase CP has limited benefit. The ubiquitous occurrence of hypoalbuminemia in disease states limits the diagnostic utility of the CP measurement.
Collapse
Affiliation(s)
- David G Levitt
- Department of Integrative Biology and Physiology, University of Minnesota
| | - Michael D Levitt
- Research Service, Veterans Affairs Medical Center, Minneapolis, MN, USA
| |
Collapse
|
7
|
Waltzman ML. Pediatric Shock. J Emerg Nurs 2015; 41:113-8. [DOI: 10.1016/j.jen.2014.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/12/2014] [Accepted: 12/16/2014] [Indexed: 01/20/2023]
|
8
|
Ince C, Groeneveld ABJ. The case for 0.9% NaCl: is the undefendable, defensible? Kidney Int 2014; 86:1087-95. [PMID: 25007167 DOI: 10.1038/ki.2014.193] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/07/2014] [Accepted: 01/31/2014] [Indexed: 12/12/2022]
Abstract
Although 0.9% NaCl solution is by far the most-used fluid for fluid therapy in resuscitation, it is difficult to find a paper advocating its use over other types of crystalloid solutions. Literature on the deleterious effects of 0.9% NaCl has accumulated over the last decade, but critical appraisal of alternative crystalloid solutions is lacking. As such, the literature seems to suggest that 0.9% NaCl should be avoided at all costs, whereas alternative crystalloid solutions can be used without scrutiny. The basis of this negative evaluation of 0.9% NaCl is almost exclusively its effect on acid-base homeostasis, whereas the potentially deleterious effects present in other types of crystalloids are neglected. We have the challenging task of defending the use of 0.9% NaCl and reviewing its positive attributes, while an accompanying paper will argue against the use of 0.9% NaCl. It is challenging because of the large amount of literature, including our own, showing adverse effects of 0.9% NaCl. We will discuss why 0.9% NaCl solution is the most frequently used resuscitation fluid. Although it has some deleterious effects, all fluids share common features of concern. As such the emphasis on fluid resuscitation should be on volume rather than on composition and should be accompanied by a physiological assessment of the impact of fluids. In this paper, we hope to discuss the context within which fluids, specifically 0.9% NaCl, can be given in a safe and effective manner.
Collapse
Affiliation(s)
- Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Fialho AS, Celi LA, Cismondi F, Vieira SM, Reti SR, Sousa JMC, Finkelstein SN. Disease-based modeling to predict fluid response in intensive care units. Methods Inf Med 2013; 52:494-502. [PMID: 23986268 DOI: 10.3414/me12-01-0093] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 05/30/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare general and disease-based modeling for fluid resuscitation and vasopressor use in intensive care units. METHODS Retrospective cohort study involving 2944 adult medical and surgical intensive care unit (ICU) patients receiving fluid resuscitation. Within this cohort there were two disease-based groups, 802 patients with a diagnosis of pneumonia, and 143 patients with a diagnosis of pancreatitis. Fluid resuscitation either progressing to subsequent vasopressor administration or not was used as the primary outcome variable to compare general and disease-based modeling. RESULTS Patients with pancreatitis, pneumonia and the general group all shared three common predictive features as core variables, arterial base excess, lactic acid and platelets. Patients with pneumonia also had non-invasive systolic blood pressure and white blood cells added to the core model, and pancreatitis patients additionally had temperature. Disease-based models had significantly higher values of AUC (p < 0.05) than the general group (0.82 ± 0.02 for pneumonia and 0.83 ± 0.03 for pancreatitis vs. 0.79 ± 0.02 for general patients). CONCLUSIONS Disease-based predictive modeling reveals a different set of predictive variables compared to general modeling and improved performance. Our findings add support to the growing body of evidence advantaging disease specific predictive modeling.
Collapse
Affiliation(s)
- A S Fialho
- André S. Fialho, PhD, Massachusetts Institute of Technology, Engineering Systems Division, 77 Massachusetts Avenue, 02139 Cambridge, MA, USA, E-mail:
| | | | | | | | | | | | | |
Collapse
|
10
|
Julien F, Hilly J, Sallah TB, Skhiri A, Michelet D, Brasher C, Varin L, Nivoche Y, Dahmani S. Plethysmographic variability index (PVI) accuracy in predicting fluid responsiveness in anesthetized children. Paediatr Anaesth 2013; 23:536-46. [PMID: 23521073 DOI: 10.1111/pan.12139] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Plethysmographic Variability Index (PVI) has been shown to accurately predict responsiveness to fluid loads in adults. The goal of this study was to evaluate PVI accuracy when predicting fluid responsiveness during noncardiac surgery in children. MATERIAL AND METHODS Children aged 2-10 years scheduled for noncardiac surgery under general anesthesia were included. PVI was assessed concomitantly with stroke volume index (SVI). A response to fluid load was defined by an SVI increase of more than 15%. A 10 ml·kg(-1) normal saline intravenous fluid challenge was administered before surgical incision and after anesthetic induction. After incision, fluid challenges were administered when SVI values decreased by more than 15% or where judged necessary by the anesthesiologist. Statistical analyses include receiving operator characteristics (ROC) analysis and the determination of gray zone method with an error tolerance of 10%. RESULTS Fifty-four patients were included, 97 fluid challenges administered and 45 responses recorded. Area under the curve of ROC curves was 0.85 [0.77-0.93] and 0.8 [0.7-0.89] for baseline PVI and SVI values, respectively. Corresponding gray zone limits were [10-17%] and [22-31 ml·m(-2)], respectively. PVI values exhibited different gray zone limits for pre-incision and postincision fluid challenges, whereas SVI values were comparable. PVI value percentages in the gray zone were 34% overall and 44% for challenges performed after surgical incision. DISCUSSION This study found both PVI and prechallenge SVI to be accurate when used to predict fluid load response during anesthetized noncardiac surgery in children. However, a third of recorded PVI values were inconclusive.
Collapse
Affiliation(s)
- Florence Julien
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Silverstein DC, Kleiner J, Drobatz KJ. Effectiveness of intravenous fluid resuscitation in the emergency room for treatment of hypotension in dogs: 35 cases (2000-2010). J Vet Emerg Crit Care (San Antonio) 2012; 22:666-73. [DOI: 10.1111/j.1476-4431.2012.00822.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 09/30/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Deborah C. Silverstein
- Matthew J. Ryan Veterinary Hospital; Department of Clinical Studies-Philadelphia; University of Pennsylvania; Philadelphia; PA; 19104-6010
| | - Jennifer Kleiner
- Matthew J. Ryan Veterinary Hospital; Department of Clinical Studies-Philadelphia; University of Pennsylvania; Philadelphia; PA; 19104-6010
| | - Kenneth J. Drobatz
- Matthew J. Ryan Veterinary Hospital; Department of Clinical Studies-Philadelphia; University of Pennsylvania; Philadelphia; PA; 19104-6010
| |
Collapse
|
12
|
Abstract
Prehospital pediatric care is an important component in the treatment of the injured child, as the prehospital responders are the first medical providers performing life saving and directed medical care. Traumatic injuries are the leading cause of morbidity and mortality in the pediatric patient population. Nevertheless, for most prehospital provider it is a rare event to treat pediatric trauma patients and there is a still existing gap between the quality of care for pediatric patients compared to adults. To improve pediatric prehospital trauma care more provider need to be trained in identifying the specific differences between adult and pediatric patients.
Collapse
Affiliation(s)
- Terrence Seid
- Department of Anesthesiology and Pain Medicine, University of Washington/Harborview Medical Center, Seattle, WA, USA
| | | | | |
Collapse
|
13
|
Riley C, Basu RK, Kissoon N, Wheeler DS. Pediatric sepsis: preparing for the future against a global scourge. Curr Infect Dis Rep 2012; 14:503-11. [PMID: 22864953 DOI: 10.1007/s11908-012-0281-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis is a leading cause of morbidity and mortality among children worldwide. As consensus statements emerge regarding early recognition and goal-directed management of sepsis, scrutiny should be given to the unique characteristics of sepsis in children. Pediatric patients are not small adults! Sepsis epidemiology, pathophysiology, and management strategy can vary significantly from those for adults. Herein, we describe the epidemiology of pediatric sepsis, in both resource-rich and resource-poor worlds, and discuss how the pathophysiology of pediatric sepsis differs from that for adults. We discuss the timeline of management of pediatric sepsis, studying how discoveries over the past 50 years have changed the way sepsis is treated. Finally, we discuss the future of pediatric sepsis. We focus on approaches that carry the most substantive impact on the global burden of disease.
Collapse
Affiliation(s)
- Carley Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, Division of Critical Care, ML 2005, Cincinnati, OH, 45229, USA
| | | | | | | |
Collapse
|
14
|
Abstract
Perioperative fluid management in paediatrics has been the subject of many controversies in recent years, but fluid management in the neonatal period has not been considered in most reviews and guidelines. The literature regarding neonatal fluid management mainly appears in the paediatric textbooks and few recent data are available, except for resuscitation and fluid loading during shock and major surgery. In the context of anaesthesia, many neonates requiring surgery within the first month of life have organ malformation and/or dysfunction. This article aims at reviewing basic physiological considerations important for neonatal fluid management and mainly focusses on fluid maintenance and replacement during surgery.
Collapse
Affiliation(s)
- Isabelle Murat
- Department of Anesthesia, Hôpital d'Enfants Armand Trousseau, 26 avenue du Dr. Arnold Netter, 75571 Paris, Cedex 12, France.
| | | | | | | |
Collapse
|
15
|
Severe malaria and sepsis: will one fluid strategy suit both? Crit Care Med 2010; 38:1744-5. [PMID: 20647801 DOI: 10.1097/ccm.0b013e3181e876c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Naing CM, Win DK. Do colloids in comparison to crystalloids for fluid resuscitation improve mortality? Trans R Soc Trop Med Hyg 2010; 104:311-2. [PMID: 20206954 DOI: 10.1016/j.trstmh.2010.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 02/03/2010] [Accepted: 02/03/2010] [Indexed: 10/19/2022] Open
Abstract
Permanent neurological impairment or death arising from hospital-acquired hyponatremia in both children and adults is well documented. The choice of intravenous fluids for fluid resuscitation in critically ill patients is a top priority in evidence-based medicine. The question of whether colloids in comparison to crystalloids can improve mortality in such cases remains to be answered. Well powered, randomized clinical trials addressing the comparative efficacy of different types of intravenous fluids is a high priority as is the ethical justification for such trials. The understanding of the pathophysiological process serves important information on clinical practice.
Collapse
Affiliation(s)
- Cho-Min Naing
- School of Medical Sciences, International Medical University, Kuala Lumpur 57000, Malaysia.
| | | |
Collapse
|
17
|
de Boode WP. Clinical monitoring of systemic hemodynamics in critically ill newborns. Early Hum Dev 2010; 86:137-41. [PMID: 20171815 DOI: 10.1016/j.earlhumdev.2010.01.031] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 01/29/2010] [Indexed: 11/30/2022]
Abstract
Circulatory failure is a major cause of mortality and morbidity in critically ill newborn infants. Since objective measurement of systemic blood flow remains very challenging, neonatal hemodynamics is usually assessed by the interpretation of various clinical and biochemical parameters. An overview is given about the predictive value of the most used indicators of circulatory failure, which are blood pressure, heart rate, urine output, capillary refill time, serum lactate concentration, central-peripheral temperature difference, pH, standard base excess, central venous oxygen saturation and colour.
Collapse
Affiliation(s)
- Willem-Pieter de Boode
- Radboud University Nijmegen Medical Centre, Department of Neonatology, Nijmegen, The Netherlands.
| |
Collapse
|
18
|
Tabbers MM, Boluyt N, Offringa M. Implementation of an evidence-based guideline on fluid resuscitation: lessons learnt for future guidelines. Eur J Pediatr 2010; 169:749-58. [PMID: 19937452 PMCID: PMC2859220 DOI: 10.1007/s00431-009-1108-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 11/09/2009] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is little experience with the nationwide implementation of an evidence-based pediatric guideline on first-choice fluid for resuscitation in hypovolemia. METHODS We investigated fluid prescribing behavior at (1) guideline development, (2) after guideline development, and (3) after active implementation and identified potential barriers and facilitators for guideline implementation. In order to minimize costs and to optimize implementation effect, we continuously developed and adjusted implementation strategies according to identified barriers. Implementation success was evaluated using questionnaires, pharmaceutical data, and data from medical records. DISCUSSION The most remarkable change occurred after guideline development and dissemination: Normal saline use by neonatologists increased from 22-89% to 100% and by pediatric intensivists from 43-71% to 88-100%, and synthetic colloid use by pediatric intensivists declined from 29-43% to 0-13% with a reduction in albumin use by neonatologists from 11-44% to 0%. After active guideline implementation, most of specialist's management behavior was according to the guideline. CONCLUSION Stakeholders involved in the developmental process are of great importance in disseminating recommendations before active implementation. Therefore, to successfully implement guidelines and reduce costs of active implementation, any guideline development should consider implementation right from the beginning. Implementation strategies should target identified barriers and will therefore always be guideline specific.
Collapse
Affiliation(s)
- Merit M. Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole Boluyt
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martin Offringa
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
19
|
Bailey AG, McNaull PP, Jooste E, Tuchman JB. Perioperative crystalloid and colloid fluid management in children: where are we and how did we get here? Anesth Analg 2009; 110:375-90. [PMID: 19955503 DOI: 10.1213/ane.0b013e3181b6b3b5] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It has been more than 50 yr since the landmark article in which Holliday and Segar (Pediatrics 1957;19:823-32) proposed the rate and composition of parenteral maintenance fluids for hospitalized children. Much of our practice of fluid administration in the perioperative period is based on this article. The glucose, electrolyte, and intravascular volume requirements of the pediatric surgical patient may be quite different than the original population described, and consequently, use of traditional hypotonic fluids proposed by Holliday and Segar may cause complications, such as hyperglycemia and hyponatremia, in the postoperative surgical patient. There is significant controversy regarding the choice of isotonic versus hypotonic fluids in the postoperative period. We discuss the origins of perioperative fluid management in children, review the current options for crystalloid fluid management, and present information on colloid use in pediatric patients.
Collapse
Affiliation(s)
- Ann G Bailey
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA.
| | | | | | | |
Collapse
|
20
|
|
21
|
Abstract
OBJECTIVES The aims of this review were to summarize a) the consensus definitions of normal and pathologic intra-abdominal pressure (IAP); b) the techniques to measure IAP; c) the risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); d) the pathophysiology of ACS; and e) the current recommendations for management and prevention of ACS. DATA SOURCES PubMed was searched using the following terms: ACS, IAH, IAP, and abdominal decompression. DATA SYNTHESIS ACS represents the natural progression of end-organ dysfunction caused by increased IAP and develops if IAH is not recognized and treated appropriately. Although the reported incidence of ACS is relatively low in critically ill children (0.6%-4.7%) it may be under-recognized and under-reported. The diagnosis of IAH/ACS depends on a high index of suspicion and the accurate and frequent measurement of IAP in patients at risk. Mortality from ACS remains high (50%-60%) even when decompression of the abdomen is performed early, which highlights the importance of detection and treatment of elevated IAP before end-organ damage occurs. CONCLUSIONS A widespread awareness of the recognition and current approach to management and prevention of IAH and ACS is needed among pediatric intensivists, so outcome of these life-threatening disease processes might be improved.
Collapse
|
22
|
Dauger S, Holvoet L, Pinto-Da-Costa N, Michot C, Aizenfisz S, Angoulvant F. A teaching programme to improve compliance with guidelines about management of hypovolaemia in the emergency department. Acta Paediatr 2008; 97:1746-8. [PMID: 18945277 DOI: 10.1111/j.1651-2227.2008.01068.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S Dauger
- Paediatric Intensive Care Unit, Robert-Debré University Hospital, AP-HP and University Paris Diderot-Paris 7, Paris, France.
| | | | | | | | | | | |
Collapse
|
23
|
Abstract
INTRODUCTION A transcutaneous ultrasound monitor has recently been developed which noninvasively and quickly measures cardiac output. Validity and reliability testing has been reported in adults. No reliability testing has been undertaken in the pediatric population. OBJECTIVE Our objective was to evaluate the inter-rater reliability of a transcutaneous Doppler ultrasound technique to measure cardiac index (CI) and stroke volume index (SVI) in pediatric emergency department patients. METHODS An 8-month prospective observational study was conducted on a convenience sample of emergency department patients younger than 18 years old. Five raters were trained to use an ultrasound cardiac output monitoring device. Two raters, blinded to each other's results, obtained independent measurements from the same patient within 15 minutes of each other. Inter-rater agreement was measured with the Pearson product correlation coefficient. Bland-Altman analysis demonstrated the extent of deviation from a line of agreement between raters. RESULTS Ninety-seven patients were enrolled. Major diagnostic categories included infection, trauma, and gastrointestinal disorders. There was significant inter-rater correlation for CI (r = 0.76; 95% confidence interval, 0.66Y0.83; P G 0.0001) and SVI (r = 0.79; 95% confidence interval, 0.70Y0.86; P G 0.0001). Bland-Altman analysis of CI measurements between 2 raters showed bias of 0.06, SD of bias 1.00, and 95% limits of agreement j1.91 to 2.02 L/min/m2. Stroke volume index showed bias of j0.5, SD of bias 11.01, and 95% limits of agreement j22.08 to 21.08 mL/m2. CONCLUSIONS Transcutaneous Doppler ultrasound technique demonstrates acceptable inter-rater agreement for measuring CI and SVI in children.
Collapse
|
24
|
Khashu M, Balasubramaniam V. In neonates requiring intravascular volume resuscitation is the use of gelofusine safe and efficacious? Arch Dis Child 2007; 92:1037-8. [PMID: 17954486 PMCID: PMC2083624 DOI: 10.1136/adc.2007.124438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
25
|
Meybohm P, Renner J, Boening A, Cavus E, Gräsner JT, Grünewald M, Scholz J, Bein B. Impact of norepinephrine and fluid on cerebral oxygenation in experimental hemorrhagic shock. Pediatr Res 2007; 62:440-4. [PMID: 17667840 DOI: 10.1203/pdr.0b013e3181425858] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Few data exist regarding resuscitation of hypovolemic shock in infants, and alternative strategies such as vasopressor therapy merit further evaluation. However, the effects of norepinephrine on cerebral perfusion and oxygenation during hemorrhagic shock in the pediatric population are still unclear. Eight anesthetized piglets were subjected to hypotension by blood withdrawal of 25 mL/kg. Norepinephrine was titrated to achieve baseline mean arterial blood pressure (MAP), and cerebral oxygenation was determined by brain tissue Po2 (Ptio2) and near-infrared spectroscopy-derived tissue oxygen index (TOI). Then, norepinephrine was stopped, MAP was allowed to decrease again below 30 mm Hg, and shed blood was retransfused. During hemorrhage, TOI dropped from 69+/-3 to 59+/-3%, and Ptio2 from 29+/-6 to 13+/-1 mm Hg (mean+/-SEM; p<0.001). Following norepinephrine, cerebral perfusion pressure (CPP) could be restored immediately, whereas TOI and Ptio2 did not increase significantly. In contrast, following retransfusion, TOI and Ptio2 increased to 68+/-3% and 27+/-7 mm Hg reaching baseline values, respectively. In conclusion, while norepinephrine increased CPP immediately, cerebral oxygenation as reflected by TOI and Ptio2 could not be improved by norepinephrine, but only by retransfusion.
Collapse
Affiliation(s)
- Patrick Meybohm
- Department of Anesthesiology and Intensive Care Medicine, Pediatric Anesthesia Research Unit, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
One of the fundamental skills required for practicing evidence-based medicine is the development of a well-built clinical question, which specifies the patient group or problem, intervention, and outcome of interest. For this purpose, various "levels of evidence" have been developed in the human literature, which rank the validity of evidence. Our established conclusions and advice are thus supported by specific "grades of recommendations," which are intended to give an indication of the "strength" of a clinical recommendation. This article was compiled with these principles in mind.
Collapse
|
27
|
|
28
|
Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, De Backer D, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Macrae D, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C. Year in Review in Intensive Care Medicine, 2006. III. Circulation, ethics, cancer, outcome, education, nutrition, and pediatric and neonatal critical care. Intensive Care Med 2007; 33:414-22. [PMID: 17325834 DOI: 10.1007/s00134-007-0553-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 01/08/2023]
Affiliation(s)
- Peter Andrews
- Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Carcillo JA, Tasker RC. Fluid resuscitation of hypovolemic shock: acute medicine's great triumph for children. Intensive Care Med 2006; 32:958-61. [PMID: 16791656 DOI: 10.1007/s00134-006-0189-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Accepted: 04/12/2006] [Indexed: 01/20/2023]
|