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Cave DG, Bautista MJ, Mustafa K, Bentham JR. Cardiac output monitoring in children: a review. Arch Dis Child 2023; 108:949-955. [PMID: 36927620 DOI: 10.1136/archdischild-2022-325030] [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: 11/04/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
Cardiac output monitoring enables physiology-directed management of critically ill children and aids in the early detection of clinical deterioration. Multiple invasive techniques have been developed and have demonstrated ability to improve clinical outcomes. However, all require invasive arterial or venous catheters, with associated risks of infection, thrombosis and vascular injury. Non-invasive monitoring of cardiac output and fluid responsiveness in infants and children is an active area of interest and several proven techniques are available. Novel non-invasive cardiac output monitors offer a promising alternative to echocardiography and have proven their ability to influence clinical practice. Assessment of perfusion remains a challenge; however, technologies such as near-infrared spectroscopy and photoplethysmography may prove valuable clinical adjuncts in the future.
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Affiliation(s)
- Daniel Gw Cave
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, West Yorkshire, UK
| | - Melissa J Bautista
- General Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
- General Surgery, University of Leeds, Leeds, West Yorkshire, UK
| | - Khurram Mustafa
- Paediatric Intensive Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James R Bentham
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Mestiri Y, Thabet F. Management of septic shock by pediatric residents: An area for quality improvement. Arch Pediatr 2023:S0929-693X(23)00029-5. [PMID: 37061357 DOI: 10.1016/j.arcped.2023.01.012] [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: 11/29/2021] [Revised: 08/03/2022] [Accepted: 01/07/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Compliance with sepsis guidelines has been shown to be linked to better outcomes in patients with septic shock; however, adherence to these guidelines is not consistent among pediatric healthcare providers. In Tunisia, the management of children with septic shock is initiated by the pediatric resident on call. METHODS This study assessed the compliance of Tunisian pediatric residents with the 2020 "Surviving Sepsis Campaign" guidelines and identified factors that could improve compliance. We conducted a cross-sectional national study based on an online survey (SurveyMonkey) presenting a clinical pediatric case of septic shock. The survey was sent to the 200 residents registered in the Tunisian pediatric residency program. RESULTS The response rate was 72%, with 144 residents replying to the survey. Up to 72.9% of the residents had good compliance with the 1-h bundle: obtaining blood cultures prior to antibiotics, early administration of intravenous (IV) antibiotics, IV fluid expansion, and vasopressor for fluid-refractory septic shock. Factors independently associated with good compliance were a pediatric intensive care unit rotation (odds ratio [OR]: 5.17, 95% confidence interval [CI]: 1.44-18.58; p = 0.012), availability of a written protocol (OR: 9.09, 95% CI: 2.67-30.97; p<0.001), an on-call senior supervisor on site (OR: 6.76, 95% CI: 2.24-20.40; p = 0.001), and European Pediatric Advanced Life Support (EPALS) certification (OR: 13.47, 95% CI: 3.05-59.31; p = 0.001). CONCLUSION These factors could be considered in the process of a quality improvement strategy that ultimately better promotes performance in pediatric sepsis management and may improve patient outcomes.
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Affiliation(s)
- Y Mestiri
- Faculty of Medicine of Monastir, University of Monastir, Tunisia
| | - F Thabet
- Faculty of Medicine of Monastir, University of Monastir, Tunisia.
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3
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Babu S, Sreedhar R, Munaf M, Gadhinglajkar SV. Sepsis in the Pediatric Cardiac Intensive Care Unit: An Updated Review. J Cardiothorac Vasc Anesth 2023; 37:1000-1012. [PMID: 36922317 DOI: 10.1053/j.jvca.2023.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
Sepsis remains among the most common causes of mortality in children with congenital heart disease (CHD). Extensive literature is available regarding managing sepsis in pediatric patients without CHD. Because the cardiovascular pathophysiology of children with CHD differs entirely from their typical peers, the available diagnosis and management recommendations for sepsis cannot be implemented directly in children with CHD. This review discusses the risk factors, etiopathogenesis, available diagnostic tools, resuscitation protocols, and anesthetic management of pediatric patients suffering from various congenital cardiac lesions. Further research should focus on establishing a standard guideline for managing children with CHD with sepsis and septic shock admitted to the intensive care unit.
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Affiliation(s)
- Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India.
| | - Rupa Sreedhar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Mamatha Munaf
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
| | - Shrinivas V Gadhinglajkar
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal institute for medical sciences and technology, Trivandrum, India
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4
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Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S45-S60. [PMID: 36661435 DOI: 10.1097/pcc.0000000000003158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation). DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.
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Choosri N, Kungsuwan S. Feasibility study of using mobile application to support triage and diagnosis clinical decisions for pediatricians: User-centered design approach. Digit Health 2023; 9:20552076231203930. [PMID: 37780067 PMCID: PMC10540580 DOI: 10.1177/20552076231203930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/08/2023] [Indexed: 10/03/2023] Open
Abstract
Background While there is some evidence in the literature demonstrating success in using a triage software application in ED, none of the solution was developed specifically to support a holistic decision of pediatricians in triage and diagnosis purposes to initiate the first treatment properly. To explore the usefulness and possibility of employing a digital-based solution to enhance clinician performance, the mobile application was developed and then assessed in different perspectives. Objective The primary objective of this study is to contribute implementation practice of an application to support pediatric triage and diagnoses. The secondary objective is to present the results of the preliminary evaluation of the application. Methods The application called Pedicmeter was developed. Formative tests with revisions were applied throughout the development phase. A number of summative extensive evaluations were also conducted to investigate the efficacy of the proposed method. The evaluation focused on measuring the ability of an application to support a pediatric staff's decision to determine an overall severity level and disease diagnosis. Finally, the user's (clinician's) satisfaction of using the application was measured. Results The application Pedicmeter enables clinicians to make more accurate decisions in determining emergency level of pediatric patients by 6.66%. The application accurately diagnosed a disease with 73.08% accuracy and 66.67% accuracy for respiratory and infectious diseases, respectively. The diagnostic information that the application suggested shows that it does have an influence on a clinician's diagnosis. Using the app showed improvements in diagnostic accuracy for asthma, croup, sepsis, but it showed a decrease in the accuracy of a clinician's decision for pneumonia. The benefit of the application that satisfies the pediatricians the most is the helpfulness of the features of the application (86%), while the least satisfying factor was the required number of inputs (63%). Conclusion The developed application conceptually shows a promising opportunity to enhance clinicians' decisions from the pilot study. However, the study also reveals further tweaks are required and unveils challenging issues and the concerns of clinician users when use the application. Further research will be conducted to investigate and determine the limiting factors and specific issues revealed by this study. Longitudinal data collection and analysis also need to be conducted to investigate the clinical implications.
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Affiliation(s)
- Noppon Choosri
- Daksh Research Group, Chiang Mai University, Chiang Mai, Thailand
- College of Arts, Media and Technology, Chiang Mai University, Chiang Mai, Thailand
| | - Supakanya Kungsuwan
- Department of Pediatric, Chiang Mai University Faculty of Medicine, Chiang Mai, Thailand
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Karlsson J, Lönnqvist PA. Capnodynamics - noninvasive cardiac output and mixed venous oxygen saturation monitoring in children. Front Pediatr 2023; 11:1111270. [PMID: 36816378 PMCID: PMC9936087 DOI: 10.3389/fped.2023.1111270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Hemodynamic monitoring in children is challenging for many reasons. Technical limitations in combination with insufficient validation against reference methods, makes reliable monitoring systems difficult to establish. Since recent studies have highlighted perioperative cardiovascular stability as an important factor for patient outcome in pediatrics, the need for accurate hemodynamic monitoring methods in children is obvious. The development of mathematical processing of fast response mainstream capnography signals, has allowed for the development of capnodynamic hemodynamic monitoring. By inducing small changes in ventilation in intubated and mechanically ventilated patients, fluctuations in alveolar carbon dioxide are created. The subsequent changes in carbon dioxide elimination can be used to calculate the blood flow participating in gas exchange, i.e., effective pulmonary blood flow which equals the non-shunted pulmonary blood flow. Cardiac output can then be estimated and continuously monitored in a breath-by-breath fashion without the need for additional equipment, training, or calibration. In addition, the method allows for mixed venous oxygen saturation (SvO2) monitoring, without pulmonary artery catheterization. The current review will discuss the capnodyamic method and its application and limitation as well as future potential development and functions in pediatric patients.
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Affiliation(s)
- Jacob Karlsson
- Dept of Physiology & Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Dept of Physiology & Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making. Anesthesiology 2022; 137:604-619. [PMID: 36264089 DOI: 10.1097/aln.0000000000004357] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article presents current literature and scientific evidence on hemoglobin thresholds and physiologic parameters to guide decisions regarding perioperative erythrocyte transfusions in pediatric patients based on the most up-to-date studies and expert consensus recommendations.
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Loomba RS, Villarreal EG, Farias JS, Flores S, Bronicki RA. Fluid bolus administration in children, who responds and how? A systematic review and meta-analysis. Paediatr Anaesth 2022; 32:993-999. [PMID: 35736026 DOI: 10.1111/pan.14512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fluid boluses are frequently utilized in children. Despite their frequency of use, there is little objective data regarding the utility of fluid boluses, who they benefit the most, and what the effects are. AIMS This study aimed to conduct pooled analyses to identify those who may be more likely to respond to fluid boluses as well as characterize clinical changes associated with fluid boluses. METHODS A systematic review of the literature and meta-analysis was conducted to identify pediatric studies investigating the response to fluid boluses and clinical changes associated with fluid boluses. RESULTS A total of 15 studies with 637 patients were included in the final analyses with a mean age of 650 days ± 821.01 (95% CI 586 to 714) and a mean weight of 10.5 kg ± 7.19 (95% CI 9.94 to 11.1). The mean bolus volume was 12.14 ml/kg ± 4.09 (95% CI 11.8 to 12.5) given over a mean of 19.55 min ± 10.16 (95% CI 18.8 to 20.3). The following baseline characteristics were associated with increased likelihood of response [represented in mean difference (95% CI)]: greater age [207.2 days (140.8 to 273.2)], lower cardiac index [-0.5 ml/min/m2 (-0.9 to -0.3)], and lower stroke volume [-5.1 ml/m2 (-7.9 to -2.3)]. The following clinical parameters significantly changed after a fluid bolus: decreased HR [-5.6 bpm (-9.8 to -1.3)], increased systolic blood pressure [7.7 mmHg (1.0 to 14.4)], increased mean arterial blood pressure [5.5 mmHg (3.1 to 7.8)], increased cardiac index [0.3 ml/min/m2 (0.1 to 0.6)], increased stroke volume [4.3 ml/m2 (3.5 to 5.2)], increased central venous pressure [2.2 mmHg (1.1 to 3.3)], and increased systemic vascular resistance [2.1 woods units/m2 (0.1 to 4.2)]. CONCLUSION Fluid blouses increase arterial blood pressure or cardiac output by 10% in approximately 56% of pediatric patients. Fluid blouses lead to significant decrease in HR and significant increases in cardiac output, stroke volume, and systemic vascular resistance. Limited published data are available on the effects of fluid blouses on systemic oxygen delivery.
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Affiliation(s)
- Rohit S Loomba
- Cardiology, Advocate Children's Hospital, Chicago, Illinois, USA.,Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, Illinois, USA
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, Mexico
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, Mexico
| | - Saul Flores
- Critical Care and Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
| | - Ronald A Bronicki
- Critical Care and Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
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9
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Zhao CC, Ye Y, Li ZQ, Wu XH, Zhao C, Hu ZJ. Effect of goal-directed fluid therapy on renal function in critically ill patients: a systematic review and meta-analysis. Ren Fail 2022; 44:777-789. [PMID: 35535511 PMCID: PMC9103701 DOI: 10.1080/0886022x.2022.2072338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate whether goal-directed fluid therapy (GDFT) reduces the risk of renal injury in critical illness. Methods MEDLINE via PubMed, EMBASE, CENTRAL and CBM was searched from inception to 13 March 2022, for studies comparing the effect of GDFT with usual care on renal function in critically ill patients. GDFT was defined as a protocolized intervention based on hemodynamic and/or oxygen delivery parameters. A fixed or random effects model was applied to calculate the pooled odds ratio (OR) based on heterogeneity through the included studies. Results A total of 28 studies with 9,019 patients were included. The pooled data showed that compared with usual care, GDFT reduced the incidence of acute kidney injury (AKI) in critical illness (OR 0.62, 95% confidence interval (CI) 0.47 to 0.80, p< 0.001). Sensitivity analysis with only low risk of bias studies showed the same result. Subgroup analyses found that GDFT was associated with a lower AKI incidence in both postoperative and medical patients. The reduction was significant in GDFT aimed at dynamic indicators. However, no significant difference was found between groups in RRT support (OR 0.88, 95% CI 0.74 to 1.05, p= 0.17). GDFT tended to increase fluid administration within the first 6 h, decrease fluid administration after 24 h, and was associated with more vasopressor requirements. Conclusions This meta-analysis suggests that GDFT aimed at dynamic indicators may be an effective way to prevent AKI in critical illness. This may indicate a benefit from early adequate fluid resuscitation and the combined effect of vasopressors.
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Affiliation(s)
- Cong-Cong Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Ye
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-Qiang Li
- Department of Intensive Care Unit, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Xin-Hui Wu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chai Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Roy KL, Fisk A, Forbes P, Holland CC, Schenkel SR, Vitali S, DeGrazia M. Inadequate Oxygen Delivery Dose and Major Adverse Events in Critically Ill Children With Sepsis. Am J Crit Care 2022; 31:220-228. [PMID: 35466350 DOI: 10.4037/ajcc2022125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The inadequate oxygen delivery (IDo2) index is used to estimate the probability that a patient is experiencing inadequate systemic delivery of oxygen. Its utility in the care of critically ill children with sepsis is unknown. OBJECTIVE To evaluate the relationship between IDo2 dose and major adverse events, illness severity metrics, and outcomes among critically ill children with sepsis. METHODS Clinical and IDo2 data were retrospectively collected from the records of 102 critically ill children with sepsis, weighing >2 kg, without preexisting cardiac dysfunction. Descriptive, nonparametric, odds ratio, and correlational statistics were used for data analysis. RESULTS Inadequate oxygen delivery doses were significantly higher in patients who experienced major adverse events (n = 13) than in those who did not (n = 89) during the time intervals of 0 to 12 hours (P < .001), 12 to 24 hours (P = .01), 0 to 24 hours (P < .001), 0 to 36 hours (P < .001), and 0 to 48 hours (P < .001). Patients with an IDo2 dose at 0 to 12 hours at or above the 80th percentile had the highest odds of a major adverse event (odds ratio, 23.6; 95% CI, 5.6-99.4). Significant correlations were observed between IDo2 dose at 0 to 12 hours and day 2 maximum vasoactive inotropic score (ρ = 0.27, P = .006), day 1 Pediatric Logistic Organ Dysfunction (PELOD-2) score (ρ = 0.41, P < .001), day 2 PELOD-2 score (ρ = 0.44, P < .001), intensive care unit length of stay (ρ = 0.35, P < .001), days receiving invasive ventilation (ρ = 0.42, P < .001), and age (ρ = -0.47, P < .001). CONCLUSIONS Routine IDo2 monitoring may identify critically ill children with sepsis who are at the highest risk of adverse events and poor outcomes.
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Affiliation(s)
- Katie L. Roy
- Katie L. Roy is a nurse practitioner in the medical-surgical intensive care unit (ICU), Cardiovascular and Critical Care Services, Boston Children’s Hospital, and a DNP graduate, Northeastern University, Boston, Massachusetts
| | - Anna Fisk
- Anna Fisk is a clinical coordinator in the cardiovascular ICU, Cardiovascular and Critical Care Services, Boston Children’s Hospital
| | - Peter Forbes
- Peter Forbes is a senior biostatistician, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital
| | - Conor C. Holland
- Conor C. Holland is a research engineer, Etiometry Inc, Boston, Massachusetts
| | - Sara R. Schenkel
- Sara R. Schenkel is a clinical research program manager, Massachusetts General Hospital, Boston
| | - Sally Vitali
- Sally Vitali is a senior associate in critical care medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, and an assistant professor of anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Michele DeGrazia
- Michele DeGrazia is director of nursing research, neonatal ICU, Cardiovascular and Critical Care Services, Boston Children’s Hospital, and an assistant professor of pediatrics, Harvard Medical School
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Yuliarto S, Pudjiadi AH, Latief A. Characteristics of hemodynamic parameters after fluid resuscitation and vasoactive drugs administration in pediatric shock: A prospective observational study. Ann Med Surg (Lond) 2022; 76:103521. [PMID: 35495407 PMCID: PMC9052134 DOI: 10.1016/j.amsu.2022.103521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 11/25/2022] Open
Abstract
Background Prior studies have shown that septic shock survivors had a normal cardiac index (CI) and systemic vascular resistance index (SVRI). However, this feature seems to be questionable in other-caused shock, since several factors are associated with the hemodynamic profile. This study aims to describe hemodynamic profiles (preload, inotropy, afterload, stroke volume, and cardiac output) after fluid resuscitation and vasoactive therapy in children with shock. Methods Children aged 1 month to 18 years old with shock conditions were included in this study. Fluid resuscitation was administered following the American College of Critical Care Medicine (ACCM) protocol. Hemodynamic profiles were assessed at 1 and 6 h from the start of fluid resuscitation. Grouping of the subjects was determined by the USCOM examination in 1st hour until the end of the study and we divided into 3 groups. Results At 1 h, group 1 (low CI) was 14% (CI:2.5[1.2–3.2]L/min/m2), group 2 (normal CI) was 66% (CI:4.2[3.4–5.8]L/min/m2), and group 3 (high CI) was 20% (CI:7.1[6.1–9.4]L/min/m2). SVRI was higher in groups 1 and 2 compared to group 3 (p < 0.05). Group 1 and 2 revealed fluid-refractory shock (SVV:25[12–34]% and 29(13–58)%, respectively), lower Smith-Madigan Inotropy Index (SMII) and higher Potential to Kinetic Ratio (PKR) compared to group 3 (p < 0.05). Group 3 revealed fluid-responsive shock (Stroke Volume Variation (SVV):32[18–158]%), higher SMII and lower PKR. At 6th hour, CI in all groups were normal (group 1:3.5[1.2–7.5]; group 2:4.0[1.7–6.1]; group 3:6.0[3.1–6.2]). However, 71.4% and 54.5% of subjects in groups 1 and 2, respectively, still revealed low inotropy. Group 3 revealed a significant increase in SVRI and PKR (p < 0.01). Conclusions Most pediatric shock patients were hypodynamic. Even when the CI was normal, the preload, inotropy, and afterload may still be abnormal. It represented the inotropy as a key to hemodynamic. Describe the macrocirculation parameter (preload, inotropy, afterload) in children with shock. Most pediatric shock tend to be hypodynamic. Fluid and vasoactive agent therapy should be guided by combination of the hemodynamic parameters.
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12
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Kusumastuti NP, Ontoseno T, Endaryanto A. Renal Oxygen Saturation as an Early Indicator of Shock in Children. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:123-131. [PMID: 35388273 PMCID: PMC8977478 DOI: 10.2147/oaem.s357320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Shock is a life-threatening syndrome in which tissue perfusion and oxygen delivery are inadequate. Near-infrared spectroscopy (NIRS) has been suggested as a noninvasive tool for monitoring and detecting the state of inadequate tissue perfusion. Renal and mesenteric oximetry show decreased cardiac output earlier than systemic or global parameters of tissue oxygenation or cerebral oximetry. However, until now there has been no study on the validity of regional renal oxygen saturation (rRSO2) by NIRS for diagnosing shock in children. Purpose To analyze the validity of rRSO2 by NIRS to diagnose shock in children. Patients and Methods This cross-sectional study was conducted in critically ill children (aged 1 month–18 years) who were admitted to the pediatric intensive care unit (PICU), from September to November 2020, consecutively. Patients were classified into two groups: shock and non-shock. The diagnosis of shock is based on clinical criteria (tachycardia, sign of hypoperfusion and decrease systolic blood pressure <P5 according to age). Measurement of rRSO2 by NIRS was performed by the doctor in charge when the patient came to PICU. The baseline rRSO2 value (%) made a receiver operating characteristic (ROC) curve and was used to find the optimal cut-off value and calculated sensitivity and specificity. Results We enrolled 20 critically ill patients. The baseline rRSO2 in the shock (n=10) and non-shock (n=10) groups were, 44.00±4.95 vs 78.70±4.52 (p 0.003). The optimal cutoff value of the baseline rRSO2 to predict shock is less than 58.5% with area under the curve (AUC) value is 94.4% (95% CI of 84.4–100%), p 0.001, sensitivity 90% and specificity 90% in critically ill children. Conclusion The rRSO2 value by NIRS can differentiate between shock and non-shock in critically ill patients accurately.
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Affiliation(s)
- Neurinda Permata Kusumastuti
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
- Departement of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
- Correspondence: Neurinda Permata Kusumastuti, Department of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Jl. Mayjend Prof. Dr. Moestopo No. 6-8, Airlangga, Gubeng, Surabaya, East Java, 60286, Indonesia, Tel +62 811316712, Email
| | - Teddy Ontoseno
- Departement of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Anang Endaryanto
- Departement of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
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Liu YM, Zheng ML, Sun X, Chen XB, Sun YX, Feng ZC, He SR. The clinical value of ultrasonic cardiac output monitor in very-low birth-weight and extremely-low-birth-weight infants undergoing PDA ligation. Early Hum Dev 2022; 165:105522. [PMID: 34959193 DOI: 10.1016/j.earlhumdev.2021.105522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/15/2021] [Accepted: 12/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiorespiratory instability occurs very often in very-low-birth-weight (VLBW) and extremely-low-birth-weight (ELBW) infants undergoing patent ductus arteriosus (PDA) ligation during the early postoperative period. This study aimed to investigate ultrasonic cardiac output monitor (USCOM) as a bedside tool by evaluating the hemodynamic changes in preterm infants following PDA ligation and assessing factors that may influence these changes. METHODS This was a single-center prospective observational study at a third-level neonatal intensive care unit. A total of 33 infants, including 21 VLBW and 12 ELBW infants, were involved. Hemodynamic measurements were performed in these infants using a USCOM preoperatively as well as 0-1 h, 8-10 h, and 24 h postoperatively. RESULTS The PDA ligation was associated with reductions of the left ventricular cardiac output (LVCO) (P < 0.001), cardiac index (P < 0.001), flow time corrected (FTC) (P < 0.001), Smith-Madigan inotropy index (SMII) (P < 0.001), oxygen delivery (DO2) (P < 0.001), and oxygen delivery index (DO2I) (P < 0.001) and an increase of the systemic vascular resistance index (SVRI) (P < 0.001) at 0-1 h, 8-10 h, and 24 h post-ligation compared with the respective preoperative values. Compared with the respective values at 0-1 h post-ligation, there was no significant difference in the CI, SMII, or FTC at 8-10 h and 24 h post-ligation. However, the SVRI decreased at 8-10 h and 24 h post-ligation. Moreover, the DO2I increased at 8-10 h and 24 h post-ligation, and the LVCO and DO2 increased at 24 h post-ligation. CONCLUSION Our study confirmed that the hemodynamic changes measured by the USCOM were similar to those measured by echocardiography in previous reports. Thus, USCOM is a useful and convenient bedside tool for assessing hemodynamic changes to guide the use of fluids, inotropic agents, and vasopressors and help modify the post-ligation course, and they may be a surrogate for repeated echocardiography during the early post-ligation period in preterm infants or a preliminary screening method.
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Affiliation(s)
- Yu-Mei Liu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510280, China; Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Man-Li Zheng
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xin Sun
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiao-Bo Chen
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yun-Xia Sun
- Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zhi-Chun Feng
- Department of Neonatology, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing 100853, China
| | - Shao-Ru He
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510280, China; Department of Neonatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China.
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14
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Shah AP, Batra P. Intermittent Mixed Venous Oxygen Saturation in Pediatric Septic Shock. Indian Pediatr 2022. [DOI: 10.1007/s13312-021-2390-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Mileder LP, Buchmayer J, Baik-Schneditz N, Schwaberger B, Höller N, Andersen CC, Stark MJ, Pichler G, Urlesberger B. Non-invasively Measured Venous Oxygen Saturation as Early Marker of Impaired Oxygen Delivery in Preterm Neonates. Front Pediatr 2022; 10:834045. [PMID: 35155310 PMCID: PMC8831784 DOI: 10.3389/fped.2022.834045] [Citation(s) in RCA: 1] [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] [Received: 12/12/2021] [Accepted: 01/05/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Adequate oxygen supply for preterm neonates may be defined through non-invasive measurement of venous oxygen saturation (SvO2) and fractional oxygen extraction using near-infrared spectroscopy (NIRS). We investigated whether there was a difference in peripheral muscle SvO2 (pSvO2) and peripheral fractional oxygen extraction (pFOE) in preterm neonates with early inflammation/infection compared to healthy subjects during the first 72 h after birth. MATERIALS AND METHODS We retrospectively analyzed secondary outcome parameters of prospective observational studies, including preterm neonates at risk of infection in whom peripheral NIRS measurements were performed in combination with venous occlusions. Early neonatal inflammation/infection was diagnosed by clinical signs and laboratory parameters. Peripheral muscle tissue oxygenation index (pTOI) was measured using either NIRO 300 or NIRO 200-NX (both Hamamatsu Photonics, Japan) on the patients' lower legs. Using 20-s venous occlusions, pSvO2 and pFOE were calculated incorporating simultaneous measurements of arterial oxygen saturation (SpO2). RESULTS We analyzed measurements from 226 preterm neonates (median gestational age 33.9 weeks), 64 (28.3%) of whom were diagnosed with early neonatal inflammation/infection. During the first 24 h after birth, pSvO2 (66.9% [62.6-69.2] vs. 69.4% [64.6-72.0]; p = 0.04) and pTOI (68.6% [65.3-71.9] vs. 71.7% [67.3-75.1]; p = 0.02) were lower in those neonates with inflammation/infection, while there was no such difference for measurements between 24-48 and 48-72 h. DISCUSSION NIRS measurement of pSvO2 and pFOE is feasible and may be utilized for early detection of impaired peripheral oxygen delivery. As pTOI was also significantly lower, this parameter may serve as substitute for diminished regional oxygen supply.
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Affiliation(s)
- Lukas P Mileder
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Julia Buchmayer
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Nariae Baik-Schneditz
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Chad C Andersen
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, SA, Australia.,School of Medicine, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Michael J Stark
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, SA, Australia.,School of Medicine, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Gerhard Pichler
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Queensland Pediatric Sepsis Breakthrough Collaborative: Multicenter Observational Study to Evaluate the Implementation of a Pediatric Sepsis Pathway Within the Emergency Department. Crit Care Explor 2021; 3:e0573. [PMID: 34765981 PMCID: PMC8577679 DOI: 10.1097/cce.0000000000000573] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. To evaluate the implementation of a pediatric sepsis pathway in the emergency department as part of a statewide quality improvement initiative in Queensland, Australia.
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17
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de Souza DC, Gonçalves Martin J, Soares Lanziotti V, de Oliveira CF, Tonial C, de Carvalho WB, Roberto Fioretto J, Pedro Piva J, Juan Troster E, Siqueira Bossa A, Gregorini F, Ferreira J, Lubarino J, Biasi Cavalcanti A, Ribeiro Machado F. The epidemiology of sepsis in paediatric intensive care units in Brazil (the Sepsis PREvalence Assessment Database in Pediatric population, SPREAD PED): an observational study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:873-881. [PMID: 34756191 DOI: 10.1016/s2352-4642(21)00286-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Data on the prevalence and mortality of paediatric sepsis in resource-poor settings are scarce. We aimed to assess the prevalence and in-hospital mortality of severe sepsis and septic shock treated in paediatric intensive care units (PICUs) in Brazil, and risk factors for mortality. METHODS We performed a nationwide, 1-day, prospective point prevalence study with follow-up of patients with severe sepsis and septic shock, using a stratified random sample of all PICUs in Brazil. Patients were enrolled at each participating PICU on a single day between March 25 and 29, 2019. All patients occupying a bed at the PICU on the study day (either admitted previously or on that day) were included if they were aged 28 days to 18 years and met the criteria for severe sepsis or septic shock at any time during hospitalisation. Patients were followed up until hospital discharge or death, censored at 60 days. Risk factors for mortality were assessed using a Poisson regression model. We used prevalence to generate national estimates. FINDINGS Of 241 PICUs invited to participate, 144 PICUs (capacity of 1242 beds) included patients in the study. On the day of the study, 1122 children were admitted to the participating PICUs, of whom 280 met the criteria for severe sepsis or septic shock during hospitalisation, resulting in a prevalence of 25·0% (95% CI 21·6-28·8), with a mortality rate of 19·8% (15·4-25·2; 50 of 252 patients with complete clinical data). Increased risk of mortality was associated with higher Pediatric Sequential Organ Failure Assessment score (relative risk per point increase 1·21, 95% CI 1·14-1·29, p<0·0001), unknown vaccination status (2·57, 1·26-5·24; p=0·011), incomplete vaccination status (2·16, 1·19-3·92; p=0·012), health care-associated infection (2·12, 1·23-3·64, p=0·0073), and compliance with antibiotics (2·38, 1·46-3·86, p=0·0007). The estimated incidence of PICU-treated sepsis was 74·6 cases per 100 000 paediatric population (95% CI 61·5-90·5), which translates to 42 374 cases per year (34 940-51 443) in Brazil, with an estimated mortality of 8305 (6848-10 083). INTERPRETATION In this representative sample of PICUs in a middle-income country, the prevalences of severe sepsis or septic shock and in-hospital mortality were high. Modifiable factors, such as incomplete vaccination and health care-associated infections, were associated with greater risk of in-hospital mortality. FUNDING Fundação de Amparo à Pesquisa do Estado de São Paulo and Conselho Nacional de Desenvolvimento Científico e Tecnológico. TRANSLATION For the Portuguese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Daniela Carla de Souza
- Instituto Latino Americano de Sepsis, São Paulo, Brazil; Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil.
| | - Joelma Gonçalves Martin
- Department of Pediatrics, Medical School of Universidade Estadual Paulista-UNESP, Botucatu, Brazil
| | - Vanessa Soares Lanziotti
- Pediatric Intensive Care Unit & Research and Education Division/Maternal and Child Health Postgraduate Program, Universidade Federal do Rio de Janeiro, Rio de Janiero, Brazil
| | | | - Cristian Tonial
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Intensive Care/Neonatology of the Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Roberto Fioretto
- Department of Pediatrics, Medical School of Universidade Estadual Paulista-UNESP, Botucatu, Brazil
| | - Jefferson Pedro Piva
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Eduardo Juan Troster
- Medical School of Faculdade Israelita Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | - Flávia Ribeiro Machado
- Instituto Latino Americano de Sepsis, São Paulo, Brazil; Anesthesiology, Pain and Intensive Care Department, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, Brazil
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18
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Lee EP, Wu HP, Chan OW, Lin JJ, Hsia SH. Hemodynamic monitoring and management of pediatric septic shock. Biomed J 2021; 45:63-73. [PMID: 34653683 PMCID: PMC9133259 DOI: 10.1016/j.bj.2021.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/03/2021] [Accepted: 10/06/2021] [Indexed: 12/14/2022] Open
Abstract
Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with “usual care”. Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, China Medical University Children Hospital, Taichung, Taiwan; Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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19
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Peters MJ. Fluid resuscitation in diabetic ketoacidosis and the BPSED guidelines: what we still don't know. Arch Dis Child Educ Pract Ed 2021; 106:223-225. [PMID: 33741655 DOI: 10.1136/archdischild-2020-320078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/20/2020] [Accepted: 02/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Mark J Peters
- Great Ormond Street Institute of Child Health, UCL, London, UK .,PICU, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
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20
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Souza DCD, Oliveira CFD, Lanziotti VS. Pediatric sepsis research in low- and middle-income countries: overcoming challenges. Rev Bras Ter Intensiva 2021; 33:341-345. [PMID: 35107544 PMCID: PMC8555391 DOI: 10.5935/0103-507x.20210062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 12/17/2022] Open
Affiliation(s)
- Daniela Carla de Souza
- Unidade de Terapia Intensiva Pediátrica, Hospital Universitário, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Vanessa Soares Lanziotti
- Unidade de Terapia Intensiva Pediátrica, Divisão de Pesquisa e Ensino, Programa de Pós-Graduação em Saúde Materno-Infantil, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
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21
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Sankar JM, Das RR, Kumar UV. Comparison of Intermittent versus Continuous Superior Venal Caval Oxygen Saturation Monitoring in Early Goal Directed Therapy in Septic Shock: A Systematic Review. J Pediatr Intensive Care 2021; 11:267-274. [DOI: 10.1055/s-0041-1729742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/20/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractEarly goal directed therapy (EGDT) is a bundle of care (monitoring ScvO2 and lactate along with clinical parameters and instituting therapy) that has shown to improve outcomes in patients with septic shock. We conducted a systematic review of clinical trials and observational studies to compare intermittent versus continuous monitoring of ScvO2. We did major database searches till August 2020. Hospitalized children (>2 months age) and adults with septic shock were included. The intervention was “intermittent ScvO2 monitoring,” and the comparator was “continuous ScvO2 monitoring.” The primary outcome is “all-cause mortality.” Of 564 citations, 3 studies (n = 541) including both children and adults were included in the analysis. There was no significant difference in the “overall/all-cause mortality” (two randomized controlled trials; 258 participants) between the “intermittent” and “continuous” ScvO2 monitoring groups (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.8–1.24). However, a single observational study (283 participants) showed a significant increase in mortality in the intermittent group (RR: 1.46; 95% CI: 1.03–2.05). The GRADE evidence generated for “overall/all-cause mortality” was of “moderate certainty.” To conclude, the present meta-analysis did not find any significant difference between “intermittent” and “continuous” ScvO2 monitoring in patients with septic shock.
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Affiliation(s)
- Jhuma Mondal Sankar
- Department of Pediatrics, All India Institute of Medical Sciences New Delhi, New Delhi, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, India
| | - Udhaya Vijaya Kumar
- Department of Pediatrics, All India Institute of Medical Sciences New Delhi, New Delhi, India
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22
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Jain P, Rameshkumar R, Satheesh P, Mahadevan S. Early Goal-Directed Therapy With and Without Intermittent Superior Vena Cava Oxygen Saturation Monitoring in Pediatric Septic Shock: A Randomized Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2392-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
OBJECTIVES To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity. DESIGN Retrospective multicenter cohort study. SETTING Eighty-three centers in the Virtual Pediatric Systems database. PATIENTS Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001). CONCLUSIONS Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume.
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Horvat CM, Simon DW, Aldewereld Z, Evans I, Aneja R, Carcillo JA. Merging Pediatric Index of Mortality (a physiologic instability measure), lactate, and Systemic Inflammation Mortality Risk to better predict outcome in pediatric sepsis. J Pediatr (Rio J) 2021; 97:256-259. [PMID: 33242412 PMCID: PMC9432282 DOI: 10.1016/j.jped.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Christopher M Horvat
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Dennis W Simon
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Zachary Aldewereld
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Idris Evans
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Rajesh Aneja
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA.
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25
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Tonial CT, Costa CAD, Andrades GRH, Crestani F, Bruno F, Piva JP, Garcia PCR. Performance of prognostic markers in pediatric sepsis. J Pediatr (Rio J) 2021; 97:287-294. [PMID: 32991837 PMCID: PMC9432292 DOI: 10.1016/j.jped.2020.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate the prognostic performance of the Pediatric Index of Mortality 2 (PIM2), ferritin, lactate, C-reactive protein (CRP), and leukocytes, alone and in combination, in pediatric patients with sepsis admitted to the pediatric intensive care unit (PICU). METHODS A retrospective study was conducted in a PICU in Brazil. All patients aged 6 months to 18 years admitted with a diagnosis of sepsis were eligible for inclusion. Those with ferritin and C-reactive protein measured within 48h and lactate and leukocytes within 24h of admission were included in the prognostic performance analysis. RESULTS Of 350 eligible patients with sepsis, 294 had undergone all measurements required for analysis and were included in the study. PIM2, ferritin, lactate, and CRP had good discriminatory power for mortality, with PIM2 and ferritin being superior to CRP. The cutoff values for PIM2 (> 14%), ferritin (> 135ng/mL), lactate (> 1.7mmol/L), and CRP (> 6.7mg/mL) were associated with mortality. The combination of ferritin, lactate, and CRP had a positive predictive value of 43% for mortality, similar to that of PIM2 alone (38.6%). The combined use of the three biomarkers plus PIM2 increased the positive predictive value to 76% and accuracy to 0.945. CONCLUSIONS PIM2, ferritin, lactate, and CRP alone showed good prognostic performance for mortality in pediatric patients older than 6 months with sepsis. When combined, they were able to predict death in three-fourths of the patients with sepsis. Total leukocyte count was not useful as a prognostic marker.
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Affiliation(s)
- Cristian Tedesco Tonial
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Medicina Intensiva Pediátrica, Departamento de Pediatria, Porto Alegre, RS, Brazil.
| | - Caroline Abud Drumond Costa
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Medicina Intensiva Pediátrica, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Gabriela Rupp Hanzen Andrades
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Medicina Intensiva Pediátrica, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Francielly Crestani
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Medicina Intensiva Pediátrica, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Francisco Bruno
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Medicina Intensiva Pediátrica, Departamento de Pediatria, Porto Alegre, RS, Brazil
| | - Jefferson Pedro Piva
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Pedro Celiny Ramos Garcia
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Medicina Intensiva Pediátrica, Departamento de Pediatria, Porto Alegre, RS, Brazil
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Fitzgerald JC, Ross ME, Thomas NJ, Weiss SL, Balamuth F, Chilutti M, Grundmeier RW, Anderson AH. Association of early hypotension in pediatric sepsis with development of new or persistent acute kidney injury. Pediatr Nephrol 2021; 36:451-461. [PMID: 32710239 PMCID: PMC7856266 DOI: 10.1007/s00467-020-04704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine how hypotension in the first 48 h of sepsis management impacts acute kidney injury (AKI) development and persistence. STUDY DESIGN Retrospective study of patients > 1 month to < 20 years old with sepsis in a pediatric ICU between November 2012 and January 2015 (n = 217). All systolic blood pressure (SBP) data documented within 48 h after sepsis recognition were collected and converted to percentiles for age, sex, and height. Time below SBP percentiles and below pediatric advanced life support (PALS) targets was calculated by summing elapsed time under SBP thresholds during the first 48 h. The primary outcome was new or persistent AKI, defined as stage 2 or 3 AKI present between sepsis day 3-7 using Kidney Disease: Improving Global Outcomes creatinine definitions. Secondary outcomes included AKI-free days (days alive and free of AKI) and time to kidney recovery. RESULTS Fifty of 217 sepsis patients (23%) had new or persistent AKI. Patients with AKI spent a median of 35 min under the first SBP percentile, versus 4 min in those without AKI. After adjustment for potential confounders, the odds of AKI increased by 9% with each doubling of minutes spent under this threshold (p = 0.03). Time under the first SBP percentile was also associated with fewer AKI-free days (p = 0.02). Time spent under PALS targets was not associated with AKI. CONCLUSIONS The duration of severe systolic hypotension in the first 48 h of pediatric sepsis management is associated with AKI incidence and duration when defined by age, sex, and height norms, but not by PALS definitions. Graphical abstract.
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Affiliation(s)
- Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., 6th Floor Wood Building, Room 6117, Philadelphia, PA, 19104, USA.
| | - Michelle E Ross
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA, USA
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., 6th Floor Wood Building, Room 6117, Philadelphia, PA, 19104, USA
| | - Fran Balamuth
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marianne Chilutti
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert W Grundmeier
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amanda Hyre Anderson
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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Hegamyer E, Smith N, Thompson AD, Depiero AD. Treatment of suspected sepsis and septic shock in children with chronic disease seen in the pediatric emergency department. Am J Emerg Med 2021; 44:56-61. [PMID: 33581601 DOI: 10.1016/j.ajem.2021.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Research demonstrates that timely recognition and treatment of sepsis can significantly improve pediatric patient outcomes, especially regarding time to intravenous fluid (IVF) and antibiotic administration. Further research suggests that underlying chronic disease in a septic pediatric patient puts them at higher risk for poor outcomes. OBJECTIVE To compare treatment time for suspected sepsis and septic shock in pediatric patients with chronic disease versus those without chronic disease seen in the Pediatric Emergency Department (PED). METHODS We reviewed patient data from a pediatric sepsis outcomes dataset collected at two tertiary care pediatric hospital sites from January 2017-December 2018. Patients were stratified into two groups: those with and without chronic disease, defined as any patient with at least one of eight chronic health conditions. INCLUSION CRITERIA patients seen in the PED ultimately diagnosed with sepsis or septic shock, patient age 0 to 20 years and time zero for identification of sepsis in the PED. EXCLUSION CRITERIA time zero unavailable, inability to determine time of first IVF or antibiotic administration or patient death within the PED. Primary analysis included comparison of time zero to first IVF and antibiotic administration between each group. RESULTS 312 patients met inclusion criteria. 169 individuals had chronic disease and 143 did not. Median time to antibiotics in those with chronic disease was 41.9 min versus 43.0 min in patients without chronic disease (p = 0.181). Time to first IVF in those with chronic disease was 22.0 min versus 12.0 min in those without (p = 0.010). Those with an indwelling line/catheter (n = 40) received IVF slower than those without (n = 272), with no significant difference in time to antibiotic administration by indwelling catheter status (p = 0.063). There were no significant differences in the mode of identification of suspected sepsis or septic shock between those with versus without chronic disease (p = 0.27). CONCLUSIONS Study findings suggest pediatric patients with chronic disease with suspected sepsis or septic shock in the PED have a slower time to IVF administration but equivocal use of sepsis recognition tools compared to patients without chronic disease.
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Affiliation(s)
- Emily Hegamyer
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Nadine Smith
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Amy D Thompson
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Andrew D Depiero
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
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Medeiros DNM, Shibata AO, Pizarro CF, Rosa MDLA, Cardoso MP, Troster EJ. Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols. Front Pediatr 2021; 9:755484. [PMID: 34858905 PMCID: PMC8631453 DOI: 10.3389/fped.2021.755484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/23/2022] Open
Abstract
The implementation of managed protocols contributes to a systematized approach to the patient and continuous evaluation of results, focusing on improving clinical practice, early diagnosis, treatment, and outcomes. Advantages to the adoption of a pediatric sepsis recognition and treatment protocol include: a reduction in time to start fluid and antibiotic administration, decreased kidney dysfunction and organ dysfunction, reduction in length of stay, and even a decrease on mortality. Barriers are: absence of a written protocol, parental knowledge, early diagnosis by healthcare professionals, venous access, availability of antimicrobials and vasoactive drugs, conditions of work, engagement of healthcare professionals. There are challenges in low-middle-income countries (LMIC). The causes of sepsis and resources differ from high-income countries. Viral agent such as dengue, malaria are common in LMIC and initial approach differ from bacterial infections. Some authors found increased or no impact in mortality or increased length of stay associated with the implementation of the SCC sepsis bundle which reinforces the importance of adapting it to most frequent diseases, disposable resources, and characteristics of healthcare professionals. Conclusions: (1) be simple; (2) be precise; (3) education; (5) improve communication; (5) work as a team; (6) share and celebrate results.
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Affiliation(s)
| | - Audrey Ogawa Shibata
- Pediatric Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Marta Pessoa Cardoso
- Pediatric Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Juan Troster
- Faculdade Israelita de Ciências em Saúde, Hospital Albert Einstein, São Paulo, Brazil
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Fremuth J, Kobr J, Sasek L, Pizingerova K, Zamboryova J, Sykora J. Ultrasound cardiac output monitoring in mechanically ventilated children. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:428-434. [PMID: 33087939 DOI: 10.5507/bp.2020.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To non-invasively identify the hemodynamic changes in critically ill children during the first 48 h following initiation of mechanical ventilation by the ultrasound cardiac output monitor (USCOM) method and compare the data in children with pulmonary and non-pulmonary pathology. MATERIALS AND METHODS This was a prospective observational study to evaluate the influence of mechanical ventilation on hemodynamic changes and to describe hemodynamic profiles of mechanically ventilated children. A total of 56 children with respiratory failure were included in the present study. Ventilated patients are divided into two groups. Group A (n=36) includes patients with pulmonary pathology. Group B (n=20) consists of patients with extra pulmonary etiology of respiratory failure. Hemodynamic parameters (cardiac index and systemic vascular resistance index) were evaluated using ultrasound cardiac output monitoring (USCOM 1A) immediately following initiation of mechanical ventilation and again at 6, 12, and 48 h. Pharmacological circulatory support (inotropes, vasopressors, levosimendan and phosphodiesterase III inhibitors) was individually and continuously modified based on real-time hemodynamic parameters and optimal fluid balance. RESULTS No significant differences in hemodynamic profiles were found between Group A and Group B. CONCLUSION The protective strategy of mechanical ventilation was not associated with significant differences in hemodynamic profiles between children ventilated for pulmonary and non-pulmonary pathologies. CLINICAL SIGNIFICANCE Hemodynamically unstable children ventilated for pulmonary pathology with the protective strategy of mechanical ventilation had a greater requirement for inotropic and combined inotropic and vasoactive circulatory support than children ventilated for non-pulmonary causes of respiratory failure.
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Affiliation(s)
- Jiri Fremuth
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Jiri Kobr
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Lumir Sasek
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Katerina Pizingerova
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Jana Zamboryova
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Josef Sykora
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
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Singh Y, Villaescusa JU, da Cruz EM, Tibby SM, Bottari G, Saxena R, Guillén M, Herce JL, Di Nardo M, Cecchetti C, Brierley J, de Boode W, Lemson J. Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:620. [PMID: 33092621 PMCID: PMC7579971 DOI: 10.1186/s13054-020-03326-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. METHODS Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature-a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. RESULTS Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached "strong agreement," 20 "weak agreement," and 2 had "no agreement." Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. CONCLUSIONS These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Javier Urbano Villaescusa
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Eduardo M da Cruz
- Department of Pediatrics, Children's Hospital Colorado, Section of Cardiac Intensive Care, The Heart Institute, Pittsburgh, USA
| | - Shane M Tibby
- Department of Pediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Gabriella Bottari
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Rohit Saxena
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Marga Guillén
- Department of Pediatric Intensive Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jesus Lopez Herce
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Matteo Di Nardo
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Joe Brierley
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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The authors reply. Pediatr Crit Care Med 2020; 21:931-932. [PMID: 33009319 PMCID: PMC9757102 DOI: 10.1097/pcc.0000000000002532] [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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Bline KE, Moore-Clingenpeel M, Hensley J, Steele L, Greathouse K, Anglim L, Hanson-Huber L, Nateri J, Muszynski JA, Ramilo O, Hall MW. Hydrocortisone treatment is associated with a longer duration of MODS in pediatric patients with severe sepsis and immunoparalysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:545. [PMID: 32887651 PMCID: PMC7650515 DOI: 10.1186/s13054-020-03266-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022]
Abstract
Background Severe critical illness-induced immune suppression, termed immunoparalysis, is associated with longer duration of organ dysfunction in septic children. mRNA studies have suggested differential benefit of hydrocortisone in septic children based on their immune phenotype, but this has not been shown using a functional readout of the immune response. This study represents a secondary analysis of a prospectively conducted immunophenotyping study of pediatric severe sepsis to test the hypothesis that hydrocortisone will be differentially associated with clinical outcomes in children with or without immunoparalysis. Methods Children with severe sepsis/septic shock underwent blood sampling within 48 h of sepsis onset. Immune function was measured by quantifying whole blood ex vivo LPS-induced TNFα production capacity, with a TNFα response < 200 pg/ml being diagnostic of immunoparalysis. The primary outcome measure was number of days in 14 with MODS. Univariate and multivariable negative binomial regression models were used to examine associations between hydrocortisone use, immune function, and duration of MODS. Results One hundred two children were enrolled (age 75 [6–160] months, 60% male). Thirty-one subjects received hydrocortisone and were more likely to be older (106 [52–184] vs 38 [3–153] months, p = 0.04), to have baseline immunocompromise (32 vs 8%, p = 0.006), to have higher PRISM III (13 [8–18] vs 7 [5–13], p = 0.0003) and vasoactive inotrope scores (20 [10–35] vs 10 [3–15], p = 0.0002) scores, and to have more MODS days (3 [1–9] vs 1 [0–3], p = 0.002). Thirty-three subjects had immunoparalysis (TNFα response 78 [52–141] vs 641 [418–1047] pg/ml, p < 0.0001). Hydrocortisone use was associated with longer duration of MODS in children with immunoparalysis after adjusting for covariables (aRR 3.7 [1.8–7.9], p = 0.0006) whereas no association with MODS duration was seen in children without immunoparalysis (aRR 1.2 [0.6–2.3], p = 0.67). Conclusion Hydrocortisone use was independently associated with longer duration of MODS in septic children with immunoparalysis but not in those with more robust immune function. Prospective clinical trials using a priori immunophenotyping are needed to understand optimal hydrocortisone strategies in this population.
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Affiliation(s)
- Katherine E Bline
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Melissa Moore-Clingenpeel
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH, USA
| | - Josey Hensley
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Lisa Steele
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kristin Greathouse
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Larissa Anglim
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Lisa Hanson-Huber
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Jyotsna Nateri
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer A Muszynski
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Octavio Ramilo
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark W Hall
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
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Shock Severity Modifies Associations Between RBC Transfusion in the First 48 Hours of Sepsis Onset and the Duration of Organ Dysfunction in Critically Ill Septic Children. Pediatr Crit Care Med 2020; 21:e475-e484. [PMID: 32195902 DOI: 10.1097/pcc.0000000000002338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To test the hypothesis that early RBC transfusion is associated with duration of organ dysfunction in critically ill septic children. DESIGN Secondary analysis of a single-center prospective observational study. Multivariable negative binomial regression was used to determine relationships between RBC transfusion within 48 hours of sepsis onset and number of days in 14 with organ dysfunction, or with multiple organ dysfunction syndrome. SETTING A PICU at a quaternary care children's hospital. PATIENTS Children less than 18 years old with severe sepsis/septic shock by consensus criteria were included. Patients with RBC transfusion prior to sepsis onset and those on extracorporeal membrane oxygenation support within 48 hours of sepsis onset were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ninety-four patients were included. Median age was 6 years (0-13 yr); 61% were male. Seventy-eight percentage had septic shock, and 41 (44%) were transfused RBC within 48 hours of sepsis onset (early RBC transfusion). On multivariable analyses, early RBC transfusion was independently associated with 44% greater organ dysfunction days (adjusted relative risk, 1.44 [1.04-2.]; p = 0.03), although risk differed by severity of illness (interaction p = 0.004) and by shock severity (interaction p = 0.04 for Vasoactive Inotrope Score and 0.03 for shock index). Relative risks for multiple organ dysfunction syndrome days varied by shock severity (interaction p = 0.008 for Vasoactive Inotrope Score and 0.01 for shock index). Risks associated with early RBC transfusion were highest for the children with the lowest shock severities. CONCLUSIONS In agreement with previous studies, early RBC transfusion was independently associated with longer duration of organ dysfunction. Ours is among the first studies to document different transfusion-associated risks based on clinically available measures of shock severity, demonstrating greater transfusion-associated risks in children with less severe shock. Larger multicenter studies to verify these interaction effects are essential to plan much-needed RBC transfusion trials for critically ill septic children.
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McBride MA, Owen AM, Stothers CL, Hernandez A, Luan L, Burelbach KR, Patil TK, Bohannon JK, Sherwood ER, Patil NK. The Metabolic Basis of Immune Dysfunction Following Sepsis and Trauma. Front Immunol 2020; 11:1043. [PMID: 32547553 PMCID: PMC7273750 DOI: 10.3389/fimmu.2020.01043] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Critically ill, severely injured and high-risk surgical patients are vulnerable to secondary infections during hospitalization and after hospital discharge. Studies show that the mitochondrial function and oxidative metabolism of monocytes and macrophages are impaired during sepsis. Alternatively, treatment with microbe-derived ligands, such as monophosphoryl lipid A (MPLA), peptidoglycan, or β-glucan, that interact with toll-like receptors and other pattern recognition receptors on leukocytes induces a state of innate immune memory that confers broad-spectrum resistance to infection with common hospital-acquired pathogens. Priming of macrophages with MPLA, CPG oligodeoxynucleotides (CpG ODN), or β-glucan induces a macrophage metabolic phenotype characterized by mitochondrial biogenesis and increased oxidative metabolism in parallel with increased glycolysis, cell size and granularity, augmented phagocytosis, heightened respiratory burst functions, and more effective killing of microbes. The mitochondrion is a bioenergetic organelle that not only contributes to energy supply, biosynthesis, and cellular redox functions but serves as a platform for regulating innate immunological functions such as production of reactive oxygen species (ROS) and regulatory intermediates. This review will define current knowledge of leukocyte metabolic dysfunction during and after sepsis and trauma. We will further discuss therapeutic strategies that target leukocyte mitochondrial function and might have value in preventing or reversing sepsis- and trauma-induced immune dysfunction.
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Affiliation(s)
- Margaret A. McBride
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Allison M. Owen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Cody L. Stothers
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Liming Luan
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Katherine R. Burelbach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Tazeen K. Patil
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Julia K. Bohannon
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Edward R. Sherwood
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Naeem K. Patil
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
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Zheng ML, He SR, Liu YM, Chen L. Measurement of inotropy and systemic oxygen delivery in term, low- and very-low-birth-weight neonates using the Ultrasonic Cardiac Output Monitor (USCOM). J Perinat Med 2020; 48:289-295. [PMID: 32083449 DOI: 10.1515/jpm-2019-0301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/12/2020] [Indexed: 12/17/2022]
Abstract
Background The aim of this study was to assess the normal values of the Smith-Madigan inotropy index (SMII) and oxygen delivery index (DO2I) in low-birth-weight (LBW) and very-low-birth-weight (VLBW) newborns on the first 3 days of life, and to identify how different degrees of maturity influence cardiovascular alterations during the transitional period compared with term neonates. Methods Twenty-eight VLBW newborns, 46 LBW newborns and 50 normal full-term newborns admitted to our department were studied. Hemodynamics of the left heart were measured in all neonates over the first 3 days using the Ultrasonic Cardiac Output Monitor (USCOM). This was combined with hemoglobin concentration and pulse oximetry to calculate DO2I. Blood pressure was combined with the hemodynamic measures and hemoglobin concentration to calculate SMII. Results SMII showed statistically significant differences among the three groups (VLBW 0.48 ± 0.11; LBW 0.54 ± 0.13; term 0.69 ± 0.17 W/m2 P < 0.001), which was in line with the following myocardial parameters: stroke volume index (SVI) and cardiac index (CI) (P < 0.001 and <0.001). For systemic oxygen delivery (DO2) parameters, significant differences were found for DO2I (P < 0.001) while hemoglobin concentration and pulse oximetry demonstrated no significant differences. In the VLBW group, SMII and DO2I showed no significant change over the 3 days. Conclusion Normal inotropy and systemic DO2I values in VLBW neonates over the first 3 days of life were assessed. SMII and DO2I were significantly lower in VLBW neonates during the first 72 h of life. With increasing birth weight, higher myocardial inotropy and DO2 were found. The addition of USCOM examination to standard neonatal echocardiography may provide further important information regarding cardiac function.
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Affiliation(s)
- Man-Li Zheng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, P.R. China
- Department of Pediatrics, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, P.R. China
| | - Shao-Ru He
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, P.R. China
- Department of Pediatrics, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, P.R. China
| | - Yu-Mei Liu
- Department of Pediatrics, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, P.R. China
| | - Lin Chen
- Department of Pediatrics, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou, P.R. China
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Garcia PCR, Tonial CT, Piva JP. Septic shock in pediatrics: the state‐of‐the‐art. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Garcia PCR, Tonial CT, Piva JP. Septic shock in pediatrics: the state-of-the-art. J Pediatr (Rio J) 2020; 96 Suppl 1:87-98. [PMID: 31843507 PMCID: PMC9432279 DOI: 10.1016/j.jped.2019.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. SOURCE OF DATA A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. SYNTHESIS OF DATA Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. CONCLUSIONS The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.
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Affiliation(s)
- Pedro Celiny Ramos Garcia
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Terapia Intensiva Pediátrica, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Cristian Tedesco Tonial
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Terapia Intensiva Pediátrica, Departamento de Pediatria, Porto Alegre, RS, Brazil.
| | - Jefferson Pedro Piva
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, Departamento de Emergência e Cuidados Intensivos Pediátricos, Porto Alegre, RS, Brazil
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Sometimes more is not always better: ScvO 2 monitoring in pediatric sepsis. Intensive Care Med 2020; 46:1264-1266. [PMID: 32047943 DOI: 10.1007/s00134-020-05946-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 01/21/2020] [Indexed: 10/25/2022]
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Donnelly P, Fine-Goulden MR. How to use near-infrared spectroscopy. Arch Dis Child Educ Pract Ed 2020; 105:58-63. [PMID: 31186270 DOI: 10.1136/archdischild-2018-315532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Peter Donnelly
- Paediatric Intensive Care Unit, Belfast Children's Hospital, Belfast, UK
| | - Miriam R Fine-Goulden
- Paediatric Intensive Care, Evelina Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 275] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 478] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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Sepsis in Complex Patients in the Emergency Department: Time to Recognition and Therapy in Pediatric Patients With High-Risk Conditions. Pediatr Emerg Care 2020; 36:63-65. [PMID: 31929394 DOI: 10.1097/pec.0000000000002038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare timeliness of sepsis recognition and initial treatment in patients with and without high-risk comorbid conditions. METHODS This was a retrospective cohort study of patients presenting to a pediatric emergency department (ED) who triggered a vital sign-based electronic sepsis alert resulting in bedside "huddle" assessment per institutional practice. A positive sepsis alert was defined as age-specific tachycardia or hypotension, concern for infection, and at least 1 of the following: abnormal capillary refill, abnormal mental status, or a high-risk condition. High-risk conditions were derived from the American Academy of Pediatrics sepsis alert tool. Patients with a positive alert underwent bedside huddle resulting in a decision regarding initiation of sepsis protocol. Placement on the protocol and time to initiation of protocol and individual therapies were compared for patients with and without high-risk conditions. RESULTS During the 1-year study period, there were 1107 sepsis huddle alerts out of 96,427 ED visits. Of these, 713 (65%) had identified high-risk conditions, and 394 (35%) did not. Among patients with sepsis huddles, there was no difference in sepsis protocol initiation for patients with high-risk conditions compared with those without (24.8% vs 22.0%, P = 0.305). Between patients with high-risk conditions and those without, there were no differences in median time from triage to sepsis protocol activation, triage to initial intravenous antibiotic, triage to initial intravenous fluid therapy, or ED length of stay. CONCLUSIONS Timeliness of care initiation was no different in high-risk patients with sepsis when using an electronic sepsis alert and protocolized sepsis care.
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'Intermittent' versus 'continuous' ScvO 2 monitoring in children with septic shock: a randomised, non-inferiority trial. Intensive Care Med 2019; 46:82-92. [PMID: 31781836 DOI: 10.1007/s00134-019-05858-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/07/2019] [Indexed: 01/20/2023]
Abstract
PURPOSE To compare the effect of 'intermittent' central venous oxygen saturation (ScvO2) monitoring with 'continuous' ScvO2 monitoring on shock resolution and mortality in children with septic shock. METHODS Primary outcome was the achievement of therapeutic goals or shock resolution in the first 6 h. We randomly assigned children < 17 years' age with septic shock to 'intermittent ScvO2' or 'continuous ScvO2' groups. All children were subjected to subclavian/internal jugular line insertion and managed as per Surviving Sepsis Campaign Guidelines. To guide resuscitation, we used ScvO2 estimated at other clinical and laboratory parameters were monitored similarly in both groups. RESULTS We enrolled 75 and 77 children [median (IQR) age: 6 (1.5-10) years] in the 'intermittent' and 'continuous' groups, respectively. Baseline characteristics were comparable between the groups. When compared to the 'continuous' group, fewer children in the 'intermittent' group achieved shock resolution within first 6 h [19% vs. 36%; relative risk (RR) 0.51; 95% CI 0.29-0.89; risk difference - 18.0%; 95% CI - 32.0 to - 4.0]. The lower bound of confidence interval, however, crossed the pre-specified non-inferiority margin. There was no difference in the proportion of children attaining shock resolution within 24 h (63% vs. 69%; RR 0.86; 95% CI 0.68-1.08) or risk of mortality between the groups (47% vs. 43%; RR 1.06; 95% CI 0.74-1.51). CONCLUSIONS Given that a greater proportion of children attained therapeutic end points in the first 6 h, continuous monitoring of ScvO2 should preferably be used to titrate therapy in the first few hours in children with septic shock. In the absence of such facility, intermittent monitoring of ScvO2 can be used to titrate therapy in these children, given the lack of difference in the proportion of patients achieving shock resolution at 24 h or in risk of mortality between the intermittent and continuous groups.
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Odetola FO, Gebremariam A. Resource Use and Outcomes for Children Hospitalized With Severe Sepsis or Septic Shock. J Intensive Care Med 2019; 36:89-100. [PMID: 31707898 DOI: 10.1177/0885066619885894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe patient and hospital characteristics associated with in-hospital mortality, length of stay (LOS), and charges for children with severe sepsis or septic shock who often require specialized organ-supportive technology to enhance outcomes, availability of which might vary across hospitals. DESIGN Retrospective study among children hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. Multivariate regression methods identified factors associated with mortality, LOS, and charges. MEASUREMENTS AND MAIN RESULTS Of an estimated 11 972 hospitalizations for pediatric severe sepsis or septic shock, most hospitalizations (85%) were to urban teaching hospitals. Hospitalizations were more frequent among neonates and older adolescents than other age groups. Mortality was 17%, average LOS was 24 days, and average hospital charges were US$314 950. Higher mortality was associated with neonates, cumulative organ dysfunction, more comorbidities, and cardiopulmonary resuscitation. Longer hospitalization and higher charges were associated with neonates, more comorbidities, higher illness severity, invasive medical technology, and urban hospitals. CONCLUSIONS Efforts to mitigate the substantial in-hospital mortality and resource use observed in pediatric severe sepsis or septic shock should be age-specific and focused on the influence of comorbidities and organ dysfunction on outcomes. Future research should elucidate reasons for higher resource use at urban hospitals.
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Affiliation(s)
- Folafoluwa O Odetola
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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Weiss SL, Nicolson SC, Naim MY. Clinical Update in Pediatric Sepsis: Focus on Children With Pre-Existing Heart Disease. J Cardiothorac Vasc Anesth 2019; 34:1324-1332. [PMID: 31734080 DOI: 10.1053/j.jvca.2019.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 11/11/2022]
Abstract
SEPSIS REMAINS one of the most common causes of childhood morbidity, mortality, and higher healthcare costs, with over 75,000 hospital admissions in the United States and an estimated 4 million cases worldwide per year. While standardized criteria to define sepsis are in flux, the general concept of sepsis is a severe infection that results in organ dysfunction. Although sepsis can affect previously healthy children, those with certain pre-existing comorbid conditions, including congenital and acquired heart disease, are at higher risk for both developing sepsis and having a poor outcome after sepsis. Multiple specialists including intensivists, cardiologists, surgeons, and anesthesiologists commonly contribute to the management and outcome of sepsis in children. In this article, the authors examine the evolving epidemiology of pediatric sepsis, including the subset of patients with underlying heart disease; contrast pediatric and adult sepsis; review the latest hemodynamic guidelines for management of pediatric septic shock and their application to children with heart disease; discuss the role of mechanical circulatory support; and review key aspects of anesthetic management for children with sepsis.
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Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Mitochondrial and Epigenomic Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA
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Mu TS, Becker AM, Clark AJ, Batts SG, Murata LAM, Uyehara CFT. ECMO with vasopressor use during early endotoxic shock: Can it improve circulatory support and regional microcirculatory blood flow? PLoS One 2019; 14:e0223604. [PMID: 31600278 PMCID: PMC6786553 DOI: 10.1371/journal.pone.0223604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/24/2019] [Indexed: 11/24/2022] Open
Abstract
Introduction While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs. Methods Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors. Results ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors. Conclusion ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.
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Affiliation(s)
- Thornton S. Mu
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas, United States of America
- * E-mail:
| | - Amy M. Becker
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Aaron J. Clark
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Sherreen G. Batts
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Lee-Ann M. Murata
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Catherine F. T. Uyehara
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America
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Morin L, Kneyber M, Jansen NJG, Peters MJ, Javouhey E, Nadel S, Maclaren G, Schlapbach LJ, Tissieres P. Translational gap in pediatric septic shock management: an ESPNIC perspective. Ann Intensive Care 2019; 9:73. [PMID: 31254125 PMCID: PMC6598895 DOI: 10.1186/s13613-019-0545-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 06/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations. Methods A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios. Results Among the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in < 20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specific situations, whereas the use of high-flow hemofiltration was considered for 44%. Conclusions This pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these findings outline some limitation of existing pediatric guidelines in regard to context and patient’s specificity. Electronic supplementary material The online version of this article (10.1186/s13613-019-0545-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luc Morin
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, South Paris University, Le Kremlin-Bicêtre, France
| | - Martin Kneyber
- Pediatric Intensive Care Unit, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands.,Critical Care, Anesthesiology, Peri-operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Nicolaas J G Jansen
- Paediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark J Peters
- Pediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Lyon University Hospitals, Hospices Civils de Lyon, Bron, France
| | - Simon Nadel
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Graeme Maclaren
- Department of Pediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Luregn Jan Schlapbach
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Brisbane, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.,Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Pierre Tissieres
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, South Paris University, Le Kremlin-Bicêtre, France. .,Integrative Biology of the Cell, CNRS, CEA, Paris South University, Paris Saclay University, Gif-sur-Yvette, France.
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48
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Źródłowski TW, Jurkiewicz-Badacz D, Sroka-Oleksiak A, Salamon D, Bulanda M, Gosiewski T. Comparison of PCR, Fluorescent in Situ Hybridization and Blood Cultures for Detection of Bacteremia in Children and Adolescents During Antibiotic Therapy. Pol J Microbiol 2019; 67:479-486. [PMID: 30550234 PMCID: PMC7256870 DOI: 10.21307/pjm-2018-056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2018] [Indexed: 02/02/2023] Open
Abstract
The gold standard in microbiological diagnostics of bacteremia is a blood culture in automated systems. This method may take several days and has low sensitivity. New screening methods that could quickly reveal the presence of bacteria would be extremely useful. The objective of this study was to estimate the effectiveness of these methods with respect to blood cultures in the context of antibiotic therapy. Blood samples from 92 children with sepsis were analyzed. Blood cultures were carried out in standard automated systems. Subsequently, FISH (Fluorescent In-Situ Hybridization) and nested multiplex-real-time-PCR (PCR) were performed. Blood cultures, FISH and PCR yielded positive results in 18%, 39.1%, and 71.7% of samples, respectively. Significant differences were found between the results obtained through culture before and after induction of antibiotherapy: 25.5% vs. 9.7%. There was no significant difference in FISH and PCR results in relation to antibiotics. The three methods employed demonstrated significant differences in detecting bacteria effectively. Time to obtain test results for FISH and PCR averaged 4–5 hours. FISH and PCR allow to detect bacteria in blood without prior culture. These methods had high sensitivity for the detection of bacteremia regardless of antibiotherapy. They provide more timely results as compared to automated blood culture, and may be useful as rapid screening tests in sepsis.
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Affiliation(s)
- Tomasz W Źródłowski
- Thoracic Anesthesia and Respiratory Intensive Care Unit, John Paul II Hospital , Cracow , Poland
| | | | - Agnieszka Sroka-Oleksiak
- Chair of Microbiology, Department of Molecular Medical Microbiology, Faculty of Medicine, Jagiellonian University Medical College , Cracow , Poland.,Department of Mycology, Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College , Czysta 18; 31-121 Krakow , Poland
| | - Dominika Salamon
- Chair of Microbiology, Department of Molecular Medical Microbiology, Faculty of Medicine, Jagiellonian University Medical College , Cracow , Poland
| | - Małgorzata Bulanda
- Chair of Microbiology, Department of Epidemiology of Infection, Faculty of Medicine, Jagiellonian University Medical College , Cracow , Poland
| | - Tomasz Gosiewski
- Chair of Microbiology, Department of Molecular Medical Microbiology, Faculty of Medicine, Jagiellonian University Medical College , Cracow , Poland
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49
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Morin L, Pierre A, Tissieres P, Miatello J, Durand P. Actualités sur le sepsis et le choc septique de l’enfant. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’incidence du sepsis de l’enfant augmente en réanimation pédiatrique. La définition du sepsis et du choc septique de l’enfant est amenée à évoluer à l’instar de celle du choc septique de l’adulte pour détecter les patients nécessitant une prise en charge urgente et spécialisée. La prise en charge d’un patient septique repose sur une oxygénothérapie, une expansion volémique au sérum salé isotonique, une antibiothérapie et un transfert dans un service de réanimation ou de surveillance continue pédiatrique. Le taux et la cinétique d’élimination du lactate plasmatique est un bon critère diagnostic et pronostic qui permet de guider la prise en charge. La présence de plusieurs défaillances d’organes ou une défaillance circulatoire aiguë signe le diagnostic de sepsis encore dit sévère, et leur persistance et/ou la non-correction de l’hypotension artérielle malgré un remplissage vasculaire d’au moins 40 ml/kg définit le choc septique chez l’enfant. Dans ce cas, la correction rapide de l’hypotension artérielle persistante repose sur la noradrénaline initiée sur une voie intraveineuse périphérique dans l’attente d’un accès veineux central. L’échographie cardiaque est un examen clé de l’évaluation hémodynamique du patient, pour guider la poursuite de l’expansion volémique ou détecter une cardiomyopathie septique. Des thérapeutiques additionnelles ont été proposées pour prendre en charge certains patients avec des défaillances d’organes particulières. L’immunomonitorage et la modulation sont un ensemble de techniques qui permettent la recherche et le traitement de certaines complications. La Surviving Sepsis Campaign a permis d’améliorer la prise en charge de ces patients par l’implémentation d’algorithmes de détection et de prise en charge du sepsis de l’enfant. Une révision pédiatrique de cette campagne est attendue prochainement.
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50
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Skowno JJ. Hemodynamic monitoring in children with heart disease: Overview of newer technologies. Paediatr Anaesth 2019; 29:467-474. [PMID: 30667124 DOI: 10.1111/pan.13590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/26/2018] [Accepted: 01/14/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Justin J Skowno
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
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