American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

Case Report: Clinical management of a severe DBA patient with a novel RPS19 mutation

Diamond-Blackfan anemia (DBA) is a rare congenital bone marrow failure disorder characterized by defective erythropoiesis, typically caused by mutations in ribosomal protein (RP) genes, most commonly RPS19. It usually presents in early infancy with severe anemia, growth retardation, and an increased risk of congenital malformations and malignancies. However, cases of DBA leading to severe anemia and shock are exceedingly rare. This case report describes a life-threatening presentation of DBA in a 56-day-old female infant who presented with severe anemia and shock. The infant was admitted with a 2-day history of poor feeding and persistent crying, accompanied by hypothermia (34.4°C), unresponsiveness, and profound pallor. Initial laboratory findings revealed critical anemia (hemoglobin 18 g/L) and severe metabolic acidosis (pH 6.61, base excess -36.06 mmol/L). Hemodynamic instability, including undetectable blood pressure and prolonged capillary refill time, indicated shock. Immediate interventions, including volume expansion with normal saline, correction of acidosis with sodium bicarbonate, and packed red blood cells (PRBCs) transfusion, stabilized the infant. Genetic testing identified a de novo heterozygous mutation in the RPS19 gene (c.3G > T), confirming the diagnosis of DBA. Over the course of a 1-year follow-up, the infant required regular blood transfusions at approximately 4-week intervals to sustain hemoglobin levels within the range of 69-86 g/L. Growth retardation and poor appetite were observed, consistent with the known complications of DBA. This case highlights the importance of early recognition and aggressive management of severe anemia in infants, particularly in the context of DBA, to prevent life-threatening complications such as shock and metabolic acidosis. The role of genetic testing in confirming the diagnosis and guiding long-term management is emphasized. This report also reviews the literature on DBA, focusing on the pathophysiology of anemia, the association between RPS19 mutations and clinical phenotypes, and the challenges of managing transfusion-dependent patients. The findings underscore the need for a multidisciplinary approach to DBA, including regular monitoring for complications such as iron overload, growth retardation, and malignancy risk. Early genetic counseling and tailored therapeutic strategies are crucial for improving outcomes in this rare and complex disorder.

Development, Implementation, and Evaluation of an Early Sepsis Screening Tool at Triage in a Pediatric Emergency Department in Latin America

OBJECTIVE

Sepsis screening tools in Pediatric Emergency Departments (PEDs) enable timely alerts and treatment. This study aimed to develop, implement, and evaluate a sepsis screening tool applied during triage in patients with fever or hypothermia in a PED.

METHODS

The study was conducted in 3 phases (design, implementation, and evaluation) from July 1, 2023, to July 31, 2024. The screening tool included the Pediatric Assessment Triangle (PAT), parental concern, critical appearance, vital signs, mental status, skin condition, capillary refill, and risk factors, with results classified as positive or negative. Evaluation followed an observational, prospective diagnostic test design using 3 reference standards: intention-to-treat standard, Phoenix criteria, and final diagnosis at case closure. Patients aged >28 days to <18 years with fever or hypothermia were included. Results were analyzed for diagnostic accuracy (sensitivity, specificity, predictive values, and likelihood ratios). Additional analyses were performed to examine the triggers of positive alerts and causes of missed alerts.

RESULTS

During the evaluation period, 16,771 of 40,005 PED patients had fever or hypothermia. The tool was positive in 1.4% (240/16,672). These patients had significantly more triage levels I and II (99.6% vs. 4.8%), higher hospitalization rates (66% vs. 5%), pediatric intensive care unit admissions (11% vs. 0.03%), and mortality (3.8% vs. 0.01%). For sepsis at case closure, the tool showed sensitivity of 0.80, specificity of 0.99, positive predictive value of 0.33, negative predictive value of 1, positive likelihood ratio of 84, and negative likelihood ratio of 0.20. Circulatory alteration in the PAT [odds ratio (OR): 2.8], abnormal capillary refill (OR: 1.9), and critical risk factors (OR: 2.1) independently increased the risk of sepsis.

CONCLUSIONS

The sepsis screening tool evaluated demonstrated good performance in detecting sepsis in the PED. Circulatory alteration in the PAT, abnormal capillary refill, and presence of a critical risk factor were key sepsis predictors.

Epinephrine vs Norepinephrine as Initial Treatment in Children With Septic Shock

Importance

There is no consensus and wide practice variation in the choice of initial vasoactive agent in children with septic shock.

Objective

To determine whether receipt of epinephrine compared with norepinephrine as the first vasoactive medication administered is associated with improved outcomes among children with septic shock without known cardiac dysfunction.

Design, Setting, and Participants

This single-center, retrospective cohort study used propensity score matching to examine encounters in which a patient was diagnosed with septic shock and required a vasoactive infusion within 24 hours of ED arrival at a freestanding quaternary care children's hospital. Participants included patients aged 1 month to 18 years who presented to the ED and were diagnosed with septic shock without known cardiac dysfunction and began an epinephrine or norepinephrine infusion within 24 hours of ED arrival between June 1, 2017, and December 31, 2023. Data were analyzed from March 1 to December 31, 2024.

Exposure

Epinephrine vs norepinephrine as the first vasoactive medication received.

Main Outcomes and Measures

The primary outcome was major adverse kidney events by 30 days (MAKE30). Secondary outcomes were 30-day in-hospital mortality, 3-day mortality, need for kidney replacement therapy or persistent kidney dysfunction, endotracheal intubation, mechanical ventilation days, extracorporeal membrane oxygenation, and hospital and intensive care unit length of stay. Primary and secondary outcomes were assessed with the χ2 test of proportions for binary variables and Wilcoxon rank sum test for continuous variables.

Results

Among 231 included encounters, the median (IQR) age was 11.4 (5.6-15.4) years, 126 were female (54.6%), and 142 had a medical history that predisposed them to sepsis (61.5%). Most (147 [63.6%]) initially received an epinephrine infusion and 84 (36.4%) received norepinephrine. In the epinephrine group, 9 of 147 (6.1%) met the outcome of MAKE30 and 6 of 147 (4.1%) died within 30 days. In the norepinephrine group, 3 of 84 (3.6%) met MAKE30 and there were no deaths. After inverse probability of treatment weighting, there were no significant differences in the primary outcome, MAKE30. With 2:1 propensity matching, epinephrine was associated with greater 30-day mortality compared with norepinephrine (3.7% vs 0%; risk difference: 3.7%; 95% CI, 0.2%-7.2%).

Conclusions and Relevance

In this study, those receiving epinephrine had greater 30-day mortality but no difference in MAKE30. Prospective, confirmatory studies are needed to determine if norepinephrine should be the first-line vasoactive agent in pediatric septic shock.

Pediatric ECMO Outcomes in Children With Severe Infections: Does Infectious Source Matter?

BACKGROUND

Although Extracorporeal Membrane Oxygenation (ECMO) utilization in pediatric patients with cardiopulmonary failure due to infection improves mortality, it is unclear whether the infectious etiology impacts outcomes. The aim of this study is to compare ECMO outcomes in children with sepsis and severe acute lung injury secondary to infections based on culture data.

METHODS

A retrospective review was done of patients aged <18 with severe infections whose management included ECMO from 2013 to 2022 at a quaternary children's hospital. Respiratory and blood cultures were reviewed. Mortality for all groups was compared using univariate and multivariate models.

RESULTS

A total of 155 patients were included. Overall mortality on ECMO was 36 % and mortality at discharge was 51 %. Using a Cox proportional hazards regression, patients with both positive blood and respiratory cultures at time of cannulation had an adjusted HR (Hazard Ratio) for mortality on ECMO of 7.65 (95 % CI 1.92-30.44, p = 0.004) and adjusted HR for mortality at discharge of 4.48 (95 % CI 1.69-11.88, p = 0.003) compared to those with only positive bacterial respiratory cultures. There was increased mortality on ECMO for patients with more than one virus identified on viral respiratory panel [HR 6.1 (CI 1.1-32.9, p = 0.03)], but no difference in mortality of patients with polymicrobial bacterial pneumonias. There was no relationship between bacterial organism and mortality, but patients with RSV and COVID viral infections demonstrated higher mortality.

CONCLUSIONS

ECMO outcomes in pediatric patients with cardiopulmonary failure secondary to infection differ based on the infectious source. This information is important when discussing prognosis with families prior to cannulation.

STUDY TYPE/LEVEL OF EVIDENCE

Retrospective Review, Cohort study.

The application of mechanical circulatory support in special conditions

Special conditions, though not typically associated with cardiovascular distress, may be considered for treatment with temporary mechanical circulatory support (tMCS) devices. Such non-classical examples of cardiovascular compromise include trauma, sepsis, and peri-partum cardiomyopathy, among others, and may require urgent treatment with a tMCS device for haemodynamic stabilization and tentatively saving the patient's life. In this section, examples of the use of tMCS in several special circumstances are presented to garner awareness for such conditions, which have previously been overlooked or even considered contraindications, and highlight the benefit of tMCS devices during treatment of these patients and the need for more research into these circumstances.

Ultrasound in pediatric emergency medicine simulation: evaluation of a longitudinal curriculum

OBJECTIVES

Pediatric resuscitations involving shock and trauma are rare but they are high-stakes events in the pediatric emergency department (ED). Effective use of point-of-care ultrasound (POCUS) can expedite diagnosis and treatment in such cases. This study aimed to assess the impact of a longitudinal pediatric emergency medicine simulation curriculum and high-fidelity POCUS simulator on residents' clinical practice, comfort level, and motivation to learn resuscitative ultrasound.

METHODS

This mixed-methods study involved 12 pediatric emergency medicine residents who participated in a 12-month simulation curriculum integrating resuscitative ultrasound. The POCUS simulator was integrated and made available for use during all simulations. Assessment and program evaluation occurred at multiple levels, according to Kirkpatrick's hierarchy, using both qualitative and quantitative methods. The residents were surveyed at baseline, 4, 8 and 12 months. Semi-structured interviews were conducted at the end of the 12-month study period.

RESULTS

Twelve residents participated in 23 simulation cases over the 12-month longitudinal curriculum. The hybrid POCUS simulator was used by participants in 18/23 (78.2%) cases. Comparing pre- and post-curriculum changes, large effect sizes were seen in residents' comfort using ultrasound in resuscitation (including in cases of trauma and undifferentiated shock). Accordingly, the mean number of POCUS scans performed per resident clinically on shift increased from a mean (SD) of 5.7 (± 2.3) scans/month to 12.4 (± 5.1) scans/month. Qualitative analysis highlighted several themes, including the value of simulation for teaching the integration of resuscitative ultrasound in high-acuity low-occurrence events and the effect of repeat exposures to resuscitative ultrasound.

CONCLUSION

Our study demonstrated that a longitudinal, simulation-based curriculum focused on resuscitative ultrasound increased residents' confidence, their motivation and likelihood of using these skills in the clinical setting. Repeated simulation exposures to resuscitative ultrasound can help participants translate this critical skill into use at the bedside, especially in high-acuity low-occurrence events.

Advances in sepsis research: Insights into signaling pathways, organ failure, and emerging intervention strategies

Sepsis is a complex syndrome resulting from an aberrant host response to infection. A hallmark of sepsis is the failure of the immune system to restore balance, characterized by hyperinflammation or immunosuppression. However, the net effect of immune system imbalance and the clinical manifestations are highly heterogeneous among patients. In recent years, research interest has shifted from focusing on the pathogenicity of microorganisms to the molecular mechanisms of host responses which is also associated with biomarkers that can help early diagnose sepsis and guide treatment decisions. Despite significant advancements in medical science, sepsis remains a major challenge in healthcare, contributing to substantial morbidity and mortality worldwide. Further research is needed to improve our understanding of this condition and develop novel therapies to improve outcomes for patients with sepsis. This review explores the related signal pathways of sepsis and underscores recent advancements in understanding its mechanisms. Exploration of diverse biomarkers and the emerging concept of sepsis endotypes offer promising avenues for precision therapy in the future.

Active versus restrictive approach to isolated hypotension in preterm neonates: A Systematic Review, Meta-analysis and GRADE based Clinical Practice Guideline

OBJECTIVE

Isolated hypotension (IH) without any clinical or biochemical features of poor perfusion is a common occurrence in very preterm infants (VPTI). There exists no recommendations guiding its management.The objective of this review was to compare the effect of active vs. restrictive approach to treat IH in VPTI.

METHODOLOGY

Medline, Embase and Web of Science were searched until 1st April 2024. RCTs and non-RCTs were included. Mortality, major brain injury (MBI) (intraventricular hemorrhage >  grade 2 or cystic periventricular leukomalacia), mortality or neurodevelopmental impairment (NDI) at 18-24 months' corrected age were the critical outcomes evaluated.

RESULTS

44 studies were included: 9 were synthesized in a meta-analysis and 35 studies in the narrative review. Clinical benefit or harm could not be ruled out for the outcomes from the meta-analyses of RCTs. Meta-analysis of 3 non-RCTs suggested that active treatment of IH in VPTI of <  24 hours of life possibly increased the odds of MBI (aOR: 95% CI 1.85 (1.45; 2.36), very low certainty). Meta-analysis of 2 non-RCTs that had included VPTI <  72 hours indicated a possibly decreased risk of MBI (aOR: 95% CI 0.44 (0.24; 0.82), very low certainty) and NEC ≥  stage 2 (aOR: 95% CI 0.61 (0.41; 0.92), very low certainty) with active treatment of IH. Active treatment of IH in the first 24 hours possibly increased the risk of mortality or long-term NDI (aOR: 95% CI 1.84 (1.10; 3.09), very low certainty) and the risk of hearing loss at 2 years (aOR: 95% CI 3.60 (1.30; 9.70), very low certainty). Clinical benefit or harm could not be ruled out for other outcomes. There was insufficient evidence with respect to preterm neonates of ≥  32 weeks.

CONCLUSIONS

IH may not be treated in VPTI in the first 24 hours. However, IH occurring between 24 hours - 72 hours of life may be treated. The evidence certainty was very low.

Uncovering knowledge of pediatric sepsis and recognition of septic shock: a survey among Brazilian pediatricians

OBJECTIVE

To evaluate the ability of Brazilian pediatricians to recognize sepsis and septic shock in children.

METHODS

A cross-sectional multicenter survey was conducted among Brazilian pediatricians between May and June 2023, before the release of the new Phoenix sepsis criteria in 2024. An online electronic system was used for surveys to characterize the knowledge and skills of physicians in the diagnosis and treatment of sepsis in children. The questions related to the diagnosis and treatment of sepsis and septic shock in children were based on the International Pediatric Sepsis Consensus Conference, the American College of Critical Care Medicine Guidelines, and the Surviving Sepsis Campaign in Pediatrics. Descriptive statistical analyses were performed using R software.

RESULTS

Pediatricians were surveyed about the recognition, knowledge, and management of pediatric patients with sepsis and septic shock. The responses of 355 physicians from all regions of Brazil were analyzed, with the majority from the southeastern region of the country (53.3%). In clinical practice, the most utilized criteria for diagnosing sepsis included inappropriate tachycardia (92%), temperature alteration (88.2%), and the presence of a suspected or confirmed infectious focus (87.9%). For septic shock, capillary refill time alteration (87.1%), arterial hypotension (84.8%), and changes in the level of consciousness (82.2%) were the predominant indicators. A total of 55.6% pediatricians reported having the potential to obtain venous or intraosseous access within 5 minutes, and 59.3% could administer antibiotics within the first hour. Approximately one-quarter (27.5%) of the participants responded that it was possible to infuse 40 - 60mL/kg in 1 hour. The most commonly used solution for fluid resuscitation was isotonic saline (70.9%), followed by Ringer's lactate (45.0%). The infusion of a vasopressor was considered in patients who did not improve after receiving an infusion of 40 - 60mL/kg (75.8%).

CONCLUSION

This is the first study to assess the knowledge of sepsis and septic shock among the Brazilian pediatric population. The results reveal a significant deficiency in the recognition of sepsis. This study demonstrated a gap between evidence and clinical practice. Adherence to international guidelines needs to be improved.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Early hydrocortisone verses placebo in neonatal shock- a double blind Randomized controlled trial

OBJECTIVE

To compare early hydrocortisone (initiated along with vasoactive therapy) vs. placebo for all-cause mortality within next 14 days among neonates with fluid-refractory shock.

STUDY DESIGN

Neonates with fluid-refractory shock were randomly assigned to receive hydrocortisone or saline placebo alongside vasoactive drugs. If they developed catecholamine-resistant shock, the study drug was replaced with open-label hydrocortisone.

RESULT

Eighty-four neonates were randomized (early hydrocortisone=43 and placebo=41). Median gestational age of our cohort (n = 84) was 30.3 weeks [interquartile range (IQR): 27.7, 32.5] and median birth weight was 1148 grams (IQR: 860, 1419). The 14-day all-cause mortality was comparable between early hydrocortisone and placebo groups [OR 0.53 (95% CI 0.19, 1.52)]. Both groups had similar duration of vasoactive drugs and vasoactive-inotrope scores, incidence of adverse effects of hydrocortisone and incidence of medium-term complications.

CONCLUSION

We did not observe a significant reduction in 14-day mortality with early hydrocortisone compared to placebo in fluid-refractory neonatal shock.

Relationship between fluid overload and mortality and morbidity in pediatric intensive care unit

OBJECTIVE

The relationship between fluid overload and clinical outcomes was investigated.

DESIGN

This study is an observational and analytic study of a retrospective cohort.

SETTINGS

Pediatric intensive care units.

PATIENTS OR PARTICIPANTS

Between 2019 and 2021 children who needed intensive care were included in the study.

INTERVENTIONS

No intervention.

MAIN VARIABLE OF INTEREST

Early, peak and cumulative fluid overload were evaluated.

RESULTS

The mortality rate was 11.7% (68/513). When fluid overloads were examined in terms of mortality, the percentage of early fluid overload was 1.86 and 3.35, the percent of peak fluid overload was 2.87 and 5.54, and the percent of cumulative fluid overload was 3.40 and 8.16, respectively, in the survivor and the non-survivor groups. After adjustment for age, severity of illness, and other potential confounders, peak (aOR = 1.15; 95%CI 1.05-1.26; p: 0.002) and cumulative (aOR = 1.10; 95%CI 1.04-1.16; p < 0.001) fluid overloads were determined as independent risk factors associated with mortality. When the cumulative fluid overload is 10% or more, a 3.9-fold increase mortality rate was calculated. It is found that the peak and cumulative fluid overload, had significant negative correlation with intensive care unit free days and ventilator free days.

CONCLUSIONS

It is found that peak and cumulative fluid overload in critically ill children were independently associated with intensive care unit mortality and morbidity.

DiCARTTM device to measure capillary refill time: a validation study in patients with acute circulatory failure

Capillary Refill Time (CRT) is a valuable metric to assess cutaneous perfusion. Its prognostic value in patients with acute circulatory failure has been reported as improved when the measurement is standardized. The DiCART™ device is a fully automated CRT measurement tool requiring validation. We conducted a comparative interventional single-center study including 25 patients with acute circulatory failure, to evaluate the agreement between CRT measured by an automated measurement device (CRTDiCART) and CRT measured clinically (CRTCLIN). CRT was measured on the fingertip, chest, and knee. Three measurements were performed at each location to obtain an average for each site. The measurements were conducted both clinically and using the DiCART™ device by two different operators, each blinded to the results. Agreement was determined using intraclass correlation coefficient (ICC) and Bland and Altman analysis. The ICC between CRTCLIN and CRTDiCART was 0.46 (95% Confidence Interval (CI) 0.32, 0.59) across all measurement sites; the mean bias was 0.23s (95% CI -0.17, 0.64), with upper Limit of Agreement (LoA) 2.77s (95% CI 2.44, 3.20) and lower LoA - 2.30s (-2.73, -1.97). Intra observer ICC was 0.85 (95% CI 0.74, 0.91) for CRTCLIN and 0.43 (95% CI 0.15, 0.64) for CRTDICART. Inter observer ICC was 0.86 (95% CI 0.76, 0.92) for CRTCLIN and was 0.41 (95% CI 0.14, 0,63) for CRTDICART. The DiCART™ device showed poor agreement with clinical CRT in patients with acute circulatory failure, which does not support its use in routine practice.

Enhanced mortality prediction in pediatric sepsis using NGAL: A comparison with PRISM III scores in critical care settings

Sepsis is a critical condition that disrupts metabolic, physiological, and immune functions, often resulting in severe complications such as multi-organ failure and increased mortality. Neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for infection and inflammation, offering potential advantages for early mortality prediction. This study compared the predictive value of serum NGAL levels with pediatric risk of mortality III (PRISM III) scores in critically ill pediatric patients with sepsis. A prospective cohort study was conducted at a tertiary hospital from September 2022 to March 2023, involving 75 pediatric patients diagnosed with sepsis, septic shock, or multi-organ dysfunction syndrome (MODS), along with 25 healthy controls. Serum NGAL levels were measured within the first hour of PICU admission and analyzed alongside PRISM III scores to evaluate their correlation with mortality and sepsis severity. The results demonstrated that serum NGAL levels were significantly elevated in septic patients compared to controls, with the highest levels observed in those with MODS. NGAL showed greater sensitivity and specificity for predicting mortality than PRISM III scores, with ROC curve analysis revealing that NGAL levels > 599 mg/ml were strongly associated with increased mortality risk (sensitivity 70.4% and specificity 50%). Multivariate analysis confirmed NGAL as an independent predictor of mortality, outperforming PRISM III scores in identifying severe cases.

CONCLUSION

Serum NGAL is a valuable biomarker for early prediction of mortality and sepsis severity in pediatric patients, providing faster and more accurate assessments than PRISM III scores. Its integration into clinical practice may enhance decision-making in pediatric critical care settings, allowing for timely interventions and improved patient outcomes.

WHAT IS KNOWN

• Pediatric risk of mortality III (Prism III) scores is widely used to predict sepsis severity and mortality in pediatric intensive care units, but requiring 12-24 hours to complete. Neutrophil is an established biomarker for inflammation and infection with a potentially anti-pathological value in the neutrophil gelatinus-lipocalin (NGAL) sepsis.

WHAT IS NEW

• Serum NGAL levels, PICU is measured within the first hour of entry, prism III score in pediatric patients in predicting mortality and severity of sepsis. > An NGAL cutoff of 599 mg/mL is significantly associated with mortality risk, which provides a rapid, independent and more immediate immunity tool for important care decision making.

A recommendation for the use of electrical biosensing technology in neonatology

Non-invasive cardiac output monitoring, via electrical biosensing technology (EBT), provides continuous, multi-parameter hemodynamic variable monitoring which may allow for timely identification of hemodynamic instability in some neonates, providing an opportunity for early intervention that may improve neonatal outcomes. EBT encompasses thoracic (TEBT) and whole body (WBEBT) methods. Despite the lack of relative accuracy of these technologies, as compared to transthoracic echocardiography, the use of these technologies in neonatology, both in the research and clinical arena, have increased dramatically over the last 30 years. The European Society of Pediatric Research Special Interest Group in Non-Invasive Cardiac Output Monitoring, a group of experienced neonatologists in the field of EBT, deemed it appropriate to provide recommendations for the use of TEBT and WBEBT in the field of neonatology. Although TEBT is not an accurate determinant of cardiac output or stroke volume, it may be useful for monitoring longitudinal changes of hemodynamic parameters. Few recommendations can be made for the use of TEBT in common neonatal clinical conditions. It is recommended not to use WBEBT to monitor cardiac output. The differences in technologies, study methodologies and data reporting should be addressed in ongoing research prior to introducing EBT into routine practice. IMPACT STATEMENT: TEBT is not recommended as an accurate determinant of cardiac output (CO) (or stroke volume (SV)). TEBT may be useful for monitoring longitudinal changes from baseline of hemodynamic parameters on an individual patient basis. TEBT-derived thoracic fluid content (TFC) longitudinal changes from baseline may be useful in monitoring progress in respiratory disorders and circulatory conditions affecting intrathoracic fluid volume. Currently there is insufficient evidence to make any recommendations regarding the use of WBEBT for CO monitoring in neonates. Further research is required in all areas prior to the implementation of these monitors into routine clinical practice.

Neonatal Shock: Current Dilemmas and Future Research Avenues

Neonatal shock presents a complex clinical challenge and is one of the leading causes of mortality. Traditionally, neonatal shock is equated to hypotension, and therapeutics are often initiated based on low blood pressure (BP) values alone. This fails to address the underlying goal of optimizing the tissue perfusion resulting in both over- and under-treatment of neonatal shock. Also, what defines a normal BP in neonates is still a contentious topic. Further, the most appropriate way of measuring BP in neonates with shock is still debated. Shock secondary to transient circulatory instability and patent ductus arteriosus, conditions that are unique to preterm neonates, have not been researched adequately. Treatment of myocardial dysfunction secondary to perinatal asphyxia, a leading cause of neonatal mortality, is still a conundrum. Quite similarly, there are only a handful of controlled trials evaluating therapeutics in some of the other commonly encountered conditions, namely, septic shock and hypoperfusion secondary to pulmonary hypertension. Even the universally practiced intervention of volume expansion with crystalloid boluses in shock is not backed by high-certainty evidence in neonates. Though the diagnostic modalities of functional echocardiography and near-infrared spectroscopy have aided greatly in the management of neonatal shock in recent years, these have not been proven to be associated with improved critical clinical outcomes such as mortality and major brain injury. To conclude, neonatologists often rely on limited evidence, mostly anecdotal, when treating neonatal shock. This review critically examines the current evidence with respect to various aspects of neonatal shock with an objective to identify the lacunae in the literature that may fuel future research, eventually paving the way to efficacious, safe and evidence-based clinical practice.

Outcome prediction for late-onset sepsis after premature birth

BACKGROUND

Our aim was to develop a quantitative model for immediately estimating the risk of death and/or brain injury in late-onset sepsis (LOS) in preterm infants, based on objective and measurable data available at the time sepsis is first suspected (i.e., time of blood culture collection).

METHODS

Retrospective study on neonates ≤36 weeks' gestation with a positive blood and/or cerebrospinal fluid culture after 72 hours from birth.

RESULTS

Among 3217 preterm live births, 94 cases were included (median gestational age 26.5 weeks' IQR 25.0;28.0), of whom 26 (27.7%) had poor outcomes (17 death; 9 brain injuries). Infants with poor outcomes showed lower postnatal age (11.5 vs 12.5 days, p < 0.001), lower mean blood pressure (30.5 vs 43 mmHg, p < 0.001) and higher lactate levels (4.4 vs 1.5 mmol/l, p < 0.001). Our multivariable model showed good discrimination and calibration (c statistic=0.8618, Hosmer-Lemeshow p = 0.8532), stratifying the population into 3 groups: low-risk (sensitivity 97%, specificity 52%), middle-risk, and high-risk (sensitivity 77%, specificity 80%).

CONCLUSION

This predictive model performs well as a practical and easy-to-use tool to help clinicians early identify the sickest neonates who may benefit from timely and aggressive support (e.g., central line, haemodynamic assessment) and close monitoring (e.g., 1:1 nursing assignment, frequent reassessments).

IMPACT

We lack data to early identify the severity of neonatal late-onset sepsis in preterm infants. Delay in treatment contributes to poor prognosis. We developed a model for early prediction of poor outcomes (mortality and brain injuries). The model utilizes immediately available and measurable data at the time sepsis is first suspected. This can help clinicians in tailoring management based on individual risks.

Disease burden comparison and associated risk factors of early- and late-onset neonatal sepsis in China and the USA, 1990-2019

BACKGROUND

The morbidity and mortality rates of neonatal sepsis are high, with significant differences in risk factors and disease burden observed between developing and developed countries.

OBJECTIVE

To provide evidence to support recommendations on improving public health policies using a comparative systematic analysis of the disease burden.

METHODS

Using data from the Global Burden of Disease Study 2019, the prevalence and incidence of early- and late-onset neonatal sepsis and the disability-adjusted life years (DALYs) due to both countries in both China and the United States of America (USA) were assessed. Furthermore, the DALYs and summary exposure values for the primary risk factors (short gestation and low birthweight) were analysed. Joinpoint regression models were used to analyse temporal trends in epidemiological indicators of neonatal sepsis.

RESULTS

Between 1990 and 2019, the incidence and prevalence of neonatal sepsis demonstrated a significant upwards trend in China, whereas both were largely stable in the USA. A decreasing trend in the DALYs due to neonatal sepsis caused by short gestation and low birthweight in both sexes was observed in both countries, whereas a fluctuating increasing trend in years lived with disability was observed in China.

CONCLUSIONS

The aim of the Chinese public health policy should be to control risk factors, learning from the advanced health policy planning and perinatal management experiences of developed countries.

Research Progress on the Measurement Methods and Clinical Significance of Capillary Refill Time

The monitoring of peripheral circulation, as indicated by the capillary refill time, is a sensitive and accurate method of assessing the microcirculatory status of the body. It is a widely used tool for the evaluation of critically ill patients, the guidance of therapeutic interventions, and the assessment of prognosis. In recent years, there has been a growing emphasis on microcirculation monitoring which has led to an increased focus on capillary refill time. The International Sepsis Guidelines, the American Academy of Pediatrics, the World Health Organization, and the American Heart Association all recommend its inclusion in the evaluation of the system in question. Furthermore, the methodology for its measurement has evolved from a traditional manual approach to semiautomatic and fully automatic techniques. This article presents a comprehensive overview of the current research on the measurement of capillary refill time, with a particular focus on its clinical significance. The aim is to provide a valuable reference for clinicians and researchers and further advance the development and application of microcirculation monitoring technology.

Physiologically Based Pharmacokinetic Modeling of Vancomycin in Critically Ill Neonates: Assessing the Impact of Pathophysiological Changes

Dosing vancomycin for critically ill neonates is challenging owing to substantial alterations in pharmacokinetics (PKs) caused by variability in physiology, disease, and clinical interventions. Therefore, an adequate PK model is needed to characterize these pathophysiological changes. The intent of this study was to develop a physiologically based pharmacokinetic (PBPK) model that reflects vancomycin PK and pathophysiological changes in neonates under intensive care. PK-sim software was used for PBPK modeling. An adult model (model 0) was established and verified using PK profiles from previous studies. A neonatal model (model 1) was then extrapolated from model 0 by scaling age-dependent parameters. Another neonatal model (model 2) was developed based not only on scaled age-dependent parameters but also on quantitative information on pathophysiological changes obtained via a comprehensive literature search. The predictive performances of models 1 and 2 were evaluated using a retrospectively collected dataset from neonates under intensive care (chictr.org.cn, ChiCTR1900027919), comprising 65 neonates and 92 vancomycin serum concentrations. Integrating literature-based parameter changes related to hypoalbuminemia, small-for-gestational-age, and co-medication, model 2 offered more optimized precision than model 1, as shown by a decrease in the overall mean absolute percentage error (50.6% for model 1; 37.8% for model 2). In conclusion, incorporating literature-based pathophysiological changes effectively improved PBPK modeling for critically ill neonates. Furthermore, this model allows for dosing optimization before serum concentration measurements can be obtained in clinical practice.

Principles of resuscitation for infants with severe bronchopulmonary dysplasia

Severe bronchopulmonary dysplasia (sBPD) requiring invasive mechanical ventilation is a heterogeneous disease process that contributes to morbidity and mortality in infants. As the most common lung disease of prematurity, sBPD has a multitude of overlapping cardiac, airway, pulmonary vascular, and infectious phenotypic presentations that progress through four different phases of care. Premature infants with sBPD are at a high risk of acute decompensation and subsequent cardiopulmonary arrest. A comprehensive determination of the complex phenotypes that contribute to the clinical presentation will help clinicians decipher the phase of care, identify cardiopulmonary compromise earlier and guide targeted therapeutic intervention during acute episodes of deterioration. The approach to resuscitation of premature infants with sBPD undergoing an acute decompensation differs from general neonatal and pediatric resuscitation practices. This review summarizes the phenotypes of sBPD, the phases of care, the common triggers of acute exacerbations, and the principles of resuscitation of a deteriorating infant with sBPD. We offer a framework for sBPD resuscitation with a focus on prevention, assessment, and post-resuscitative care.

Identification of coagulation-related genes as potential diagnostic biomarkers for pediatric septic shock

This study aimed to identify important clotting associated genes (CRGs) associated with septic shock in children and explore possible important mechanisms of the disease. Five hub genes with diagnostic performance were identified using GEO database and data from literature. These hub genes have strong correlation with immune cells. ceRNA network was constructed to explore potential pathogenic mechanisms. Ten candidate small molecule compounds were identified. In summary, the hub genes may play an important role in the immunity and disease development of septic shock, providing new ideas and strategies for future diagnosis and mechanism evaluation of children with septic shock.

Neonatal Sequential Organ Failure Assessment Score Predicts Respiratory Outcomes in Preterm Newborns with Late-Onset Sepsis: A Retrospective Study

INTRODUCTION

Neonatal sequential organ failure assessment (nSOFA) score predicts mortality in preterm newborns. The aim of the study was to assess whether nSOFA score could predict respiratory outcomes in preterm infants with late-onset sepsis (LOS).

METHODS

This retrospective, observational, single-center study enrolled infants with gestational age <32 weeks born between January 2016 and June 2023 who experienced an episode of LOS during NICU stay. The primary outcome was death or bronchopulmonary dysplasia (BPD); secondary outcomes were BPD, death or mechanical ventilation (MV) on day 5 after the onset of LOS, and MV on day 5 after the onset of LOS. The nSOFA score was assessed at the onset of LOS and after 6 ± 1, 12 ± 3, and 24 ± 3 h.

RESULTS

Neonatal SOFA score was significantly higher in patients who developed each outcome versus those who did not at all timings. Maximal nSOFA score during the first 24 h after onset of LOS was an independent predictive factor for death or BPD (p = 0.007), BPD (p = 0.009), and death or MV on day 5 (p = 0.009), areas under the curve (AUC) were 0.740 (95% CI: 0.656-0.828), 0.700 (95% CI: 0.602-0.800), and 0.800 (95% CI: 0.710-0.889), respectively. Maximal nSOFA score also predicted moderate to severe BPD (p = 0.019) and death or moderate to severe BPD (p < 0.001). Maximal nSOFA ≥4 was associated with odds ratio (OR) of 7.37 (95% CI: 2.42-22.44) for death or BPD, 4.86 (95% CI: 1.54-15.28) for BPD, and 7.99 (95% CI: 3.47-18.36) for death or MV on day 5. AUC of the predicting model was 0.895 (95% CI: 0.801-0.928) for BPD, 0.897 (95% CI: 0.830-0.939) for death or BPD, 0.904 (95% CI: 0.851-0.956) for MV on day 5, 0.923 (95% CI: 0.892-0.973) for death or MV on day 5.

CONCLUSION

Maximal nSOFA score during the first 24 h after the onset of LOS predicts respiratory outcomes and allows identification of patients who may crucially benefit from lung-protective measures.

Preprocedural Oxygenation and Procedural Oxygenation During Pediatric Procedural Sedation: Patterns of Use and Association With Interventions

STUDY OBJECTIVE

Preprocedural oxygenation (pre-emptive oxygenation started during presedation and/or induction) and procedural oxygenation (pre-emptive oxygenation started during any phase of sedation) are easy-to-use strategies with potential to decrease adverse events. Here, we describe practice patterns of preprocedural oxygenation and procedural oxygenation. We hypothesized that patients who received preprocedural oxygenation or procedural oxygenation would have a lower risk of airway/breathing/circulation interventions during sedation compared with patients without procedural oxygenation.

METHODS

We performed a retrospective, multicenter, cross-sectional study of pediatric sedations from April 2020 to July 2023 using the Pediatric Sedation Research Consortium multicenter database. The patient-level and sedation-level characteristics were described using frequencies and proportions, stratified by preprocedural oxygenation and procedural oxygenation status. We determined the site-level frequency of preprocedural oxygenation and procedural oxygenation use. We used inverse probability of treatment weighting to calculate the risk difference for interventions associated with preprocedural oxygenation and procedural oxygenation.

RESULTS

This study included a total of 85,599 pediatric sedations; 43,242 (50.5%) patients received preprocedural oxygenation (used oxygen before sedation and/or at induction) and a total of 52,219 (61.0%) received procedural oxygenation pre-emptively at any time during the sedation. There was no statistical difference in overall interventions with either preprocedural oxygenation (risk difference -0.06%; 95% confidence interval -4.26% to 4.14%) or procedural oxygenation (risk difference -1.07%; 95% confidence interval -6.44% to 4.30%).

CONCLUSION

Pre-emptive preprocedural oxygenation and procedural oxygenation were not associated with a difference in the use of airway/breathing/circulation interventions in pediatric sedations.

Mixed Cardiogenic Shock: A Proposal for Standardized Classification, a Hemodynamic Definition, and Framework for Management

The classification of cardiogenic shock (CS) has evolved from a singular cold-and wet-hemodynamic profile. Data from registries and clinical trials have contributed to a broader recognition that although all patients with CS have insufficient cardiac output leading to end organ hypoperfusion, there is considerable variability in CS acuity, underlying etiologies, volume status, and systemic vascular resistance. Mixed CS can be broadly categorized as CS with at least 1 additional shock state. Mixed CS states are now the second leading cause of shock in contemporary coronary intensive care units, but there is little high-quality evidence to guide routine care, and there are no standardized classification frameworks or well-established hemodynamic definitions. This primer summarizes the current epidemiology and proposes a classification framework and invasive hemodynamic parameters to guide categorization that could be applied to help better phenotype patients captured in registries and trials, as well as guide management of mixed CS states.

A pilot randomized controlled trial comparing noradrenaline and adrenaline as a first-line vasopressor for fluid-refractory septic shock in neonates

Background and study design

Limited data exists on noradrenaline therapy in neonatal septic shock. We compared the efficacy of noradrenaline with adrenaline in neonatal septic shock. This single center, open label, pilot randomized controlled trial included neonates with clinical evidence of sepsis and shock.

Study outcomes

Primary outcomes were: 1) resolution of shock one hour after treatment, and 2) mortality during hospital stay. Secondary outcomes included: need for additional vasopressors; hemodynamic stability without further administration of vasopressors for ≥2 h; changes in blood pressure and heart rate after 1 h of vasopressor treatment; and morbidities during the hospital stay.

Results

Of 65 eligible neonates, 42 were randomized (21 each in adrenaline and noradrenaline treatment arms) between August 2020 and January 2022, at level III neonatal intensive care unit (NICU) of Bharati Vidyapeeth Deemed University Medical College and Hospital (BVDUMCH). The mean (SD) gestational age and mean (SD) birth weight were 36.1(4.2) weeks and 1.8 (0.2) kilograms birth weight for noradrenaline and 36.9 (4.1) weeks and 1.7 (0.7) kilograms for adrenaline. Shock resolved within 1 h of vasopressor therapy in 76.2% neonates in the noradrenaline arm and 61.9% in adrenaline arm (p value-0.53). Mortality during hospital stay was 28.6% (6/21) in noradrenaline group and 33.3% (7/21) in adrenaline group (p value- 0.58). Additional vasopressors were required in 23.8% neonates of the noradrenaline group compared to 38.1% neonates in adrenaline arm (p value-0.53). Median (SD) duration of intensive care stay was 6 (SD) days in the noradrenaline group and 10 (SD) days in the adrenaline group (p value-0.045).

Conclusion

Among neonates with septic shock, the efficacy of noradrenaline was comparable to adrenaline in resolving septic shock after one hour of infusion and on the mortality during hospital stay.

Clinical Trial Registration

https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDI2NTc=&Enc=&userName=noradrenaline, Clinical Trials Registry - India with identifier CTRI/2020/08/027185 (17/08/2020).

Monitoring and evaluation of hypotension in the extremely preterm

With the development of neonatal medicine, more and more extremely preterm infants have been treated. How to deal with hypotension is a big challenge for neonatologist in the process of diagnosis and treatment. The lack of uniformity in the definition of hypotension, challenges in measuring blood pressure accurately, and insufficient consistency between digital hypotension and hypoperfusion are the primary causes. How to check for hypotension and monitor blood pressure is thoroughly explained in the article. To give neonatologists a resource for the clinical management of hypotension in extremely preterm.

Therapeutic plasma exchange in critically ill children: A single center experience

INTRODUCTION

Therapeutic plasma exchange (TPE) is used in a wide spectrum of diseases in critically ill pediatric patients. We aim to review the indications, complications, safety, and outcomes of critically ill children who received TPE.

METHODS

All of the TPE procedures performed in a pediatric intensive care unit providing tertiary care during 19 years (January 2013-January 2023) were evaluated retrospectively. A total of 154 patients underwent 486 TPE sessions.

RESULTS

Median age was 6 years (2-12.5) and 35 children had a body weight of <10 kg (22.7%). Number of organ failure was 4 (2-6). Liver diseases were the most common indication for TPE (31.2%) followed by sepsis with multiorgan dysfunction syndrome (27.3%). Overall survival rate was 72.7%. The highest mortality was observed in hemophagocytic lymphohistiocytosis group. Non-survivors had significantly higher number of organ failure (p < 0.001), higher PRISM score (p < 0.001), and higher PELOD score on admission (p < 0.001). Adverse events were observed in 68 (13.9%) sessions. Hypotension (7.8%) and hypocalcemia (5.1%) were the most frequent adverse events.

CONCLUSION

TPE is safe for critically ill pediatric patients with experienced staff. Survival rate may vary depending on the underlying disease. Survival decreases with the increase in the number of failed organs.

Neutrophil Gelatinase-Associated Lipocalin (NGAL) as a Predictor for Sepsis Mortality in Children Admitted to Pediatric Intensive Care Unit (PICU): A Comparison With Prothrombin Time/International Normalized Ratio (PT/INR) and Urea/Creatinine Ratio

Background Sepsis is the primary cause of death in children, and it is crucial to identify patients at high risk of mortality early on in order to provide intensive monitoring and management in the Pediatric Intensive Care Unit (PICU). Objective The objective of this study was to assess the predictive value of routinely used sepsis indicators, including neutrophil gelatinase-associated lipocalin (NGAL), urea to creatinine ratio (urea/Cr), and prothrombin time and international normalized ratio (PT/INR), in predicting death in critically unwell children. Patients and methods A total of 75 children were included in the research conducted at the PICU of Minia University. Among them, 21 (28%) were released as survivors, while the remaining 54 (72%) unfortunately passed away. All participating children were subjected to serum NGAL, urea/Cr, and PT/INR measurements during the first 24 hours of hospitalization. The severity of sepsis was assessed using the Pediatric Risk of Mortality (PRISM) III score. Results The NGAL, prothrombin, urea, and creatinine levels were considerably elevated in the group of individuals who died compared to those who survived (P < 0.001, 0.007, 0.028, and 0.032, respectively). However, no significant difference was found between survivors and deceased children in terms of the PT/INR ratio and urea/Cr ratio. When predicting mortality, NGAL with a cutoff point of more than 990 had a sensitivity of 100% and a specificity of 35%. Similarly, the PRISM score with a cutoff point greater than 18 had a sensitivity of 83.3% and a specificity of 42.9%. Conclusion Serum NGAL is reliable in the early prediction of mortality in children admitted with sepsis.

Data-driven analysis that integrates bioinformatics and machine learning uncovers PANoptosis-related diagnostic genes in early pediatric septic shock

Objectives

Sepsis is one of the leading causes of death for children worldwide. Additionally, refractory septic shock is one of the most significant groups that contributes to a high death rate. The interaction of pyroptosis, apoptosis, and necroptosis results in a unique inflammatory cell death mechanism known as PANoptosis. An increasing amount of evidence suggests that PANoptosis can be brought on by several stimuli, including cytokine storms, malignancy, and bacterial or viral infections. The goal of this study is to improve the diagnostic significance of the PANoptosis-related gene signature in early pediatric septic shock.

Design and methods

We examined children with septic shock from the GSE66099 discovery cohort and looked at differentially expressed genes (DEGs). To filter the important modules, weighted gene co-expression network analysis (WCGNA) was employed. In the end, random forest analysis and the least absolute shrinkage and selection operator (LASSO) were used to determine the PANoptosis diagnostic signature genes. To determine the PANoptosis signature genes, we also found four validation cohorts: GSE26378, GSE26440, GSE8121, and GSE13904. The area under the curve (AUC) of the receiver operating characteristic curves (ROCs), along with sensitivity, specificity, positive predictive value, and negative predictive value, were used to assess the diagnostic efficacy of these signature genes.

Results

From GSE66099, 1142 DEGs in total were tested. Following the WGCNA clustering of the data into 16 modules, the MEgrey module showed a significant correlation with pediatric septic shock (p < 0.0001). Following the use of LASSO and random forest algorithms to identify the PANoptosis-related signature genes, which include ANXA3, S100A9, TXN, CLEC5A, and TMEM263. These signature genes' receiver operating characteristic curves (ROCs) were confirmed in the external dataset from GSE26378, GSE26440, GSE8121, and GSE13904, and were 0.994 (95 % CI 0.987-0.999), 0.987 (95 % CI 0.974-0.997), 0.957 (95 % CI 0.927-0.981), 0.974 (95 % CI 0.954-0.988), 0.897 (95 % CI 0.846-0.941), respectively.

Conclusion

In summary, the discovery of PANoptosis genes, ANXA3, S100A9, TXN, CLEC5A, and TMEM263 proved to be quite helpful in the early detection of pediatric septic shock patients. These early results, which need to be further confirmed in basic and clinical research, are extremely important for understanding immune cell infiltration in the pathophysiology of pediatric septic shock.

Profiling Molecular Changes of Host Response to Predict Outcome in Children with Septic Shock

Background

Septic shock is associated with high mortality and there is significant heterogeneity in the host response. The aim of this study was to understand the genome-wide expression transcriptomic signatures in children with septic shock and correlate them with outcomes.

Methods

This was a prospective study conducted on children (aged 1 month to 18 years) admitted to the PICU (June-December 2021) with septic shock. Demographic details, clinical details, and administered treatment were collected. Differential gene expression analysis was performed to understand the genes and pathways affecting in different subjects.

Results

Fifteen patients were recruited (Septic shock survivors (n = 5), nonsurvivors (n = 5), and non-sepsis controls (n = 5). The median age of the patients in survivors and nonsurvivors was 15 (13, 24) months and 180 (180, 184) months, respectively. The sepsis-survivors vs nonsepsis possessed 983 upregulated and 624 downregulated genes while comparing sepsis nonsurvivors (SNS) with nonsepsis yielded 1,854 upregulated and 1,761 downregulated genes. Further, the lowest number of deregulated genes (383 upregulated and 486 downregulated) were present in SNS compared to sepsis survivors. The major Reactome pathways, found upregulated in SNSs relative to survivors included CD22 mediated B cell receptor (BCR) regulation, scavenging of heme from plasma, and creation of C4 and C2 activators while T cell receptor (TCR) signaling, the common pathway of fibrin clot formation and generation of second messenger molecules were found to be downregulated.

Conclusion

Mortality-related gene signatures are promising diagnostic biomarkers for pediatric sepsis.

How to cite this article

Lalitha AV, Vasudevan A, Moorthy M, Ramaswamy G. Profiling Molecular Changes of Host Response to Predict Outcome in Children with Septic Shock. Indian J Crit Care Med 2024;28(9):879-886.

Fluid resuscitation in children with severe infection and septic shock: a systematic review and meta-analysis

This study aimed to evaluate the current evidence on various aspects of fluid therapy such as type, volume, and timing of fluid bolus administration in children with septic shock. Systematic review and meta-analysis of clinical trials including children less than 18 years of age admitted to the pediatric emergency and intensive care unit with severe infection and shock requiring fluid resuscitation. The intervention included balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The primary outcome was mortality rate. Of the 219 citations retrieved, 12 trials (3526 children with severe infection with or without malaria and shock) were included. The pooled results found no significant difference in the mortality rate between groups comparing balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The risk of acute kidney injury (AKI) was significantly less in the BC group compared to the NS group. The certainty of evidence for mortality was of "moderate certainty" in the BC vs NS group, and was of "very low certainty" for the other two groups.

CONCLUSIONS

The current meta-analysis found no significant difference in the mortality rate between the types of resuscitation fluid, and their speed or volume of administration. However, a significantly decreased risk of AKI was found in the BC group. More evidence is needed regarding the speed and volume of administration of fluid boluses in critically ill children.Prospero registration: CRD42020209066.

WHAT IS KNOWN

• Balanced crystalloids (BC) may be better than normal saline (NS) for fluid resuscitation in critically ill children.

WHAT IS NEW

• BC are better than NS for fluid resuscitation in critically ill children as they decrease AKI and hyperchloremia.

Time Course of Mechanical Ventilation Driving Pressure Levels in Pediatric Acute Respiratory Distress Syndrome: Outcomes in a Prospective, Multicenter Cohort Study From Colombia, 2018-2022

OBJECTIVES

High driving pressure (DP, ratio of tidal volume (V t ) over respiratory system compliance) is a risk for poor outcomes in patients with pediatric acute respiratory distress syndrome (PARDS). We therefore assessed the time course in level of DP (i.e., 24, 48, and 72 hr) after starting mechanical ventilation (MV), and its association with 28-day mortality.

DESIGN

Multicenter, prospective study conducted between February 2018 and December 2022.

SETTING

Twelve tertiary care PICUs in Colombia.

PATIENTS

One hundred eighty-four intubated children with moderate to severe PARDS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The median (interquartile range [IQR]) age of the PARDS cohort was 11 (IQR 3-24) months. A total of 129 of 184 patients (70.2%) had a pulmonary etiology leading to PARDS, and 31 of 184 patients (16.8%) died. In the first 24 hours after admission, the plateau pressure in the nonsurvivor group, compared with the survivor group, differed (28.24 [IQR 24.14-32.11] vs. 23.18 [IQR 20.72-27.13] cm H 2 O, p < 0.01). Of note, children with a V t less than 8 mL/kg of ideal body weight had lower adjusted odds ratio (aOR [95% CI]) of 28-day mortality (aOR 0.69, [95% CI, 0.55-0.87]; p = 0.02). However, we failed to identify an association between DP level and the oxygenation index (aOR 0.58; 95% CI, 0.21-1.58) at each of time point. In a diagnostic exploratory analysis, we found that DP greater than 15 cm H 2 O at 72 hours was an explanatory variable for mortality, with area under the receiver operating characteristic curve of 0.83 (95% CI, 0.74-0.89); there was also increased hazard for death with hazard ratio 2.5 (95% CI, 1.07-5.92). DP greater than 15 cm H 2 O at 72 hours was also associated with longer duration of MV (10 [IQR 7-14] vs. 7 [IQR 5-10] d; p = 0.02).

CONCLUSIONS

In children with moderate to severe PARDS, a DP greater than 15 cm H 2 O at 72 hours after the initiation of MV is associated with greater odds of 28-day mortality and a longer duration of MV. DP should be considered a variable worth monitoring during protective ventilation for PARDS.

Citrulline and ADI-PEG20 reduce inflammation in a juvenile porcine model of acute endotoxemia

Background

Arginine is a conditionally essential amino acid that is depleted in critically ill or surgical patients. In pediatric and adult patients, sepsis results in an arginine-deficient state, and the depletion of plasma arginine is associated with greater mortality. However, direct supplementation of arginine can result in the excessive production of nitric oxide (NO), which can contribute to the hypotension and macrovascular hypo-reactivity observed in septic shock. Pegylated arginine deiminase (ADI-PEG20, pegargiminase) reduces plasma arginine and generates citrulline that can be transported intracellularly to generate local arginine and NO, without resulting in hypotension, while maintaining microvascular patency. The objective of this study was to assess the efficacy of ADI-PEG20 with and without supplemental intravenous citrulline in mitigating hypovolemic shock, maintaining tissue levels of arginine, and reducing systemic inflammation in an endotoxemic pediatric pig model.

Methods

Twenty 3-week-old crossbred piglets were implanted with jugular and carotid catheters as well as telemetry devices in the femoral artery to measure blood pressure, body temperature, heart rate, and respiration rate. The piglets were assigned to one of three treatments before undergoing a 5 h lipopolysaccharide (LPS) infusion protocol. Twenty-four hours before LPS infusion, control pigs (LPS; n=6) received saline, ADI-PEG20 pigs (n=7) received an injection of ADI-PEG20, and seven pigs (ADI-PEG20 + CIT pigs [n=7]) received ADI-PEG20 and 250 mg/kg citrulline intravenously. Pigs were monitored throughout LPS infusion and tissue was harvested at the end of the protocol.

Results

Plasma arginine levels decreased and remained low in ADI-PEG20 + CIT and ADI-PEG20 pigs compared with LPS pigs but tissue arginine levels in the liver and kidney were similar across all treatments. Mean arterial pressure in all groups decreased from 90 mmHg to 60 mmHg within 1 h of LPS infusion but there were no significant differences between treatment groups. ADI-PEG20 and ADI-PEG20 + CIT pigs had less CD45+ infiltrate in the liver and lung and lower levels of pro-inflammatory cytokines in the plasma.

Conclusion

ADI-PEG20 and citrulline supplementation failed to ameliorate the hypotension associated with acute endotoxic sepsis in pigs but reduced systemic and local inflammation in the lung and liver.

DEVELOPMENT AND VALIDATION OF A MODEL FOR PREDICTION OF SEPTIC SHOCK IN NEONATES WITH SEPSIS

ABSTRACT

Purpose: This study aimed to develop and validate a model for prediction of septic shock in neonates with sepsis. Materials and methods: This retrospective study included early-onset septic neonates in the Renmin Hospital of Wuhan University between January 2017 and June 2021. The neonates were divided into the training set and the validation set in a ratio of 7:3 and further categorized into septic shock group and none-shock group according to presence or absence of shock symptoms. Results: A total of 406 septic neonates were enrolled, including 217 in septic shock group. Sex (odds ratio [OR] = 0.092, 95% confidence interval [CI]: 0.012 to 0.683, P = 0.020), C-reactive protein at 6 h (OR = 8.475, 95% CI: 3.154 to 22.774, P < 0.001), serum amyloid A at 6 h (OR = 1.179, 95% CI: 1.094 to 1.269, P < 0.01), white blood cells at 6 h (OR = 0.173, 95% CI: 0.092 to 0.326, P < 0.001), platelets at 6 h (OR = 0.985, 95% CI: 0.975 to 0.995, P < 0.001), and Ca 2+ at 6 h (OR = 1.44 × 10 11 , 95% CI: 2.70 × 10 6 to 7.70 × 10 15 , P < 0.001) were identified as independent risk factors for septic shock and were further included in the nomogram. The areas under the receiver operator characteristic curve were 0.873 and 0.920 in training and validation sets, respectively. Conclusions: A predictive model for early diagnosis of septic shock in neonates was developed and initially validated in this study, allowing for timely intervention.

Venoarterial Extracorporeal Membrane Oxygenation Implementation in Septic Shock Rat Model

Septic shock, a global health concern, boasts high mortality rates. Research exploring the efficacy of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in septic shock remains limited. Our study aimed to establish a rodent model employing VA-ECMO in septic shock rats, assessing the therapeutic impact of VA-ECMO on septic shock. Nineteen Sprague-Dawley rats were randomly assigned to sham, septic shock, and (septic shock + VA-ECMO; SSE) groups. Septic shock was induced by intravenous lipopolysaccharides, confirmed by a mean arterial pressure drop to 25-30% of baseline. Rats in the SSE group received 2 hours of VA-ECMO support and 60 minutes of post-weaning ventilation. Sham and septic shock groups underwent mechanical ventilation for equivalent durations. Invasive mean arterial pressure monitoring, echocardiographic examinations, and blood gas analysis revealed the efficacy of VA-ECMO in restoring circulation and ensuring adequate tissue oxygenation in septic shock rats. Post-experiment pathology exhibited the potential of VA-ECMO in mitigating major organ injury. In summary, our study successfully established a stable septic shock rat model with the implementation of VA-ECMO, offering a valuable platform to explore molecular mechanisms underlying VA-ECMO's impact on septic shock.

Management Changes After Echocardiography Are Associated With Improved Outcomes in Critically Ill Children

OBJECTIVES

To evaluate management changes and outcomes in critically ill children after formal echocardiography.

DESIGN

Retrospective cohort study between January 1, 2011, and December 31, 2020.

SETTING

Tertiary care children's hospital.

PATIENTS

Patients from 1 to 18 years who had formal echocardiography within 72 hours of ICU admission and who were intubated and on vasoactive infusions at the time of the study. Patients were stratified into two cardiac function groups: 1) near-normal cardiac function and 2) depressed cardiac function.

METHODS

Clinical variables were abstracted from the electronic medical record and placed in time sequence relative to echocardiography. Vasoactive and fluid management strategies in place before echocardiography were associated with markers of tissue perfusion and volume overload. Management changes after echocardiography were characterized and associated with outcomes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among patients eventually found to have depressed cardiac function, the use of vasoconstrictors was associated with worse lactate clearance and oxygen extraction ratio. Use of vasoconstrictors in this cohort was also associated with a more liberal fluid management strategy, evidence of increased lung water, and a worse Sp o2 /F io2 . An echocardiogram demonstrated depressed cardiac function was likely to be followed by management changes that favored inotropes and more conservative fluid administration. Patients with depressed cardiac function who were switched to inotropes were more likely to be extubated and to wean off vasoactive support compared with those patients who remained on vasoconstrictors.

CONCLUSIONS

Among patients with depressed cardiac function, alterations in management strategy after echocardiography are associated with shortened duration of intensive care interventions.

Evaluation of Automated Finger Compression for Capillary Refill Time Measurement in Pediatrics

OBJECTIVES

Early shock reversal is crucial to improve patient outcomes. Capillary refill time (CRT) is clinically important to identify and monitor shock in children but has issues with inconsistency. To minimize inconsistency, we evaluated a CRT monitoring system using an automated compression device. Our objective was to determine proper compression pressure in children.

METHODS

Clinician force for CRT was collected during manual CRT measurement as a reference for automated compression in a previous study (12.9 N, 95% confidence interval, 12.5-13.4; n = 454). An automated compression device with a soft inflation bladder was fitted with a force sensor. We evaluated the effectiveness of the automated pressure to eliminate pulsatile blood flow from the distal phalange. Median and variance of CRT analysis at each pressure was compared.

RESULTS

A comparison of pressures at 300 to 500 mm Hg on a simulated finger yielded a force of 5 to 10 N, and these pressures were subsequently used for automated compression for CRT. Automated compression was tested in 44 subjects (median age, 33 months; interquartile range [IQR], 14-56 months). At interim analysis of 17 subjects, there was significant difference in the waveform with residual pulsatile blood flow (9/50: 18% at 300 mm Hg, 5/50:10% at 400 mm Hg, 0/51: 0% at 500 mm Hg, P = 0.008). With subsequent enrollment of 27 subjects at 400 and 500 mm Hg, none had residual pulsatile blood flow. There was no difference in the CRT: median 1.8 (IQR, 1.06-2.875) in 400 mm Hg vs median 1.87 (IQR, 1.25-2.8325) in 500 mm Hg, P = 0.81. The variance of CRT was significantly larger in 400 mm Hg: 2.99 in 400 mm Hg vs. 1.35 in 500 mm Hg, P = 0.02, Levene's test. Intraclass correlation coefficient for automated CRT was 0.56 at 400 mm Hg and 0.78 at 500 mm Hg.

CONCLUSIONS

Using clinician CRT measurement data, we determined either 400 or 500 mm Hg is an appropriate pressure for automated CRT, although 500 mm Hg demonstrates superior consistency.

Timing of Kidney Replacement Therapy Initiation and Survival During Pediatric Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Study

To characterize kidney replacement therapy (KRT) and pediatric extracorporeal membrane oxygenation (ECMO) outcomes and to identify the optimal timing of KRT initiation during ECMO associated with increased survival. Observational retrospective cohort study using the Extracorporeal Life Support Organization Registry database in children (0-18 yo) on ECMO from January 1, 2016, to December 31, 2020. Of the 14,318 ECMO runs analyzed, 26% of patients received KRT during ECMO. Patients requiring KRT before ECMO had increased mortality to ECMO decannulation (29% vs. 17%, OR 1.97, P < 0.001) and to hospital discharge (58% vs. 39%, OR 2.16, P < 0.001). Patients requiring KRT during ECMO had an increased mortality to ECMO decannulation (25% vs. 15%, OR 1.85, P < 0.001) and to hospital discharge (56% vs. 34%, OR 2.47, P < 0.001). Multivariable logistic regression demonstrated that the need for KRT during ECMO was an independent predictor for mortality to ECMO decannulation (OR 1.49, P < 0.001) and to hospital discharge (OR 2.02, P < 0.001). Patients initiated on KRT between 24 and 72 hours after cannulation were more likely to survive to ECMO decannulation and showed a trend towards survival to hospital discharge as compared to those initiated before 24 hours and after 72 hours.

Association between maximum norepinephrine dosage and mortality risk in neonates with septic shock

The high-dose usage of norepinephrine is thought to cause high mortality in patients with septic shock. This study aims to explores the correlation between the maximum norepinephrine (NE) dosage (MND) and mortality in neonates with septic shock. This retrospective cohort study included neonates with evidence of septic shock and those who received NE infusion. The study included 123 neonates, with 106 in the survival group and 17 in the death group. The death group exhibited significantly lower birth weight (p = 0.022), 1-min Apgar score (p = 0.005), serum albumin (p < 0.001), and base excess (BE) (p = 0.001) levels, but higher lactate (LAC) levels (p = 0.009) compared to the survival group. MND demonstrated an ROC area under the curve of 0.775 (95% CI 0.63-0.92, p < 0.001) for predicting mortality, with an optimal threshold of 0.3 µg/(kg·min), a sensitivity of 82.4%, and a specificity of 75.5%. Multivariate logistic regression indicated that an MND > 0.3 µg/(kg·min) (OR, 12.08, 95% CI 2.28-64.01) was associated with a significantly higher mortality risk. Spearman rank correlation showed a positive correlation between MND and LAC (r = 0.252, p = 0.005), vasoactive-inotropic score (VIS) (r = 0.836, p < 0.001), and a negative correlation with BE (r = - 0.311, p = 0.001). MND > 0.3 µg/(kg min) is a useful predictive marker of mortality in neonatal septic shock.

ExtraCorporeal Membrane Oxygenation in the therapy for REfractory Septic shock with Cardiac function Under Estimated (ECMO-RESCUE): study protocol for a prospective, multicentre, non-randomised cohort study

INTRODUCTION

Severe septic cardiomyopathy (SCM) is one of the main causes of refractory septic shock (RSS), with a high mortality. The application of venoarterial extracorporeal membrane oxygenation (ECMO) to support the impaired cardiac function in patients with septic shock remains controversial. Moreover, no prospective studies have been taken to address whether venoarterial ECMO treatment could improve the outcome of patients with sepsis-induced cardiogenic shock. The objective of this study is to assess whether venoarterial ECMO treatment can improve the 30-day survival rate of patients with sepsis-induced refractory cardiogenic shock.

METHODS AND ANALYSIS

ExtraCorporeal Membrane Oxygenation in the therapy for REfractory Septic shock with Cardiac function Under Estimated is a prospective, multicentre, non-randomised, cohort study on the application of ECMO in SCM. At least 64 patients with SCM and RSS will be enrolled in an estimated ratio of 1:1.5. Participants taking venoarterial ECMO during the period of study are referred to as cohort 1, and patients receiving only conventional therapy without ECMO belong to cohort 2. The primary outcome is survival in a 30-day follow-up period. Other end points include survival to intensive care unit (ICU) discharge, hospital survival, 6-month survival, quality of life for long-term survival (EQ-5D score), successful rate of ECMO weaning, long-term survivors' cardiac function, the number of days alive without continuous renal replacement therapy, mechanical ventilation and vasopressor, ICU and hospital length of stay, the rate of complications potentially related to ECMO treatment.

ETHICS AND DISSEMINATION

The trial has been approved by the Clinical Research and Application Institutional Review Board of the Second Affiliated Hospital of Guangzhou Medical University (2020-hs-51). Participants will be screened and enrolled from ICU patients with septic shock by clinicians, with no public advertisement for recruitment. Results will be disseminated in research journals and through conference presentations.

TRIAL REGISTRATION NUMBER

NCT05184296.

Resuscitating the macro- vs. microcirculation in septic shock

PURPOSE OF REVIEW

This review summarizes current literature about the relationships between macro and microcirculation and their practical clinical implications in children with septic shock.

RECENT FINDINGS

Current evidence from experimental and clinical observational studies in children and adults with septic shock reveals that the response to treatment and resuscitation is widely variable. Furthermore, there is a loss of hemodynamic coherence, as resuscitation-induced improvement in macrocirculation (systemic hemodynamic parameters) does not necessarily result in a parallel improvement in the microcirculation. Therefore, patient-tailored monitoring is essential in order to adjust treatment requirements during resuscitation in septic shock. Optimal monitoring must integrate macrocirculation (heart rate, blood pressure, cardiac output, and ultrasound images), microcirculation (videomicroscopy parameters and capillary refill time) and cellular metabolism (lactic acid, central venous blood oxygen saturation, and difference of central venous to arterial carbon dioxide partial pressure).

SUMMARY

There is a dire need for high-quality studies to assess the relationships between macrocirculation, microcirculation and tissue metabolism in children with septic shock. The development of reliable and readily available microcirculation and tissue perfusion biomarkers (other than lactic acid) is also necessary to improve monitoring and treatment adjustment in such patients.

Risk Factors of Neonatal Acute Respiratory Distress Syndrome Based on the Montreux Definition in Neonates with Sepsis: A Retrospective Case-Control Study

OBJECTIVE

The aim of the study is to analyze the risk factors for neonatal acute respiratory distress syndrome (NARDS) development based on the Montreux definition among near- and full-term neonates with sepsis and received meropenem.

STUDY DESIGN

This was a single-center, case-control, retrospective trial from January 2019 to June 2020. Newborns of gestational ages (GAs) ≥35 weeks, diagnosed with sepsis and received meropenem were included. Patients who developed NARDS subsequently were defined as the study group (NARDS group), while the others without NARDS were enrolled in the control group (non-NARDS group).

RESULTS

Out of 213 eligible neonates, NARDS occurred in 52 (24.4%) cases. In univariate analysis, infants with NARDS had a lower GA and birth weight, but a higher rate of premature birth (p <0.05). The median onset times of sepsis were earlier among neonates with NARDS compared with those without NARDS (1 [1,1] vs. 6 [1,15] days, p <0.001). Neonates with NARDS were more likely to suffer from early-onset sepsis (EOS), persistent pulmonary hypertension of newborns, pulmonary hemorrhage, septic shock, and patent ductus arteriosus (p <0.05). During labor, women whose neonates experienced NARDS were more likely to have a cesarean delivery (67.3 vs. 46.6%, p = 0.009) and likely to receive at least one dose of corticosteroids (21.2 vs. 5.0%, p = 0.001). In multivariable analyses, factors remaining independently associated with NARDS were premature birth, cesarean delivery, EOS, and septic shock. Compared with conventional inflammatory markers for NARDS, procalcitonin (PCT) was correlated with septic neonates who developed NARDS (p = 0.012) but had a low diagnostic value (area under the curve [AUC] = 0.609). C-reactive protein, white blood cells, and PLT did not correlate with morbidity of NARDS (AUC <0.05 and p >0.05).

CONCLUSION

Premature birth, cesarean delivery, EOS, and septic shock were independently associated with NARDS among near- and full-term septic neonates. PCT showed limited predictive value for NARDS.

KEY POINTS

· NARDS is serious and sepsis is proved as a cause for it.. · But rare study suggests the risk factors of NARDS based on the Montreux definition.. · This study may first found the independent risk factors associated with NARDS in septic neonates..

Survey of Thai Physicians' Practice in Pediatric Septic Shock

(1) Background: Sepsis management in children is crucial, especially in emergency services. This study aims to evaluate Thai physicians' knowledge gaps in the emergency management of sepsis in children and to evaluate their adherence to the current sepsis clinical practice guidelines. (2) Methods: This is a cross-sectional survey of Thai physicians' management of septic shock in children. The survey was conducted through online questionnaires from March 2019-April 2019. (3) Results: Of the 366 responders, 362 (98.9%) were completed. Most of the responders were general practitioners (89.2%) and pediatricians (10.8%). The time from positive sepsis screening to being evaluated by physicians within 15 min was reported by 83.9%. The most common choice of fluid resuscitation was normal saline solution (77.3%). The practice of a fluid loading dose (20 mL/kg) consistent with the guidelines was 56.3%. The selection of the first vasoactive agent in warm shock (norepinephrine) and cold shock (epinephrine) according to recommendations in the guidelines was 74.3% and 36.2%, respectively. There was a significant difference between general practitioners and pediatricians in terms of knowledge about initial fluid resuscitation and the optimal vasoactive agent in cold shock (p-value < 0.001). In the multivariate model, factors associated with the guideline-based decision-making of vasoactive agent choice for cold shock were specialist training (pediatrician) and the completion of sepsis management training certification, with adjusted odds ratios (AORs) of 7.81 and 2.96, but working experience greater than ten years was inconsistent with the guideline-based decision-making (AOR 0.14). (4) Conclusions: Thai clinicians were unfamiliar with pediatric sepsis therapy standards, specifically the quantity of early fluid resuscitation and the appropriate vasoactive medications for cold shock. To encourage adherence to the guidelines, we propose a regularly required training course on pediatric sepsis management.

Application of Cardiovascular Physiology to the Critically Ill Patient

OBJECTIVES

To use the ventricular pressure-volume relationship and time-varying elastance model to provide a foundation for understanding cardiovascular physiology and pathophysiology, interpreting advanced hemodynamic monitoring, and for illustrating the physiologic basis and hemodynamic effects of therapeutic interventions. We will build on this foundation by using a cardiovascular simulator to illustrate the application of these principles in the care of patients with severe sepsis, cardiogenic shock, and acute mechanical circulatory support.

DATA SOURCES

Publications relevant to the discussion of the time-varying elastance model, cardiogenic shock, and sepsis were retrieved from MEDLINE. Supporting evidence was also retrieved from MEDLINE when indicated.

STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS

Data from relevant publications were reviewed and applied as indicated.

CONCLUSIONS

The ventricular pressure-volume relationship and time-varying elastance model provide a foundation for understanding cardiovascular physiology and pathophysiology. We have built on this foundation by using a cardiovascular simulator to illustrate the application of these important principles and have demonstrated how complex pathophysiologic abnormalities alter clinical parameters used by the clinician at the bedside.

An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication

Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.