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Fluid bolus therapy in pediatric sepsis: a narrative review. Eur J Med Res 2022; 27:246. [DOI: 10.1186/s40001-022-00885-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/04/2022] [Indexed: 11/14/2022] Open
Abstract
AbstractLeading cause of death in children under five, pediatric sepsis remains a significant global health threat. The 2020 Surviving Sepsis Campaign guidelines revised the management of septic shock and sepsis-associated organ dysfunction in children. In addition to empiric broad-spectrum antibiotics, fluid bolus therapy is one of the cornerstones of management, due to theoretical improvement of cardiac output, oxygen delivery and organ perfusion. Despite a very low level of evidence, the possible benefit of balanced crystalloids in sepsis resuscitation has led to discussion on their position as the ideal fluid. However, the latest adult data are not consistent with this, and the debate is still ongoing in pediatrics. We provide here the current state of knowledge on fluid bolus therapy in pediatric sepsis with emphasis on balanced crystalloids.
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Abstract
OBJECTIVES In clinical practice, there are various methods that can be used for the rapid administration of fluid in infants and children. The current study prospectively evaluates gravity, pressure-assisted, and hand-pump methods for the rapid administration of fluid using an in vitro model. METHODS Thirty participants were asked to deliver 500 mL of fluid using 1 of 6 setups: (1) standard blood tubing with gravity administration, (2) standard blood tubing with pressure bag maintained at 300 mm Hg, (3) standard blood tubing with pressure bag inflated to 300 mm Hg and left to flow, (4) blood tubing with in-line bulb pump, (5) blood tubing with in-line bulb pump and pressure bag, and (6) standard blood tubing with 20-mL syringe attached to the stopcock for a push-and-pull technique using a 20-mL syringe. RESULTS The blood tubing with an in-line bulb pump to allow manual acceleration of the administration of fluid along with a pressure bag on the intravenous fluid bag achieved the fastest flow rate, requiring an average of 98 seconds to deliver 500 mL of fluid. CONCLUSIONS When considering factors that affect fluid administration, Poiseuille's law dictates that the most important variable is the radius of the intravenous cannula, whereas the length of the cannula and the viscosity of the fluid administered are of secondary importance. With these limitations in mind, other factors may be used to speed fluid administration. Our study demonstrates the advantage of using blood tubing with the in-line bulb pump combined with a pressure bag.
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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4
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What Goes Up, Must Go Down? Pediatr Crit Care Med 2018; 19:579-581. [PMID: 29863640 DOI: 10.1097/pcc.0000000000001543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Glassford NJ, Gelbart B, Bellomo R. Coming full circle: thirty years of paediatric fluid resuscitation. Anaesth Intensive Care 2017; 45:308-319. [PMID: 28486889 DOI: 10.1177/0310057x1704500306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
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Affiliation(s)
- N J Glassford
- Registrar and Clinical Research Fellow, Department of Intensive Care, Austin Hospital, PhD Candidate, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, Victoria
| | - B Gelbart
- Staff Specialist, Department of Intensive Care, Royal Children's Hospital, Honorary Fellow, Murdoch Childrens Research Institute, Melbourne, Victoria
| | - R Bellomo
- Director of Intensive Care Research, Department of Intensive Care, Austin Hospital, Co-director and Honorary Professor, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Professor of Intensive Care, School of Medicine, The University of Melbourne, Melbourne, Victoria
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Investigation of the feasibility of non-invasive optical sensors for the quantitative assessment of dehydration. Med Eng Phys 2017; 48:181-187. [PMID: 28734875 DOI: 10.1016/j.medengphy.2017.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 03/07/2017] [Accepted: 06/20/2017] [Indexed: 11/21/2022]
Abstract
This study explores the feasibility of prospectively assessing infant dehydration using four non-invasive, optical sensors based on the quantitative and objective measurement of various clinical markers of dehydration. The sensors were investigated to objectively and unobtrusively assess the hydration state of an infant based on the quantification of capillary refill time (CRT), skin recoil time (SRT), skin temperature profile (STP) and skin tissue hydration by means of infrared spectrometry (ISP). To evaluate the performance of the sensors a clinical study was conducted on a cohort of 10 infants (aged 6-36 months) with acute gastroenteritis. High sensitivity and specificity were exhibited by the sensors, in particular the STP and SRT sensors, when combined into a fusion regression model (sensitivity: 0.90, specificity: 0.78). The SRT and STP sensors and the fusion model all outperformed the commonly used "gold standard" clinical dehydration scales including the Gorelick scale (sensitivity: 0.56, specificity: 0.56), CDS scale (sensitivity: 1.0, specificity: 0.2) and WHO scale (sensitivity: 0.13, specificity: 0.79). These results suggest that objective and quantitative assessment of infant dehydration may be possible using the sensors investigated. However, further evaluation of the sensors on a larger sample population is needed before deploying them in a clinical setting.
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Parker MJ, Thabane L, Fox-Robichaud A, Liaw P, Choong K. A trial to determine whether septic shock-reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy versus usual care (SQUEEZE): study protocol for a pilot randomized controlled trial. Trials 2016; 17:556. [PMID: 27876084 PMCID: PMC5120449 DOI: 10.1186/s13063-016-1689-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/09/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Current pediatric septic shock resuscitation guidelines from the American College of Critical Care Medicine focus on the early and goal-directed administration of intravascular fluid followed by vasoactive medication infusions for persistent and fluid-refractory shock. However, accumulating adult and pediatric data suggest that excessive fluid administration is associated with worse patient outcomes and even increased risk of death. The optimal amount of intravascular fluid required in early pediatric septic shock resuscitation prior to the initiation of vasoactive support remains unanswered. METHODS/DESIGN The SQUEEZE Pilot Trial is a pragmatic, two-arm, parallel-group, open-label, prospective pilot randomized controlled trial. Participants are children aged 29 days to under 18 years with suspected or confirmed septic shock and a need for ongoing resuscitation. Eligible participants are enrolled under an exception to consent process and randomly assigned via concealed allocation to either the Usual Care (control) or Fluid Sparing (intervention) resuscitation strategy. The primary objective of this pilot trial is to determine feasibility, based on the ability to enroll participants and to adhere to the study protocol. The primary outcome measure by which success will be determined is participant enrollment rate ("pass" defined as at least two participants/site/month, recognizing that enrollment may be slower during the run-in phase). Secondary objectives include assessing (1) appropriateness of eligibility criteria, and (2) completeness of clinical outcomes to inform the endpoints for the planned multisite trial. To support the nested translational study, SQUEEZE-D, we will also evaluate the feasibility of describing cell-free DNA (a procoagulant molecule with prognostic utility) in blood samples obtained from children enrolled into the SQUEEZE Pilot Trial at baseline and at 24 h. DISCUSSION The optimal degree of fluid resuscitation and the timing of initiation of vasoactive support in order to achieve recommended therapeutic targets in children with septic shock remains unanswered. No prospective study to date has examined this important question for children in developed countries including Canada. Recruitment for the SQUEEZE Pilot Trial opened on 6 January 2014. Findings will inform the feasibility of the planned multicenter trial to answer our overall research question. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01973907 , registered on 23 October 2013.
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Affiliation(s)
- Melissa J. Parker
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Lehana Thabane
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Department of Anesthesia, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Biostatistics Unit,/FSORC, St Joseph’s Healthcare Hamilton, 3rd floor Martha Wing, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Alison Fox-Robichaud
- Department of Medicine, McMaster University, DBRI, Rm C5–106 and 107, 237 Barton Street East, Hamilton, ON L8L 2X2 Canada
| | - Patricia Liaw
- Department of Medicine, McMaster University, DBRI, Rm C5–106 and 107, 237 Barton Street East, Hamilton, ON L8L 2X2 Canada
| | - Karen Choong
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - For the Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster Children’s Hospital and McMaster University, HSC 3E-20,1280 Main Street West, Hamilton, ON L8S 4K1 Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Division of Emergency Medicine, Department of Pediatrics, the Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- Department of Anesthesia, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
- Biostatistics Unit,/FSORC, St Joseph’s Healthcare Hamilton, 3rd floor Martha Wing, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
- Department of Medicine, McMaster University, DBRI, Rm C5–106 and 107, 237 Barton Street East, Hamilton, ON L8L 2X2 Canada
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Visser C, Scheffer C, Dellimore K, Kieser E, Smith J. Development of a diagnostic dehydration screening sensor based on infrared spectrometry. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2015:1271-1274. [PMID: 26736499 DOI: 10.1109/embc.2015.7318599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The clinical assessment of dehydration is highly subjective and requires experienced and highly trained clinical personnel. At present no objective method for quantitatively determining an individual's dehydration status exists. The aim of this study is to address this deficiency by presenting the development and testing of a novel diagnostic tool for dehydration detection based on infrared spectrometry. Laboratory testing and two clinical studies were conducted to evaluate the efficacy of the device in both adults and infants. The results were promising for the infant study with a clear trend exhibited. However, a number of challenges must be overcome before this sensor can be applied in a clinical setting.
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Inwald DP, Butt W, Tasker RC. Fluid resuscitation of shock in children: what, whence and whither? Intensive Care Med 2015; 41:1457-9. [PMID: 26088913 DOI: 10.1007/s00134-015-3905-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 01/15/2023]
Affiliation(s)
- David P Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, England, UK,
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11
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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Abstract
Although the incidence of acute pancreatitis among children is less than that in adults, the physical and psychosocial impact on children and their families can be overwhelming. Pancreatitis is manifested as pain accompanied by a host of other complex issues. These issues are manifested more markedly when the patient has additional concomitant diagnoses. Pain management, liver function tests, amylase and lipase levels, endocrine and exocrine functionality, and recognition of systemic inflammation are especially important. Management after discharge from the hospital is often an ongoing stress for these patients and families, and multiple admissions to the intensive care unit may be necessary for feeding and pain complications. Presented in the context of an actual clinical case at a 500-bed tertiary care pediatric hospital, this patient’s scenario illustrates the importance of ensuring adequate nutrition, maintaining hydration, providing appropriate pain management, and preventing infection and thromboembolic events.
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Affiliation(s)
- Chris Kramer
- Chris Kramer is a registered nurse in the pediatric intensive care unit at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Alvin Jeffery
- Alvin Jeffery is an education specialist in the Center for Professional Excellence/Education at Cincinnati Children’s Hospital Medical Center
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Cole ET, Harvey G, Urbanski S, Foster G, Thabane L, Parker MJ. Rapid paediatric fluid resuscitation: a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques in a simulated setting. BMJ Open 2014; 4:e005028. [PMID: 24993757 PMCID: PMC4091513 DOI: 10.1136/bmjopen-2014-005028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Manual techniques of intravascular fluid administration are commonly used during paediatric resuscitation, although it is unclear which technique is most efficient in the hands of typical healthcare providers. We compared the rate of fluid administration achieved with the disconnect-reconnect and push-pull manual syringe techniques for paediatric fluid resuscitation in a simulated setting. METHODS This study utilised a randomised crossover trial design and enrolled 16 consenting healthcare provider participants from a Canadian paediatric tertiary care centre. The study was conducted in a non-clinical setting using a model simulating a 15 kg child in decompensated shock. Participants administered 900 mL (60 mL/kg) of normal saline to the simulated patient using each of the two techniques under study. The primary outcome was the rate of fluid administration, as determined by two blinded independent video reviewers. We also collected participant demographic data and evaluated other secondary outcomes including total volume administered, number of catheter dislodgements, number of technical errors, and subjective and objective measures of provider fatigue. RESULTS All 16 participants completed the trial. The mean (SD) rate of fluid administration (mL/s) was greater for the disconnect-reconnect technique at 1.77 (0.145) than it was for the push-pull technique at 1.62 (0.226), with a mean difference of 0.15 (95% CI 0.055 to 0.251; p=0.005). There was no difference in mean volume administered (p=0.778) or participant self-reported fatigue (p=0.736) between techniques. No catheter dislodgement events occurred. CONCLUSIONS The disconnect-reconnect technique allowed for the fastest rate of fluid administration, suggesting that use of this technique may be preferable in situations requiring rapid resuscitation. These findings may help to inform future iterations of paediatric resuscitation guidelines. TRIAL REGISTRATION NUMBER This trial was registered at ClinicalTrials.gov [NCT01774214] prior to enrolling the first participant.
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Affiliation(s)
- Evan T Cole
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Greg Harvey
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Sara Urbanski
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Gary Foster
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit,/FSORC, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Lehana Thabane
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit,/FSORC, St Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Melissa J Parker
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, University Avenue, Toronto, Ontario, Canada
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Harvey G, Foster G, Manan A, Thabane L, Parker MJ. Factors affecting pediatric isotonic fluid resuscitation efficiency: a randomized controlled trial evaluating the impact of syringe size. BMC Emerg Med 2013; 13:14. [PMID: 23883424 PMCID: PMC3729679 DOI: 10.1186/1471-227x-13-14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 07/17/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Goal-directed therapy guidelines for pediatric septic shock resuscitation recommend fluid delivery at speeds in excess of that possible through use of regular fluid infusion pumps. In our experience, syringes are commonly used by health care providers (HCPs) to achieve rapid fluid resuscitation in a pediatric fluid resuscitation scenario. At present, it is unclear which syringe size health care providers should use when performing fluid resuscitation to achieve maximal fluid resuscitation efficiency. The objective of this study was therefore to determine if an optimal syringe size exists for conducting manual pediatric fluid resuscitation. METHODS This 48-participant parallel group randomized controlled trial included 4 study arms (10, 20, 30, 60 mL syringe size groups). Eligible participants were HCPs from McMaster Children's Hospital, Hamilton, Canada blinded to the purpose of the trial. Consenting participants were randomized using a third party technique. Following a standardization procedure, participants administered 900 mL (60 mL/kg) of isotonic saline to a simulated 15 kg child using prefilled provided syringes of the allocated size in rapid sequence. Primary outcome was total time to administer the 900 mL and this data was collected through video review by two blinded outcome assessors. Sample size was predetermined based upon a primary outcome analysis using one-way ANOVA. RESULTS 12 participants were randomized to each group (n=48) and all completed trial protocol to analysis. Analysis was conducted according to intention to treat principles. A significant difference in fluid resuscitation time (in seconds) was found between syringe size group means: 10 mL, 563s [95% CI 521; 606]; 20 mL, 506s [95% CI 64; 548]; 30 mL, 454s [95% CI 412; 596]; 60 mL, 455s [95% CI 413; 497] (p<0.001). CONCLUSIONS The syringe size used when performing manual pediatric fluid resuscitation has a significant impact on fluid resuscitation speed, in a setting where fluid filled syringes are continuously available. Greatest efficiency was achieved with 30 or 60 mL syringes. TRIAL REGISTRATION ClinicalTrials.gov, NCT01494116.
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Affiliation(s)
- Greg Harvey
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
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Couto-Alves A, Wright VJ, Perumal K, Binder A, Carrol ED, Emonts M, de Groot R, Hazelzet J, Kuijpers T, Nadel S, Zenz W, Ramnarayan P, Levin M, Coin L, Inwald DP. A new scoring system derived from base excess and platelet count at presentation predicts mortality in paediatric meningococcal sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R68. [PMID: 23577792 PMCID: PMC3672696 DOI: 10.1186/cc12609] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 04/03/2013] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The aim of this study was to derive a novel prognostic score for mortality in paediatric meningococcal sepsis (MS) based on readily available laboratory markers. METHODS A multicentre retrospective cohort study for the consortium set and a single centre retrospective study for replication set. The consortium set were 1,073 children (age 1 week to 17.9 years) referred over a 15-year period (1996 to 2011), who had an admission diagnosis of MS, referred to paediatric intensive care units (PICUs) in six different European centres. The consortium set was split into a development set and validation set to derive the score. The replication set were 134 children with MS (age 2 weeks to 16 years) referred over a 4-year period (2007 to 2011) to PICUs via the Children's Acute Transport Service (CATS), London. RESULTS A total of 85/1,073 (7.9%) children in the consortium set died. A total of 16/134 (11.9%) children in the replication set died. Children dying in the consortium set had significantly lower base excess, C-reactive protein (CRP), platelet and white cell count, more deranged coagulation and higher lactate than survivors. Paediatric risk of mortality (PRISM) score, Glasgow meningococcal septicaemia prognosis score (GMSPS) and Rotterdam score were also higher. Using the consortium set, a new scoring system using base excess and platelet count at presentation, termed the BEP score, was mathematically developed and validated. BEP predicted mortality with high sensitivity and specificity scores (area under the curve (AUC) in the validation set=0.86 and in the replication set=0.96). In the validation set, BEP score performance (AUC=0.86, confidence interval (CI): 0.80 to 0.91) was better than GMSPS (AUC=0.77, CI: 0.68, 0.85), similar to Rotterdam (AUC=0.87, CI: 0.81 to 0.93) and not as good as PRISM (AUC=0.93, CI: 0.85 to 0.97). CONCLUSIONS The BEP score, relying on only two variables that are quickly and objectively measurable and readily available at presentation, is highly sensitive and specific in predicting death from MS in childhood.
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Cole ET, Harvey G, Foster G, Thabane L, Parker MJ. Study protocol for a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques. BMJ Open 2013; 3:bmjopen-2013-002754. [PMID: 23524045 PMCID: PMC3612816 DOI: 10.1136/bmjopen-2013-002754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Paediatric shock is a life-threatening condition with many possible causes and a global impact. Current resuscitation guidelines require rapid fluid administration as a cornerstone of paediatric shock management. However, little evidence is available to inform clinicians how to most effectively perform rapid fluid administration where this is clinically required, resulting in suboptimal knowledge translation of current resuscitation guidelines into clinical practice. OBJECTIVES This study aims to determine which of the two commonly used techniques for paediatric fluid resuscitation (disconnect-reconnect technique and push-pull technique) yields a higher fluid administration rate in a simulated clinical scenario. Secondary objectives include determination of catheter dislodgement rates, subjective and objective measures of provider fatiguability and descriptive information regarding any technical issues encountered with performance of each method under the study. METHODS AND ANALYSIS This study will utilise a randomised crossover trial design. Participants will include consenting healthcare providers from McMaster Children's Hospital. Each participant will administer 900 ml (60 ml/kg) of normal saline to a simulated 15 kg infant as quickly as possible on two separate occasions using the manual fluid administration techniques under the study. The primary outcome, rate of fluid administration, will be evaluated using a paired two-tailed Student t test. ETHICS AND DISSEMINATION This protocol has been approved by the Hamilton Health Sciences Research Ethics Board. RESULTS These will be published in a peer-reviewed scientific journal and presented at one or more scientific conferences. PROTOCOL REGISTRATION Protocol Registered on ClinicalTrials.gov NCT01774214.
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Affiliation(s)
- Evan T Cole
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Greg Harvey
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Gary Foster
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit/FSORC, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Lehana Thabane
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit/FSORC, St Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Melissa J Parker
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
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17
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Ralston ME, Day LT, Slusher TM, Musa NL, Doss HS. Global paediatric advanced life support: improving child survival in limited-resource settings. Lancet 2013; 381:256-65. [PMID: 23332963 DOI: 10.1016/s0140-6736(12)61191-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.
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Affiliation(s)
- Mark E Ralston
- Department of Pediatrics, Naval Hospital, Oak Harbor, WA 98278, USA
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18
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Gaieski DF, Goldman JD, Holtzman DL, Shoff WH, Shepherd SM, Mehta N, Goyal M. Algid malaria treated with early goal-directed therapy. Am J Emerg Med 2013; 31:263.e5-10. [DOI: 10.1016/j.ajem.2012.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022] Open
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19
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Bacterial Sepsis and Shock. TEXTBOOK OF CLINICAL PEDIATRICS 2012. [PMCID: PMC7123967 DOI: 10.1007/978-3-642-02202-9_61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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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.
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Affiliation(s)
- Isabelle Murat
- Department of Anesthesia, Hôpital d'Enfants Armand Trousseau, 26 avenue du Dr. Arnold Netter, 75571 Paris, Cedex 12, France.
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21
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Akech S, Ledermann H, Maitland K. Choice of fluids for resuscitation in children with severe infection and shock: systematic review. BMJ 2010; 341:c4416. [PMID: 20813823 PMCID: PMC2933356 DOI: 10.1136/bmj.c4416] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systemically review the evidence from clinical trials comparing the use of crystalloids and colloids for fluid resuscitation in children with severe infection. DATA SOURCES Medline (1950-2008), PubMed, the Cochrane Library, Embase (1980-2008), and reference lists. Eligibility criteria Published studies comparing fluid resuscitation with crystalloid or colloidal solutions in severe infectious illness in children aged >1 month to <or=12 years. Controlled trials and randomised controlled trials were separately selected by two unblinded investigators who also independently extracted data. MAIN OUTCOME MEASURES Efficacy in the treatment of shock, mortality, and reported adverse events. RESULTS Nine trials fulfilled criteria, eight of which compared crystalloids with colloids. All trials were conducted in settings with poor resources and predominantly included patients with malaria or dengue haemorrhagic shock. None of the trials had mortality as a primary outcome. Three out of six studies that reported at least one death showed better survival in children resuscitated with colloids compared with crystalloids (Peto fixed odds ratio ranging from 0.18 (95% confidence interval 0.02 to 1.42) to 0.48 (0.06 to 3.99)). Studies contributing data on mortality had some methodological limitations so caution is recommended when interpreting this finding. Studies were heterogeneous so combined estimates were not calculated. The review was limited by inclusion of only published studies. CONCLUSIONS The current evidence on choice of fluids for resuscitation in children with infections is weak. While existing trials have provided important evidence in malaria and dengue, resuscitation in children with paediatric sepsis, for which colloids could theoretically be of benefit, has not been studied. The evidence from existing studies is not robust enough to make any definitive recommendations over the choice of resuscitation fluid and a definitive trial is required to address this.
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Affiliation(s)
- Samuel Akech
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
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23
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Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin North Am 2007; 25:1009-40, vi. [DOI: 10.1016/j.emc.2007.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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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.
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Affiliation(s)
- Patrick Meybohm
- Department of Anesthesiology and Intensive Care Medicine, Pediatric Anesthesia Research Unit, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany.
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25
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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
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26
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Clark IA, Budd AC, Alleva LM, Cowden WB. Human malarial disease: a consequence of inflammatory cytokine release. Malar J 2006; 5:85. [PMID: 17029647 PMCID: PMC1629020 DOI: 10.1186/1475-2875-5-85] [Citation(s) in RCA: 201] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Accepted: 10/10/2006] [Indexed: 12/24/2022] Open
Abstract
Malaria causes an acute systemic human disease that bears many similarities, both clinically and mechanistically, to those caused by bacteria, rickettsia, and viruses. Over the past few decades, a literature has emerged that argues for most of the pathology seen in all of these infectious diseases being explained by activation of the inflammatory system, with the balance between the pro and anti-inflammatory cytokines being tipped towards the onset of systemic inflammation. Although not often expressed in energy terms, there is, when reduced to biochemical essentials, wide agreement that infection with falciparum malaria is often fatal because mitochondria are unable to generate enough ATP to maintain normal cellular function. Most, however, would contend that this largely occurs because sequestered parasitized red cells prevent sufficient oxygen getting to where it is needed. This review considers the evidence that an equally or more important way ATP deficiency arises in malaria, as well as these other infectious diseases, is an inability of mitochondria, through the effects of inflammatory cytokines on their function, to utilise available oxygen. This activity of these cytokines, plus their capacity to control the pathways through which oxygen supply to mitochondria are restricted (particularly through directing sequestration and driving anaemia), combine to make falciparum malaria primarily an inflammatory cytokine-driven disease.
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Affiliation(s)
- Ian A Clark
- School of Biochemistry and Molecular Biology, Australian National University, Canberra, ACT 0200, Australia
| | - Alison C Budd
- School of Biochemistry and Molecular Biology, Australian National University, Canberra, ACT 0200, Australia
| | - Lisa M Alleva
- School of Biochemistry and Molecular Biology, Australian National University, Canberra, ACT 0200, Australia
| | - William B Cowden
- John Curtin School of Medical Research, Australian National University, Canberra, ACT 0200, Australia
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