1
|
Sankar J, Das RR, Banothu KK. Fluid resuscitation in children with severe infection and septic shock: a systematic review and meta-analysis. Eur J Pediatr 2024:10.1007/s00431-024-05653-w. [PMID: 38916738 DOI: 10.1007/s00431-024-05653-w] [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: 10/01/2023] [Revised: 02/09/2024] [Accepted: 06/12/2024] [Indexed: 06/26/2024]
Abstract
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.
Collapse
Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.
| | - Rashmi Ranjan Das
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, 751019, India
| | - Kiran Kumar Banothu
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| |
Collapse
|
2
|
Huang W, Huang Y, Ke L, Hu C, Chen P, Hu B. Perspectives for capillary refill time in clinical practice for sepsis. Intensive Crit Care Nurs 2024; 84:103743. [PMID: 38896965 DOI: 10.1016/j.iccn.2024.103743] [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: 01/04/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Recent studies demonstrated the benefits of CRT in guiding fluid therapy for sepsis. However, lack of consistency among physicians in how to perform and interpret CRT has led to a low interobserver agreement for this assessment tool, which prevents its availability in sepsis clinical settings. OBJECTIVE To give physicians a concise overview of CRT and explore recent evidence on its reliability and value in the management of sepsis. RESEARCH DESIGN A narrative review. RESULTS This narrative review summarizes the factors affecting CRT values, for example, age, sex, temperature, light, observation techniques, work experience, training level and differences in CRT measurement methods. The methods of reducing the variability of CRT are synthesized. Based on studies with highly reproducible CRT measurements and an excellent inter-rater concordance, we recommend the standardized CRT assessment method. The threshold of normal CRT values is discussed. The application of CRT in different phases of sepsis management is summarized. CONCLUSIONS Recent data confirm the value of CRT in critically ill patients. CRT should be detected by trained physicians using standardized methods and reducing the effect of ambient-related factors. Its association with severe infection, microcirculation, tissue perfusion response, organ dysfunction and adverse outcomes makes this approach a very attractive tool in sepsis. Further studies should confirm its value in the management of sepsis. IMPLICATIONS FOR CLINICAL PRACTICE As a simple assessment, CRT deserves more attention even though it has not been widely applied at the bedside. CRT could provide nursing staff with patient's microcirculatory status, which may help to develop individualized nursing plans and improve the patient's care quality and treatment outcomes.
Collapse
Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Yiyan Huang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
| | - Li Ke
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Pengyu Chen
- Department of Urology, Shenzhen Children's Hospital, Futian District, Shenzhen 518000, Guangdong, China.
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| |
Collapse
|
3
|
Chen WY, Guo ZB, Kong TY, Chen WX, Chen XH, Yang Q, Wen YC, Wen QR, Zhou F, Xiong XM, Wen DL, Zhang ZH. 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. BMJ Open 2024; 14:e079212. [PMID: 38858161 PMCID: PMC11168177 DOI: 10.1136/bmjopen-2023-079212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 05/10/2024] [Indexed: 06/12/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Wei-Yan Chen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Ze-Bin Guo
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Tian-Yu Kong
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Wei-Xiao Chen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Xiao-Hua Chen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Qilin Yang
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Yi-Chao Wen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Qi-Rui Wen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Feng Zhou
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Xu-Ming Xiong
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - De-Liang Wen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Zhen-Hui Zhang
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| |
Collapse
|
4
|
Lane RD, Richardson T, Scott HF, Paul RM, Balamuth F, Eisenberg MA, Riggs R, Huskins WC, Horvat CM, Keeney GE, Hueschen LA, Lockwood JM, Gunnala V, McKee BP, Patankar N, Pinto VL, Sebring AM, Sharron MP, Treseler J, Wilkes JJ, Workman JK. Delays to Antibiotics in the Emergency Department and Risk of Mortality in Children With Sepsis. JAMA Netw Open 2024; 7:e2413955. [PMID: 38837160 PMCID: PMC11154154 DOI: 10.1001/jamanetworkopen.2024.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/07/2024] [Indexed: 06/06/2024] Open
Abstract
Importance Pediatric consensus guidelines recommend antibiotic administration within 1 hour for septic shock and within 3 hours for sepsis without shock. Limited studies exist identifying a specific time past which delays in antibiotic administration are associated with worse outcomes. Objective To determine a time point for antibiotic administration that is associated with increased risk of mortality among pediatric patients with sepsis. Design, Setting, and Participants This retrospective cohort study used data from 51 US children's hospitals in the Improving Pediatric Sepsis Outcomes collaborative. Participants included patients aged 29 days to less than 18 years with sepsis recognized within 1 hour of emergency department arrival, from January 1, 2017, through December 31, 2021. Piecewise regression was used to identify the inflection point for sepsis-attributable 3-day mortality, and logistic regression was used to evaluate odds of sepsis-attributable mortality after adjustment for potential confounders. Data analysis was performed from March 2022 to February 2024. Exposure The number of minutes from emergency department arrival to antibiotic administration. Main Outcomes and Measures The primary outcome was sepsis-attributable 3-day mortality. Sepsis-attributable 30-day mortality was a secondary outcome. Results A total of 19 515 cases (median [IQR] age, 6 [2-12] years) were included. The median (IQR) time to antibiotic administration was 69 (47-116) minutes. The estimated time to antibiotic administration at which 3-day sepsis-attributable mortality increased was 330 minutes. Patients who received an antibiotic in less than 330 minutes (19 164 patients) had sepsis-attributable 3-day mortality of 0.5% (93 patients) and 30-day mortality of 0.9% (163 patients). Patients who received antibiotics at 330 minutes or later (351 patients) had 3-day sepsis-attributable mortality of 1.2% (4 patients), 30-day mortality of 2.0% (7 patients), and increased adjusted odds of mortality at both 3 days (odds ratio, 3.44; 95% CI, 1.20-9.93; P = .02) and 30 days (odds ratio, 3.63; 95% CI, 1.59-8.30; P = .002) compared with those who received antibiotics within 330 minutes. Conclusions and Relevance In this cohort of pediatric patients with sepsis, 3-day and 30-day sepsis-attributable mortality increased with delays in antibiotic administration 330 minutes or longer from emergency department arrival. These findings are consistent with the literature demonstrating increased pediatric sepsis mortality associated with antibiotic administration delay. To guide the balance of appropriate resource allocation with time for adequate diagnostic evaluation, further research is needed into whether there are subpopulations, such as those with shock or bacteremia, that may benefit from earlier antibiotics.
Collapse
Affiliation(s)
- Roni D. Lane
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City
| | | | - Halden F. Scott
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Raina M. Paul
- Pediatric Emergency Medicine, Children’s Hospital of Orange County, Orange, California
| | - Fran Balamuth
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Matthew A. Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruth Riggs
- Children’s Hospital Association, Lenexa, Kansas
| | - W. Charles Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Christopher M. Horvat
- Department of Critical Care Medicine, UPMC, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Grant E. Keeney
- Department of Pediatric Emergency Medicine, Mary Bridge Children’s Hospital, Tacoma, Washington
| | - Leslie A. Hueschen
- Division of Emergency Medicine, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City, Kansas City
| | - Justin M. Lockwood
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Vishal Gunnala
- Division of Critical Care Medicine, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Bryan P. McKee
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio
| | - Nikhil Patankar
- Pediatric Critical Care, Baptist St Anthony’s Health System, Amarillo, Texas
| | - Venessa Lynn Pinto
- Division of Pediatric Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Sebring
- Division of Pediatric Critical Care, Department of Pediatrics, Atrium Health Levine Children’s, Charlotte, North Carolina
| | - Matthew P. Sharron
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Jennifer Treseler
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Jennifer J. Wilkes
- Division of Cancer and Blood Disorders, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jennifer K. Workman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City
| |
Collapse
|
5
|
Abdelaziz TA, Karam NA, Ismail WI, Askary NMA, Baz EG. Lactate dynamics in paediatric patients with severe sepsis: insights from a prospective cohort study. BMC Pediatr 2024; 24:345. [PMID: 38760748 PMCID: PMC11102193 DOI: 10.1186/s12887-024-04809-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/03/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Sepsis is an infection-related systemic inflammatory response that often leads to elevated lactate levels. Monitoring lactate levels during severe sepsis is vital for influencing clinical outcomes. The aim of this study was to assess the association between plasma lactate levels and mortality in children with severe sepsis or septic shock. METHODS The current prospective study was conducted in the PICU of University Children's Hospital. The International Paediatric Sepsis Consensus Conference criteria for Definitions of Sepsis and Organ Failure in 2005 were used to diagnose patients with sepsis. We measured plasma lactate levels upon admission (Lac H0) and 6 h later (Lac H6). The static indices included the absolute lactate values (Lac H0 and Lac H6), while the dynamic indices included the delta-lactate level (ΔLac) and the 6-hour lactate clearance. The 6-hour lactate clearance was calculated using the following formula: [(Lac H0-Lac H6)100/Lac H0]. ΔLac was calculated as the difference between the Lac H0 and Lac H6 levels. Patient survival or death after a PICU stay was the primary outcome. RESULTS A total of 46 patients were included in this study: 25 had septic shock, and 21 had severe sepsis. The mortality rate was 54.3%. The Lac H0 did not significantly differ between survivors and nonsurvivors. In contrast, the survivors had significantly lower Lac H6 levels, higher ΔLac levels, and higher 6-hour lactate clearance rates than nonsurvivors. Lactate clearance rates below 10%, 20%, and 30% were significantly associated with mortality. The best cut-off values for the lactate clearance rate and Lac H6 for the prediction of mortality in the PICU were < 10% and ≥ 4 mmol/L, respectively. Patients with higher Lac H6 levels and lower lactate clearance rates had significantly higher PICU mortality based on Kaplan-Meier survival curve analysis. CONCLUSIONS This study highlights the significance of lactate level trends over time for the prediction of mortality in the PICU in patients with severe sepsis or septic shock. Elevated lactate levels and decreased lactate clearance six hours after hospitalisation are associated with a higher mortality rate.
Collapse
Affiliation(s)
- Tarek A Abdelaziz
- Paediatric Department, Faculty of Medicine, Zagazig University, Zagazig city, Egypt.
| | - Nehad Ahmed Karam
- Paediatric Department, Faculty of Medicine, Zagazig University, Zagazig city, Egypt
| | - Weaam Ibrahim Ismail
- Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig city, Egypt
| | | | - Eman Gamal Baz
- Paediatric Department, Faculty of Medicine, Zagazig University, Zagazig city, Egypt
| |
Collapse
|
6
|
Chen T, Ye L, Zhu J, Tan B, Yi Q, Sun Y, Xie Q, Xiang H, Wang R, Tian J, Xu H. Inhibition of Pyruvate Dehydrogenase Kinase 4 Attenuates Myocardial and Mitochondrial Injury in Sepsis-Induced Cardiomyopathy. J Infect Dis 2024; 229:1178-1188. [PMID: 37624974 DOI: 10.1093/infdis/jiad365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/10/2023] [Accepted: 08/23/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Sepsis-induced cardiomyopathy (SIC) is a cardiac dysfunction caused by sepsis, with mitochondrial dysfunction being a critical contributor. Pyruvate dehydrogenase kinase 4 (PDK4) is a kinase of pyruvate dehydrogenase with multifaceted actions in mitochondrial metabolism. However, its role in SIC remains unknown. METHODS Serum PDK4 levels were measured and analyzed in 27 children with SIC, 30 children with sepsis, and 29 healthy children. In addition, for mice exhibiting SIC, the effects of PDK4 knockdown or inhibition on the function and structure of the myocardium and mitochondria were assessed. RESULTS The findings from the analysis of children with SIC revealed that PDK4 was significantly elevated and correlated with disease severity and organ injury. Nonsurvivors displayed higher serum PDK4 levels than survivors. Furthermore, mice with SIC benefited from PDK4 knockdown or inhibition, showing improved myocardial contractile function, reduced myocardial injury, and decreased mitochondrial structural injury and dysfunction. In addition, inhibition of PDK4 decreased the inhibitory phosphorylation of PDHE1α (pyruvate dehydrogenase complex E1 subunit α) and improved abnormal pyruvate metabolism and mitochondrial dysfunction. CONCLUSIONS PDK4 is a potential biomarker for the diagnosis and prognosis of SIC. In experimental SIC, PDK4 promoted mitochondrial dysfunction with increased phosphorylation of PDHE1α and abnormal pyruvate metabolism.
Collapse
Affiliation(s)
- Tangtian Chen
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Liang Ye
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China
- Department of Pediatrics, Chongqing Health Center for Women and Children, Chongqing 401147, China
| | - Jing Zhu
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Bin Tan
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Qin Yi
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Yanting Sun
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
- Centre of Clinical Laboratory, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Qiumin Xie
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Han Xiang
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Rui Wang
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Jie Tian
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
- Department of Cardiovascular Internal Medicine, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Hao Xu
- Department of Pediatric Research Institute, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
- Department of Clinical Laboratory, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| |
Collapse
|
7
|
Baker AH, Mazandi VM, Norton JS, Melendez E. Emergency Department Sepsis Triage Scoring Tool Elements Associated With Hypotension Within 24 Hours in Children With Fever and Tachycardia. Pediatr Emerg Care 2024:00006565-990000000-00416. [PMID: 38471759 DOI: 10.1097/pec.0000000000003153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE Pediatric sepsis screening is becoming the standard of care for children presenting to the emergency department (ED) and has been shown to improve recognition of severe sepsis, but it is unknown if these screening tools can predict progression of disease. The objective of this study was to determine if any elements of a sepsis triage trigger tool were predictive of progression to hypotensive shock in children presenting to the ED with fever and tachycardia. METHODS This study is a retrospective case-control study of children ≤18 years presenting to an ED with fever and tachycardia, comparing those who went on to develop hypotensive shock in the subsequent 24 hours (case) to those who did not (control). Primary outcome was the proportion of encounters where the patient had specific abnormal vital signs or clinical signs as components of the sepsis triage score. The secondary outcomes were the proportion of encounters where the patient had a sepsis risk factor. RESULTS During the study period, there were 94 patients who met case criteria and 186 controls selected. In the adjusted multivariable model, the 2 components of the sepsis triage score that were more common in case patients were the presence of severe cerebral palsy (adjusted odds ratio, 9.4 [3.7, 23.9]) and abnormal capillary refill at triage (adjusted odds ratio, 3.1 [1.4, 6.9]). CONCLUSIONS Among children who present to a pediatric ED with fever and tachycardia, those with prolonged capillary refill at triage or severe cerebral palsy were more likely to progress to decompensated septic shock, despite routine ED care.
Collapse
Affiliation(s)
| | | | - Jackson S Norton
- Division of Medical Critical Care, Boston Children's Hospital, Boston, MA
| | - Elliot Melendez
- Division of Pediatric Critical Care, Connecticut Children's Medical Center, Hartford, CT
| |
Collapse
|
8
|
Huang D, You C, Mai X, Li L, Meng Q, Liang Z. Lung ultrasound-guided fluid resuscitation in neonatal septic shock: A randomized controlled trial. Eur J Pediatr 2024; 183:1255-1263. [PMID: 38095714 DOI: 10.1007/s00431-023-05371-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 03/20/2024]
Abstract
This randomized controlled trial aimed to determine whether lung ultrasound-guided fluid resuscitation improves the clinical outcomes of neonates with septic shock. Seventy-two patients were randomly assigned to undergo treatment with lung ultrasound-guided fluid resuscitation (LUGFR), or with usual fluid resuscitation (Control) in the first 6 h since the start of the sepsis treatment. The primary study outcome was 14-day mortality after randomization. Fourteen-day mortalities in the two groups were not significantly different (LUGFR group, 13.89%; control group, 16.67%; p = 0.76; hazard ratio 0.81 [95% CI 0.27-2.50]). The LUGFR group experienced shorter length of neonatal intensive care unit (NICU) stays (21 vs. 26 days, p = 0.04) and hospital stays (32 vs. 39 days, p = 0.01), and less fluid was used in the first 6 h (77 vs. 106 mL/kg, p = 0.02). Further, our study found that ultrasound-guided fluid resuscitation can significantly reduce the incidence of acute kidney injury (25% vs. 47.2%, p = 0.05) and intracranial hemorrhage (grades I-II) within 72 h (13.9% vs. 36.1%, p = 0.03). However, no significant difference was found in the resolution of shock within 1 h or 6 h, use of mechanical ventilation or vasopressor support, time to achieve lactate level < 2 mmol/L, and the number of participants developing hepatomegaly in the first 6 h. CONCLUSION Lung ultrasound is a noninvasive and convenient tool for predicting fluid overload in neonatal septic shock. Fluid resuscitation guided by lung ultrasound can shorten the length of hospital and NICU stays, reduce the amount of fluid used in the first 6 h, and reduce the risk of acute kidney injury and intracranial hemorrhage. TRIAL REGISTRATION Registered in Guangdong Second Provincial General Hospital: 2021-IIT-156-EK, date of registration: November 13, 2021. And ClinicalTrials.gov: NCT06144463 (retrospectively registered). WHAT IS KNOWN • Excessive fluid resuscitation in neonates with septic shock had worse outcomes. WHAT IS NEW • Lung ultrasound should be routinely used to guide fluid resuscitation in neonatal septic shock.
Collapse
Affiliation(s)
- Dabin Huang
- Department of Pediatrics, Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong Province, China
- Department of Pediatrics, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuming You
- Department of Pediatrics, Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong Province, China
| | - Xiaowei Mai
- Department of Emergency, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Lin Li
- Department of Pediatrics, Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong Province, China
| | - Qiong Meng
- Department of Pediatrics, Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong Province, China.
| | - Zhenyu Liang
- Department of Pediatrics, Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong Province, China.
| |
Collapse
|
9
|
Gendreau S, Frapard T, Carteaux G, Kwizera A, Adhikari NKJ, Mer M, Hernandez G, Mekontso Dessap A. Geo-economic Influence on the Effect of Fluid Volume for Sepsis Resuscitation: A Meta-Analysis. Am J Respir Crit Care Med 2024; 209:517-528. [PMID: 38259196 DOI: 10.1164/rccm.202309-1617oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/22/2024] [Indexed: 01/24/2024] Open
Abstract
Rationale: Sepsis management relies on fluid resuscitation avoiding fluid overload and its related organ congestion. Objectives: To explore the influence of country income group on risk-benefit balance of fluid management strategies in sepsis. Methods: We searched e-databases for all randomized controlled trials on fluid resuscitation in patients with sepsis or septic shock up to January 2023, excluding studies on hypertonic fluids, colloids, and depletion-based interventions. The effect of fluid strategies (higher versus lower volumes) on mortality was analyzed per income group (i.e., low- and middle-income countries [LMICs] or high-income countries [HICs]). Measurements and Main Results: Twenty-nine studies (11,798 patients) were included in the meta-analysis. There was a numerically higher mortality in studies of LMICs as compared with those of HICs: median, 37% (interquartile range [IQR]: 26-41) versus 29% (IQR: 17-38; P = 0.06). Income group significantly interacted with the effect of fluid volume on mortality: Higher fluid volume was associated with higher mortality in LMICs but not in HICs: odds ratio (OR), 1.47; 95% confidence interval (95% CI): 1.14-1.90 versus 1.00 (95% CI: 0.87-1.16), P = 0.01 for subgroup differences. Higher fluid volume was associated with increased need for mechanical ventilation in LMICs (OR, 1.24 [95% CI: 1.08-1.43]) but not in HICs (OR, 1.02 [95% CI: 0.80-1.29]). Self-reported access to mechanical ventilation also significantly influenced the effect of fluid volume on mortality, which increased with higher volumes only in settings with limited access to mechanical ventilation (OR: 1.45 [95% CI: 1.09-1.93] vs. 1.09 [95% CI: 0.93-1.28], P = 0.02 for subgroup differences). Conclusions: In sepsis trials, the effect of fluid resuscitation approach differed by setting, with higher volume of fluid resuscitation associated with increased mortality in LMICs and in settings with restricted access to mechanical ventilation. The precise reason for these differences is unclear and may be attributable in part to resource constraints, participant variation between trials, or other unmeasured factors.
Collapse
Affiliation(s)
- Ségolène Gendreau
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
| | - Thomas Frapard
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
| | - Guillaume Carteaux
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
- INSERM U955, Faculté de Santé de Créteil, Université Paris Est Créteil, Créteil, France
| | - Arthur Kwizera
- Department of Anaesthesia and Critical Care, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Neill K J Adhikari
- Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Glenn Hernandez
- Facultad de Medicina, Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Armand Mekontso Dessap
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
- INSERM U955, Faculté de Santé de Créteil, Université Paris Est Créteil, Créteil, France
| |
Collapse
|
10
|
Swami VS, V. LA, Ghosh S, Reddy M. Sepsis-Induced Myocardial Dysfunction in Pediatric Septic Shock: Prevalence, Predictors, and Outcome-A Prospective Observational Study. J Pediatr Intensive Care 2024; 13:87-94. [PMID: 38571983 PMCID: PMC10987216 DOI: 10.1055/s-0041-1736550] [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: 05/15/2021] [Accepted: 09/15/2021] [Indexed: 10/19/2022] Open
Abstract
There is a paucity of literature on the prevalence, predictors, prognostic markers, and outcomes of sepsis-induced myocardial dysfunction (SMD) in pediatric septic shock. The objectives of our study were to estimate the prevalence of SMD in pediatric septic shock by point-of-care functional echocardiography (POCFE) and to study the association of SMD with severity of illness, organ dysfunctions, and outcomes. This prospective, observational study was conducted over a period of 1 year (from July 2018 to July 2019) in a 12-bed, tertiary pediatric intensive care unit (PICU) of an academic and referral hospital in South India. Children presenting with septic shock were enrolled in the study. POCFE was done within 6 hours of PICU admission and patients were categorized as having SMD based on POCFE findings. The prevalence of SMD (left ventricle ± right ventricle) was 32% (32/100). More than half of the children (54.5%) died in SMD group, whereas only 7.5% died in non-SMD group ( p < 0.001). SMD was associated with higher organ dysfunctions, worse patient outcomes, and was found to be an independent predictor of mortality. The median lactate levels were higher in SMD group (3.15 [2.7, 5] vs. 2 [1.3, 2.7], p < 0.001) as compared with non-SMD group. We observed significantly lower median lactate clearance at 6 hours in SMD than non-SMD (30.0% [-14.44, 44.22] vs. 59.8% [45.83, 71.43], p < 0.001). Lactate levels at 6 hours with a threshold of 2.4 mmol/L was a good predictor of SMD with sensitivity and specificity of 73 and 80%, respectively. SMD is not an uncommon entity in children with septic shock. SMD was associated with worse patient outcomes, organ dysfunction, and mortality. Serum lactate trends may predict SMD and can be used as prognosticate markers as well.
Collapse
Affiliation(s)
- Viresh S. Swami
- Dr. Bidari's Ashwini Institute of Child Health and Research Centre, Vijayapur, Karnataka, India
| | - Lalitha A. V.
- Department of Pediatric Intensive Care, St John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Santu Ghosh
- Department of Biostatistics, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Mounika Reddy
- Department of Pediatrics, All India Institute of Medical Sciences Bibinagar, Telangana, India
| |
Collapse
|
11
|
Warnock B, Lafferty GM, Farhat A, Colgate C, Dhar A, Gray B. Peripheral Veno-Arterial-Extracorporeal Membrane Oxygenation for Refractory Septic Shock in Children: A Multicenter Review. J Intensive Care Med 2024; 39:196-202. [PMID: 37899622 DOI: 10.1177/08850666231193357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is utilized as a rescue therapy in the management of pediatric patients with refractory septic shock. Multiple studies support the use of a central cannulation strategy in these patients. This study aimed to assess the survival of and identify mortality risk factors in pediatric patients supported with peripheral veno-arterial (VA) ECMO in the setting of septic shock. METHODS We retrospectively reviewed and compared clinical characteristics of 40 pediatric patients supported with peripheral VA ECMO for refractory septic shock, at two tertiary care children's hospitals from 2006 to 2020. Our hypothesis was that peripheral VA ECMO is effective in supporting cardiac function and improving tissue oxygenation in most pediatric patients with refractory septic shock. RESULTS The overall rate of survival to discharge was 52.5%, comparable to previously reported survival for pediatric sepsis on ECMO. With the exclusion of patients with an oncologic process, the survival rate rose to 62.5%. There was a statistically significant difference in mean pump flow rates within 2 hours of initiation of ECMO between survivors and non-survivors (98 mL/kg/min vs 76 mL/kg/min, P = .050). There was no significant difference between pre-ECMO vasoactive inotropic score (VIS) in survivors and non-survivors. A faster decrease in VIS in the first 24 hours was associated with lower mortality. CONCLUSIONS From this large case series, we conclude that peripheral VA ECMO is a safe and effective modality to support pediatric patients with refractory septic shock, provided there is establishment of high ECMO pump flows in the first few hours after cannulation and improvement in the VIS.
Collapse
Affiliation(s)
- Brielle Warnock
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indiana University Health, Indianapolis, IN, USA
| | - Gina Maria Lafferty
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
- Pediatric Intensive Care Unit, Children's Medical Center, Dallas, TX, USA
| | | | - Cameron Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Archana Dhar
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
- Pediatric Intensive Care Unit, Children's Medical Center, Dallas, TX, USA
| | - Brian Gray
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indiana University Health, Indianapolis, IN, USA
| |
Collapse
|
12
|
Charaya S, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Pattern of Fluid Overload and its Impact on Mortality Among Mechanically Ventilated Children: Secondary Analysis of the ReLiSCh Trial. Indian J Pediatr 2024:10.1007/s12098-024-05059-4. [PMID: 38403808 DOI: 10.1007/s12098-024-05059-4] [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: 10/29/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To assess the pattern of fluid overload (FO) and its impact on mortality among mechanically ventilated children. METHODS In this secondary analysis of an open-label randomized controlled trial (ReLiSCh trial, October 2020-September 2021), hemodynamically stable mechanically ventilated children (n = 100) admitted to a tertiary level pediatric intensive care unit (PICU) in North India were enrolled. The primary outcome was pattern of FO (FO% >10% and cumulative FO% from day 1-7); and secondary outcomes were pattern of FO among survivors and non-survivors, and prescription practices of maintenance fluid. RESULTS The median (IQR) age was 3.5 (0.85-7.5) y and 57% were males. Common diagnoses were pneumonia (27%), scrub typhus (14%), Landry-Guillain-Barré syndrome (9%), dengue (8%), central nervous system infections (7%) and staphylococcal sepsis (6%). Common organ dysfunction included acute respiratory distress syndrome (ARDS) (41%), shock (38%), and acute kidney injury (AKI) (9%). The duration PICU stay was 11 (7-17) d and mortality was 12%. The FO% >10% was noted in 19% children; and there was significant increase in cumulative FO% from day 1-7 [1.2 (0.2-2.6)% to 8.5 (1.7-14.3)%, (p = 0.000)]. Among non-survivors, higher proportion had FO% >10% (66.7% vs. 12.5%, p 0.0001); and trend towards higher cumulative FO% on first seven days. From day 1-7, the percentage of maintenance fluid received increased from 60 (50-71)% to 70 (60-77)% (p = 0.691). CONCLUSIONS One-fifth of mechanically ventilated children had FO% >10% and there was significant increase in cumulative FO% from day 1-7. Non-survivors had significantly higher degree of FO.
Collapse
Affiliation(s)
- Shubham Charaya
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Suresh Kumar Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| |
Collapse
|
13
|
Kallimath A, Garegrat R, Patnaik S, Singh Y, Soni NB, Suryawanshi P. Hemodynamic effects of noradrenaline in neonatal septic shock: a prospective cohort study. J Trop Pediatr 2024; 70:fmae001. [PMID: 38324898 DOI: 10.1093/tropej/fmae001] [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] [Indexed: 02/09/2024]
Abstract
BACKGROUND The incidence of neonatal septic shock in low-income countries is 26.8% with a mortality rate of 35.4%. The evidence of the hemodynamic effects of noradrenaline in neonates remains sparse. This study was carried out to evaluate the effects of noradrenaline in neonates with septic shock. METHODS This was a single-center prospective cohort study in a tertiary care hospital's level III neonatal intensive care unit. Neonates with septic shock and those who received noradrenaline as a first-line vasoactive agent were included. Clinical and hemodynamic parameters were recorded before and after one hour of noradrenaline infusion. The primary outcomes were: response at the end of one hour after starting noradrenaline infusion and mortality rate. RESULTS A total of 21 babies were analyzed. The cohort comprised 17 preterm neonates. The mean age of presentation with septic shock was 74.3 h. Resolution of shock at one hour after starting noradrenaline was achieved in 76.2% of cases. The median duration of hospital stay was 14 days. The mean blood pressure improved after the initiation of noradrenaline from 30.6 mm of Hg [standard deviation (SD) 6.1] to 37.8 mm of Hg (SD 8.22, p < 0.001). Fractional shortening improved after noradrenaline initiation from 29% (SD 13.5) to 45.1% (SD 21.1, p < 0.001). The mortality rate was 28.6% in our study. CONCLUSION Noradrenaline is a potential drug for use in neonatal septic shock, with improvement in mean blood pressure and fractional shortening; however, further studies with larger sample sizes are needed to confirm our findings before it can be recommended as first-line therapy in neonatal septic shock.
Collapse
Affiliation(s)
- Aditya Kallimath
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Reema Garegrat
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Suprabha Patnaik
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Yogen Singh
- Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA 92345, USA
| | - Naharmal B Soni
- Department of Neonatology, Sidra Medicine, 26999 Doha, Qatar
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| |
Collapse
|
14
|
Harley A, George S, Phillips N, King M, Long D, Keijzers G, Lister P, Raman S, Bellomo R, Gibbons K, Schlapbach LJ. Resuscitation With Early Adrenaline Infusion for Children With Septic Shock: A Randomized Pilot Trial. Pediatr Crit Care Med 2024; 25:106-117. [PMID: 38240535 PMCID: PMC10798589 DOI: 10.1097/pcc.0000000000003351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
OBJECTIVES In children with septic shock, guidelines recommend resuscitation with 40-60 mL/kg of fluid boluses, yet there is a lack of evidence to support this practice. We aimed to determine the feasibility of a randomized trial comparing early adrenaline infusion with standard fluid resuscitation in children with septic shock. DESIGN Open-label parallel randomized controlled, multicenter pilot study. The primary end point was feasibility; the exploratory clinical endpoint was survival free of organ dysfunction by 28 days. SETTING Four pediatric Emergency Departments in Queensland, Australia. PATIENTS Children between 28 days and 18 years old with septic shock. INTERVENTIONS Patients were assigned 1:1 to receive a continuous adrenaline infusion after 20 mL/kg fluid bolus resuscitation (n = 17), or standard care fluid resuscitation defined as delivery of 40 to 60 mL/kg fluid bolus resuscitation prior to inotrope commencement (n = 23). MEASUREMENTS AND MAIN RESULTS Forty of 58 eligible patients (69%) were consented with a median age of 3.7 years (interquartile range [IQR], 0.9-12.1 yr). The median time from randomization to inotropes was 16 minutes (IQR, 12-26 min) in the intervention group, and 49 minutes (IQR, 29-63 min) in the standard care group. The median amount of fluid delivered during the first 24 hours was 0 mL/kg (IQR, 0-10.0 mL/kg) in the intervention group, and 20.0 mL/kg (14.6-28.6 mL/kg) in the standard group (difference, -20.0; 95% CI, -28.0 to -12.0). The number of days alive and free of organ dysfunction did not differ between the intervention and standard care groups, with a median of 27 days (IQR, 26-27 d) versus 26 days (IQR, 25-27 d). There were no adverse events reported associated with the intervention. CONCLUSIONS In children with septic shock, a protocol comparing early administration of adrenaline versus standard care achieved separation between the study arms in relation to inotrope and fluid bolus use.
Collapse
Affiliation(s)
- Amanda Harley
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- Children`s Critical Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pediatric and Neonatal Intensive Care Unit, and Children`s Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Shane George
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Natalie Phillips
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Megan King
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Paula Lister
- Children`s Critical Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- Children`s Critical Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pediatric and Neonatal Intensive Care Unit, and Children`s Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Pediatric and Neonatal Intensive Care Unit, and Children`s Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
15
|
Luo L, Qin WL, Huang HM, Ou ZH, Peng ZH. Fever glove hand-shake method safe blood collection from children's fingertips in COVID-19 fever clinic. World J Clin Cases 2023; 11:7965-7971. [DOI: 10.12998/wjcc.v11.i33.7965] [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: 08/30/2023] [Revised: 09/21/2023] [Accepted: 11/17/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND During the coronavirus disease 2019 (COVID-19) epidemic, the fever clinic is an important link for screening and diagnosing whether a patient is infected with the novel coronavirus. Blood collection from children’s fingertips is a commonly used detection method; however, in children, the blood collection process may cause discomfort and resistance. To address this problem, the use of heating gloves combined with hand swinging can be considered for fingertip blood collection in children.
AIM To explore the application of fever gloves with the handshaking method for fingertip blood collection from children in fever clinics during the COVID-19 epidemic.
METHODS A total of 100 children were selected for fingertip blood collection at the fever clinic of our hospital from June 2022 to June 2023 and were divided into two groups using a randomized numerical table method, with 50 cases in each group, including the control and observation groups. The patients in the control group followed the doctor's instructions to cooperate with the routine fingertip blood collection method, and the patients in the observation group followed the doctor's instructions to cooperate with the static fever gloves with the shaking hands method of children's fingertip blood collection. The level of the six blood routine and collection indexes, and the satisfaction of the examination of the patients in the peripheral blood group and the fever gloves with the shaking hands method of the children's fingertip blood collection group were compared.
RESULTS The red and white blood cell count, hemoglobin, and red blood cell pressure volume in the observation group were higher than those in the control group (P < 0.05); the platelet count in the control group was lower than that in the observation group (P < 0.05); the number of times of squeezing the fingertip, the average time of blood collection, and the score of puncture pain in the observation group were significantly better than those in the control group (P < 0.05); and satisfaction with the routine blood examination in the observation group was greater than that in the control group.
CONCLUSION The application value of the fever gloves with shaking hands method for children's fingertip blood collection was better, the accuracy of examination indexes was higher, and patient satisfaction with the examination was greater.
Collapse
Affiliation(s)
- Ling Luo
- Department of Infectious Diseases, Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin 541000, Guangxi Zhuang Autonomous Region, China
| | - Wei-Li Qin
- Department of Emergency, Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin 541000, Guangxi Zhuang Autonomous Region, China
| | - Han-Mei Huang
- Department of Infectious Diseases, Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin 541000, Guangxi Zhuang Autonomous Region, China
| | - Zhi-Hong Ou
- Laboratory, Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin 541000, Guangxi Zhuang Autonomous Region, China
| | - Zhi-Hua Peng
- Department of Nursing, Guilin Traditional Chinese Medicine Hospital, Guilin 541000, Guangxi Zhuang Autonomous Region, China
| |
Collapse
|
16
|
Chandna A, Mwandigha L, Koshiaris C, Limmathurotsakul D, Nosten F, Lubell Y, Perera-Salazar R, Turner C, Turner P. External validation of clinical severity scores to guide referral of paediatric acute respiratory infections in resource-limited primary care settings. Sci Rep 2023; 13:19026. [PMID: 37923813 PMCID: PMC10624658 DOI: 10.1038/s41598-023-45746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
Accurate and reliable guidelines for referral of children from resource-limited primary care settings are lacking. We identified three practicable paediatric severity scores (the Liverpool quick Sequential Organ Failure Assessment (LqSOFA), the quick Pediatric Logistic Organ Dysfunction-2, and the modified Systemic Inflammatory Response Syndrome) and externally validated their performance in young children presenting with acute respiratory infections (ARIs) to a primary care clinic located within a refugee camp on the Thailand-Myanmar border. This secondary analysis of data from a longitudinal birth cohort study consisted of 3010 ARI presentations in children aged ≤ 24 months. The primary outcome was receipt of supplemental oxygen. We externally validated the discrimination, calibration, and net-benefit of the scores, and quantified gains in performance that might be expected if they were deployed as simple clinical prediction models, and updated to include nutritional status and respiratory distress. 104/3,010 (3.5%) presentations met the primary outcome. The LqSOFA score demonstrated the best discrimination (AUC 0.84; 95% CI 0.79-0.89) and achieved a sensitivity and specificity > 0.80. Converting the scores into clinical prediction models improved performance, resulting in ~ 20% fewer unnecessary referrals and ~ 30-50% fewer children incorrectly managed in the community. The LqSOFA score is a promising triage tool for young children presenting with ARIs in resource-limited primary care settings. Where feasible, deploying the score as a simple clinical prediction model might enable more accurate and nuanced risk stratification, increasing applicability across a wider range of contexts.
Collapse
Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| |
Collapse
|
17
|
Broman LM, Dubrovskaja O, Balik M. Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review. J Clin Med 2023; 12:6661. [PMID: 37892799 PMCID: PMC10607553 DOI: 10.3390/jcm12206661] [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: 08/23/2023] [Revised: 10/09/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70-90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo-arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m-2) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m-2) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers.
Collapse
Affiliation(s)
- Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Olga Dubrovskaja
- Intensive Care Department II, North Estonia Medical Centre, 13419 Tallinn, Estonia;
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12808 Prague, Czech Republic;
| |
Collapse
|
18
|
Charaya S, Angurana SK, Nallasamy K, Jayashree M. Restricted versus Usual/Liberal Maintenance Fluid Strategy in Mechanically Ventilated Children: An Open-Label Randomized Trial (ReLiSCh Trial). Indian J Pediatr 2023:10.1007/s12098-023-04867-4. [PMID: 37851328 DOI: 10.1007/s12098-023-04867-4] [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: 05/31/2023] [Accepted: 09/05/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVES To assess the impact of restricted vs. usual/liberal maintenance fluid strategy on fluid overload (FO) among mechanically ventilated children. METHODS This open-label randomized controlled trial was conducted over a period of 1 y (October 2020-September 2021) in a Pediatric intensive care unit (PICU) in North India. Hemodynamically stable mechanically ventilated children were randomized to 40% (restricted group, n = 50) and 70-80% (usual/liberal group, n = 50) of maintenance fluids. The primary outcome was cumulative fluid overload percentage (FO%) on day 7. Secondary outcomes were FO% >10%; vasoactive inotropic score, sequential organ failure assessment score, pediatric logistic organ dysfunction score and oxygenation index from day 1-7; ventilation free days (VFDs) and PICU free days (PFDs) through day 28; and mortality. RESULTS The restricted group had statistically non-significant trend towards lower cumulative FO% at day 7 [7.6 vs. 9.5, p = 0.40]; and proportion of children with FO% >10% (12% vs. 26%, p = 0.21) as compared to usual/liberal group. The increase in FO% from day 1-7 was significant in usual/liberal group as compared to restricted group (p <0.001 and p = 0.134, respectively). Restricted group received significantly lower amount of fluid in the first 5 d; had significantly higher VFDs (23 vs. 17 d, p = 0.008) and PFDs (19 vs. 15 d, p = 0.007); and trend towards lower mortality (8% vs. 16%, p = 0.21). CONCLUSIONS Restricted as compared to usual/liberal maintenance fluid strategy among mechanically ventilated children was associated with a trend towards lower rate and severity of FO and mortality; and significantly lower fluid volume received, and higher VFDs and PFDs.
Collapse
Affiliation(s)
- Shubham Charaya
- Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Suresh Kumar Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Muralidharan Jayashree
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| |
Collapse
|
19
|
Olson TL, Pollack MM, Dávila Saldaña BJ, Patel AK. Hospital survival following pediatric HSCT: changes in complications, ICU therapies and outcomes over 10 years. Front Pediatr 2023; 11:1247792. [PMID: 37900687 PMCID: PMC10601648 DOI: 10.3389/fped.2023.1247792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Hematopoietic stem cell transplantation (HSCT) is an increasingly utilized therapy for malignant and non-malignant pediatric diseases. HSCT complications, including infection, organ dysfunction, and graft-versus-host-disease (GVHD) often require intensive care unit (ICU) therapies and are associated with mortality. Our aims were to identify the HSCT characteristics, complications and ICU therapies associated with (1) survival, and (2) survival changes over a ten-year period in a national dataset. Methods A national sample from the Health Facts (Cerner Corporation, Kansas City, MO) database from 2009 to 2018 was utilized. Inclusion criteria were age 30 days to <22 years and HSCT procedure code. For patients with >1 HSCT, the first was analyzed. Data included demographics, hospital length of stay (LOS), hospital outcome, transplant type and indication. HSCT complications included GVHD and infections. ICU therapies were positive pressure ventilation (PPV), vasoactive infusion, and dialysis. Primary outcome was survival to discharge. Statistical methods included bivariate analyses and multivariate logistic regression. Results 473 patients underwent HSCT with 93% survival. 62% were allogeneic (89% survival) and 38% were autologous (98% survival). GVHD occurred in 33% of allogeneic HSCT. Infections occurred in 26% of all HSCT. ICU therapies included PPV (11% of patients), vasoactive (25%), and dialysis (3%). Decreased survival was associated with allogeneic HSCT (p < 0.01), GVHD (p = 0.02), infection (p < 0.01), and ICU therapies (p < 0.01). Survival improved from 89% (2009-2013) to 96% (2014-2018) (p < 0.01). Allogeneic survival improved (82%-94%, p < 0.01) while autologous survival was unchanged. Survival improvement over time was associated with decreasing infections (33%-21%, p < 0.01) and increasing vasoactive infusions (20%-28%, p = 0.05). On multivariate analysis, later time period was associated with improved survival (p < 0.01, adjusted OR 4.28). Discussion Hospital survival for HSCT improved from 89% to 96% from 2009 to 2018. Factors associated with mortality included allogeneic HSCT, GVHD, infections and ICU therapies. Improving survival coincided with decreasing infections and increasing vasoactive use.
Collapse
Affiliation(s)
- Taylor L. Olson
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Murray M. Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Blachy J. Dávila Saldaña
- Department of Pediatrics, Division of Blood and Marrow Transplantation, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Anita K. Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| |
Collapse
|
20
|
Kislal FM, Polat CC, Ergül E, Açıkalın AA, Güven D, Gündoğan E, Sarıcı D. Can lactate be valuable in early diagnosis and prognosis of neonatal sepsis? Niger J Clin Pract 2023; 26:1319-1325. [PMID: 37794545 DOI: 10.4103/njcp.njcp_54_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background Sepsis monitoring tissue perfusion is crucial for detecting circulatory failure early, implementing the right treatments, and assessing response. Insufficient oxygenation leads to a rise in lactate level and has been shown to be useful in predicting mortality and morbidity in newborns. There have not been many studies on how lactate measurement affects neonatal sepsis diagnosis and prognosis. Aim The aim of our study was to determine the impact of lactate on early diagnosis and prognosis in neonatal sepsis. Materials and Methods Eighty-seven newborns diagnosed with neonatal sepsis at a neonatal intensive care unit between January 2010 and July 2021 were included in the study. Venous blood gas, lactate, and C-reactive protein (CRP) levels and complete blood count on the first, second, and third day of hospitalization were noted. Lactate values were correlated with other variables to determine the impact of hyperlactatemia on morbidity and to determine factors affecting the length of stay. IBM SPSS Statistics version 22.0 for Windows was used to analyze the data (SPSS Inc., Chicago, IL, United States). Results A strong negative correlation between lactate and oxygenation and perfusion indicators (HCO3, BE, PaO2) during the therapeutic process was observed. With treatment, the initial measured lactate value decreased, and a significant increase in CRP and oxygen saturation was observed, which was interpreted as the observation of an early lactate response to infection before a CRP response. The initial lactate level, as well as the change in lactate levels, was not, however, significantly correlated with the length of stay. Conclusion Lactate can be used in the early diagnosis of neonatal sepsis and for determining prognosis.
Collapse
Affiliation(s)
- F M Kislal
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - C C Polat
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - E Ergül
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - A A Açıkalın
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - D Güven
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - E Gündoğan
- Department of Pediatrics, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| | - D Sarıcı
- Department of Neonatology, University of Health and Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
21
|
Moran E, McEvoy MT, Brackett J, Chawla R. Undifferentiated Shock in a 2-month-old Girl. Pediatr Rev 2023; 44:517-520. [PMID: 37653131 DOI: 10.1542/pir.2021-005297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Elizabeth Moran
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| | - Matthew T McEvoy
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| | - Julienne Brackett
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| | - Rolly Chawla
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| |
Collapse
|
22
|
Leite HP, Medina R, Junior EL, Konstantyner T. Troponin I as an Independent Biomarker of Outcome in Children with Systemic Inflammatory Response. J Pediatr Intensive Care 2023; 12:203-209. [PMID: 37565020 PMCID: PMC10411187 DOI: 10.1055/s-0041-1731432] [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: 01/24/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022] Open
Abstract
Cardiac troponin-I (cTnI) is a biomarker of myocardial injury with implications for clinical outcomes. May other contributing factors that could affect outcomes have not been uniformly considered in pediatric studies. We hypothesized that there is an association between admission serum cTnI and outcomes in critically ill children taking into account the magnitude of the acute systemic inflammatory response syndrome (SIRS), serum lactate concentrations, and nutritional status. Second, we tested for potential factors associated with elevated serum cTnI. This was a prospective cohort study in 104 children (median age: 21.3 months) consecutively admitted to a pediatric intensive care unit (PICU) of a teaching hospital with SIRS and without previous chronic diseases. Primary outcome variables were PICU-free days, ventilator-free days, and 30-day mortality. Exposure variables were serum cTnI concentration on admission, revised pediatric index of mortality (PIM2), pediatric logistic organ dysfunction (PELOD-2), hypotensive shock, C-reactive protein, procalcitonin, and serum lactate on admission, and malnutrition. Elevated cTnI (>0.01 μg/L) was observed in 24% of patients, which was associated with the reduction of ventilator-free days (β coefficient = - 4.97; 95% confidence interval [CI]: -8.03; -1.91) and PICU-free days (β coefficient = - 5.76; 95% CI: -8.97; -2.55). All patients who died had elevated serum cTnI. The increase of 0.1 μg/L in cTnI concentration resulted in an elevation of 2 points in the oxygenation index (β coefficient = 2.0; 95% CI: 1.22; 2.78, p < 0.001). The PIM2 score, hypotensive shock in the first 24 hours, and serum lactate were independently associated with elevated cTnI on admission. We conclude that elevated serum cTnI on admission is independently associated with adverse outcomes in children with SIRS and without associated chronic diseases.
Collapse
Affiliation(s)
- Heitor P. Leite
- Discipline of Nutrition and Metabolism, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rodrigo Medina
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Emilio L. Junior
- Discipline of Nutrition and Metabolism, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Tulio Konstantyner
- Discipline of Nutrition and Metabolism, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Pediatrics, Hospital Geral de Itapecerica da Serra—HGIS, Itapecerica da Serra, São Paulo, Brazil
| |
Collapse
|
23
|
Rice B, Hawkins J, Nakato S, Kamara N. Mortality after emergency unit fluid bolus in febrile Ugandan children. PLoS One 2023; 18:e0290790. [PMID: 37651354 PMCID: PMC10470955 DOI: 10.1371/journal.pone.0290790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda. METHODS This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria. RESULTS The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase. CONCLUSIONS This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.
Collapse
Affiliation(s)
- Brian Rice
- Department of Emergency Medicine, Stanford University, Palo Alto, California, United States of America
- Global Emergency Care, Shrewsbury, Massachusetts, United States of America
| | - Jessica Hawkins
- Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Serena Nakato
- Global Emergency Care, Shrewsbury, Massachusetts, United States of America
- Karoli Lwanga Hospital, Rukungiri, Uganda
| | | | | |
Collapse
|
24
|
Zens T, Ochoa B, Eldredge RS, Molitor M. Pediatric venoarterial and venovenous ECMO. Semin Pediatr Surg 2023; 32:151327. [PMID: 37956593 DOI: 10.1016/j.sempedsurg.2023.151327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure. To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology. This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques. Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation. Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.
Collapse
Affiliation(s)
- Tiffany Zens
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Brielle Ochoa
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - R Scott Eldredge
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Mark Molitor
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States.
| |
Collapse
|
25
|
Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
Collapse
Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| |
Collapse
|
26
|
Selewski DT, Gist KM, Basu RK, Goldstein SL, Zappitelli M, Soranno DE, Mammen C, Sutherland SM, Askenazi DJ, Ricci Z, Akcan-Arikan A, Gorga SM, Gillespie SE, Woroniecki R. Impact of the Magnitude and Timing of Fluid Overload on Outcomes in Critically Ill Children: A Report From the Multicenter International Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) Study. Crit Care Med 2023; 51:606-618. [PMID: 36821787 DOI: 10.1097/ccm.0000000000005791] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVES With the recognition that fluid overload (FO) has a detrimental impact on critically ill children, the critical care nephrology community has focused on identifying clinically meaningful targets for intervention. The current study aims to evaluate the epidemiology and outcomes associated with FO in an international multicenter cohort of critically ill children. The current study also aims to evaluate the association of FO at predetermined clinically relevant thresholds and time points (FO ≥ 5% and FO ≥ 10% at the end of ICU days 1 and 2) with outcomes. DESIGN Prospective cohort study. SETTING Multicenter, international collaborative of 32 pediatric ICUs. PATIENTS A total of 5,079 children and young adults admitted consecutively to pediatric ICUs as part of the Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology Study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The FO thresholds at the time points of interest occurred commonly in the cohort (FO ≥ 5%Day1 in 38.1% [ n = 1753], FO ≥ 10%Day1 in 11.7% [ n = 537], FO ≥ 5%Day2 in 53.3% [ n = 1,539], FO ≥ 10%Day2 in 25.1% [ n = 724]). On Day1, multivariable modeling demonstrated that FO ≥ 5% was associated with fewer ICU-free days, and FO ≥ 10% was associated with higher mortality and fewer ICU and ventilator-free days. On multivariable modeling, FO-peak, Day2 FO ≥ 5%, and Day2 FO ≥ 10% were associated with higher mortality and fewer ICU and ventilator-free days. CONCLUSIONS This study found that mild-to-moderate FO as early as at the end of ICU Day1 is associated with adverse outcomes. The current study fills an important void in the literature by identifying critical combinations of FO timing and quantity associated with adverse outcomes (FO ≥ 5%Day1, FO ≥10%Day1, FO ≥ 5%Day2, and FO ≥ 10%Day2). Those novel findings will help guide the development of interventional strategies and trials targeting the treatment and prevention of clinically relevant FO.
Collapse
Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Katja M Gist
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago/Northwestern University School of Medicine, Chicago, IL
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael Zappitelli
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Danielle E Soranno
- Section of Pediatric Nephrology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Cherry Mammen
- Department of Pediatrics, Division of Nephrology, BC Children's Hospital, Vancouver, BC, Canada
| | - Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - David J Askenazi
- Department of Pediatrics, Division of Nephrology, Pediatric and Infant Center for Acute Nephrology (PICAN), University of Alabama at Birmingham, Birmingham, AL
| | - Zaccaria Ricci
- Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Firenze, Italy
- Department of Health Science, University of Florence, Firenze, Italy
| | - Ayse Akcan-Arikan
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Stephen M Gorga
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Scott E Gillespie
- Division of Critical Care Medicine, Department of Pediatrics, Emory University, Atlanta, GA
| | - Robert Woroniecki
- Division of Nephrology, Department of Pediatrics, Renaissance School of Medicine at Stonybrook Children's Hospital, Stony Brook, NY
| |
Collapse
|
27
|
Sarmin M, Shaly NJ, Sultana T, Tariqujjaman M, Shikha SS, Mariam N, Jeorge DH, Tabassum M, Nahar B, Afroze F, Shahrin L, Hossain MI, Alam B, Faruque ASG, Islam MM, Osmany DEMMF, Ahmed CM, Manji K, Kissoon N, Chisti MJ, Ahmed T. Efficacy of dopamine, epinephrine and blood transfusion for treatment of fluid refractory shock in children with severe acute malnutrition or severe underweight and cholera or other dehydrating diarrhoeas: protocol for a randomised controlled clinical trial. BMJ Open 2023; 13:e068660. [PMID: 37045565 PMCID: PMC10106066 DOI: 10.1136/bmjopen-2022-068660] [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] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION Diarrhoea is one of the leading causes of under-5 childhood mortality and accounts for 8% of 5.4 million global under-5 deaths. In severely malnourished children, diarrhoea progresses to shock, where the risk of mortality is even higher. At icddr,b Dhaka Hospital, the fatality rate is as high as 69% in children with severe malnutrition and fluid refractory septic shock. To date, no study has evaluated systematically the effects of inotrope or vasopressor or blood transfusion in children with dehydrating diarrhoea (eg, in cholera) and severe acute malnutrition (SAM) or severe underweight who are in shock and unresponsive to WHO-recommended fluid therapy. To reduce the mortality of severely malnourished children presenting with diarrhoea and fluid refractory shock, we aim to compare the efficacy of blood transfusion, dopamine and epinephrine in fluid refractory shock in children who do not respond to WHO-recommended fluid resuscitation. METHODS AND ANALYSIS In this randomised, three-arm, controlled, non-masked clinical trial in children 1-59 months old with SAM or severe underweight and fluid refractory shock, we will compare the efficacy of dopamine or epinephrine administration versus blood transfusion in children who failed to respond to WHO-recommended fluid resuscitation. The primary outcome variable is the case fatality rate. The effect of the intervention will be assessed by performing an intention-to-treat analysis. Recruitment and data collection began in July 2021 and are now ongoing. Results are expected by May 2023. ETHICS AND DISSEMINATION This study has been approved by the icddr,b Institutional Review Board. We adhere to the 'Declaration of Helsinki' (2000), guidelines for Good Clinical Practice. Before enrolment, we collect signed informed consent from the parents or caregivers of the children. We will publish the results in a peer-reviewed journal and will arrange a dissemination seminar. TRIAL REGISTRATION NUMBER NCT04750070.
Collapse
Affiliation(s)
- Monira Sarmin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nusrat Jahan Shaly
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tania Sultana
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Tariqujjaman
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shamima Sharmin Shikha
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nafisa Mariam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Didarul Haque Jeorge
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mosharrat Tabassum
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Baitun Nahar
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Afroze
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lubaba Shahrin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Baharul Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Syed Golam Faruque
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Karim Manji
- Department of Pediatrics, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| |
Collapse
|
28
|
Luppes VAC, Willems A, Hazekamp MG, Blom NA, Ten Harkel ADJ. Fluid Overload in Pediatric Univentricular Patients Undergoing Fontan Completion. J Cardiovasc Dev Dis 2023; 10:jcdd10040156. [PMID: 37103035 PMCID: PMC10146974 DOI: 10.3390/jcdd10040156] [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: 02/28/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Fluid overload (FO) is known to occur frequently after pediatric cardiac surgery and is associated with morbidity and mortality. Fontan patients are at risk to develop FO due to their critical fluid balance. Furthermore, they need an adequate preload in order to maintain adequate cardiac output. This study aimed to identify FO in patients undergoing Fontan completion and the impact of FO on pediatric intensive care unit (PICU) length of stay (LOS) and cardiac events, defined as death, cardiac re-surgery or PICU re-hospitalization during follow-up. METHODS In this retrospective single center study, the presence of FO was assessed in 43 consecutive children undergoing Fontan completion. RESULTS Patients with more than 5% maximum FO had an extended PICU LOS (3.9 [2.9-6.9] vs. 1.9 [1.0-2.6] days; p < 0.001) and an increased length of mechanical ventilation (21 [9-121] vs. 6 [5-10] h; p = 0.001). Regression analysis demonstrated that an increase of 1% maximum FO was associated with a prolonged PICU LOS of 13% (95% CI 1.042-1.227; p = 0.004). Furthermore, patients with FO were at higher risk to develop cardiac events. CONCLUSIONS FO is associated with short-term and long-term complications. Further studies are needed to determine the impact of FO on the outcome in this specific population.
Collapse
Affiliation(s)
- Victorien A C Luppes
- Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| |
Collapse
|
29
|
Lu P, Sun Y, Gong X, Li Z, Hong W. Use of norepinephrine in preterm neonates with dopamine-resistant shock: a retrospective single-centre cross-sectional study. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001804. [PMID: 37045542 PMCID: PMC10106054 DOI: 10.1136/bmjpo-2022-001804] [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: 12/02/2022] [Accepted: 02/07/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Norepinephrine (NE) is recommended for children and full-term neonates (born at >37 gestational weeks) with septic shock. Meanwhile, data on the effectiveness of NE in preterm neonates are still limited. This study aimed to evaluate the clinical efficacy of NE in preterm neonates with dopamine-resistant shock compared with that in full-term neonates. METHODS This was a single-centre, retrospective (January 2010-December 2020) cohort study of neonates with persistent shock despite adequate fluid resuscitation and dopamine or dobutamine administration at ≥10 μg/kg/min. Medical records of neonates treated with NE were retrospectively reviewed to collect respiratory and haemodynamic parameters and results of arterial blood gas (ABG) tests before and 8 hours after NE infusion. The effectiveness of NE was assessed using changes in clinical parameters and multiple regression models for mortality among subgroups of preterm and full-term neonates. RESULTS Ninety-two neonates (76% preterm) who received NE infusion were included in the study. NE infusion was started after a median of 7 hours (IQR 2-19 hours) after shock onset. Among the preterm neonates, the maximum dose of NE infusion was 0.5 (IQR 0.3-1.0) µg/kg/min with a median duration of 45 (IQR 24.0-84.5) hours. Haemodynamic dysfunction was ameliorated with increased blood pressure, decreased heart rate and improved ABG results. Preterm neonates with septic shock tended to have a reduced response to NE; however, preterm neonates with persistent pulmonary hypertension of the newborn tended to have a better response. Thirty-four (37%) neonates died in our cohort. The timing, dose and duration of NE use were not associated with neonatal mortality. CONCLUSIONS Although using NE effectively improves clinical parameters in preterm neonates with dopamine-resistant shock, our study is underpowered to identify the association between NE infusion and mortality in preterm neonates with dopamine-resistant shock.
Collapse
Affiliation(s)
- Pei Lu
- Department of Neonatology, Shanghai Children's Hospital, school of medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yifan Sun
- Department of Neonatology, Shanghai Children's Hospital, school of medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, school of medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiling Li
- Department of Pharmacy, Shanghai Children's Hospital, school of medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wenchao Hong
- Department of Neonatology, Shanghai Children's Hospital, school of medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
30
|
Wang Z, He Y, Zhang X, Luo Z. Prognostic accuracy of SOFA and qSOFA for mortality among children with infection: a meta-analysis. Pediatr Res 2023; 93:763-771. [PMID: 35902704 DOI: 10.1038/s41390-022-02213-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Age-adjusted Sequential Organ Failure Assessment (SOFA) and age-adjusted quick SOFA (qSOFA) scores have been developed to predict poor outcomes in children with infection. We investigated the prognostic performance of age-adjusted SOFA and age-adjusted qSOFA scores and compared them with the systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in children with infection. METHODS A bivariate random-effects regression model was used for synthesis of diagnostic test data. RESULTS A total of 14 studies invoing 70,194 participants were included. The pooled sensitivity for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.82 (95% CI, 0.74-0.88), 0.46 (95% CI, 0.22-0.71), and 0.79 (95% CI, 0.66-0.88), respectively. The pooled specificity for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.62 (95% CI, 0.45-0.77), 0.90 (95% CI, 0.66-0.98), and 0.39 (95% CI, 0.26-0.54), respectively. The area under the summary receiver operating characteristic curve (AUSROC) for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.82 (95% CI, 0.79-0.85), 0.66 (95% CI, 0.62-0.70), and 0.64 (95% CI, 0.60-0.68), respectively. Different baseline populations, different SOFA adaptation methods and different cut-offs used for age-adjusted SOFA may be potential sources of heterogeneity. CONCLUSIONS Age adjusted SOFA score is a useful tool for predicting mortality in children with sepsis/suspected sepsis. IMPACT First study to investigate the prognostic performance of age-adjusted sequential organ failure assessment (SOFA) and age adjusted quick SOFA (qSOFA) scores in comparison to the systemic inflammatory response criteria (SIRS) for the prediction of mortality in children with sepsis. The age-adjusted SOFA score predicts poor outcomes with high sensitivity in children with sepsis Low sensitivity limits the utility of age-adjusted qSOFA as a simple predictive tool for adverse outcomes. Developing another enhanced or modified bedside tool with higher sensitivity may be necessary.
Collapse
Affiliation(s)
- Zhili Wang
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Yu He
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Xiaolong Zhang
- Department of Pediatrics, Jiangjin District Central Hospital, Chongqing, 400014, China
| | - Zhengxiu Luo
- Department of Respiratory Medicine Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China.
| |
Collapse
|
31
|
Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Zaman MAU, Roy O, Chowdhoury SR, Nandi M. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023; 27:139-146. [PMID: 36865513 PMCID: PMC9973056 DOI: 10.5005/jp-journals-10071-24410] [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: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023] Open
Abstract
Background To evaluate the role of ultrasound during initial fluid resuscitation along with clinical guidance in reducing the incidence of fluid overload on day 3 in children with septic shock. Materials and methods It was a prospective, parallel limb open-labeled randomized controlled superiority trial done in the PICU of a government-aided tertiary care hospital in Eastern India. Patient enrolment took place between June 2021 and March 2022. Fifty-six children aged between 1 month and 12 years, with proven or suspected septic shock, were randomized to receive either ultrasound-guided or clinically guided fluid boluses (1:1 ratio) and subsequently followed up for various outcomes. The primary outcome was frequency of fluid overload on day 3 of admission. The treatment group received ultrasound-guided fluid boluses along with the clinical guidance and the control group received the same but without ultrasound guidance upto 60 mL/kg of fluid boluses. Results The frequency of fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs 62%, p = 0.012) as was the median (IQR) cumulative fluid balance percentage on day 3 [6.5 (3.3-10.3) vs 11.3 (5.4-17.5), p = 0.02]. The amount of fluid bolus administered was also significantly lower by ultrasound [median 40 (30-50) vs 50 (40-80) mL/kg, p = 0.003]. Resuscitation time was shorter in the ultrasound group (13.4 ± 5.6 vs 20.5 ± 8 h, p = 0.002). Conclusion Ultrasound-guided fluid boluses were found to be significantly better than clinically guided therapy, in preventing fluid overload and its associated complications in children with septic shock. These factors make ultrasound a potentially useful tool for resuscitation of children with septic shock in the PICU. How to cite this article Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Uz Zaman MA, Roy O, et al. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023;27(2):139-146.
Collapse
Affiliation(s)
- Ryan Sohail Kaiser
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Mihir Sarkar
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Sumantra Kumar Raut
- Department of Nephrology, North Bengal Medical College, Kolkata, West Bengal India
| | | | | | - Oishik Roy
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Satyabrata Roy Chowdhoury
- Department of Pediatrics, North Bengal Medical College, Kolkata, West Bengal India,Satyabrata Roy Chowdhoury, Department of Pediatrics, North Bengal Medical College, Kolkata, West Bengal, India, Phone: +91 9433765529, e-mail:
| | - Mousumi Nandi
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| |
Collapse
|
32
|
Mercurio L, Pou S, Duffy S, Eickhoff C. Risk Factors for Pediatric Sepsis in the Emergency Department: A Machine Learning Pilot Study. Pediatr Emerg Care 2023; 39:e48-e56. [PMID: 36648121 DOI: 10.1097/pec.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To identify underappreciated sepsis risk factors among children presenting to a pediatric emergency department (ED). METHODS A retrospective observational study (2017-2019) of children aged 18 years and younger presenting to a pediatric ED at a tertiary care children's hospital with fever, hypotension, or an infectious disease International Classification of Diseases (ICD)-10 diagnosis. Structured patient data including demographics, problem list, and vital signs were extracted for 35,074 qualifying ED encounters. According to the Improving Pediatric Sepsis Outcomes Classification, confirmed by expert review, 191 patients met clinical sepsis criteria. Five machine learning models were trained to predict sepsis/nonsepsis outcomes. Top features enabling model performance (N = 20) were then extracted to identify patient risk factors. RESULTS Machine learning methods reached a performance of up to 93% sensitivity and 84% specificity in identifying patients who received a hospital diagnosis of sepsis. A random forest classifier performed the best, followed by a classification and regression tree. Maximum documented heart rate was the top feature in these models, with importance coefficients (ICs) of 0.09 and 0.21, which represent how much an individual feature contributes to the model. Maximum mean arterial pressure was the second most important feature (IC 0.05, 0.13). Immunization status (IC 0.02), age (IC 0.03), and patient zip code (IC 0.02) were also among the top features enabling models to predict sepsis from ED visit data. Stratified analysis revealed changes in the predictive importance of risk factors by race, ethnicity, oncologic history, and insurance status. CONCLUSIONS Machine learning models trained to identify pediatric sepsis using ED clinical and sociodemographic variables confirmed well-established predictors, including heart rate and mean arterial pressure, and identified underappreciated relationships between sepsis and patient age, immunization status, and demographics.
Collapse
Affiliation(s)
- Laura Mercurio
- From the Section of Pediatric Emergency Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Sovijja Pou
- Alpert Medical School of Brown University, Providence, RI
| | | | | |
Collapse
|
33
|
SooHoo MM, Shah A, Mayen A, Williams MH, Hyslop R, Buckvold S, Basu RK, Kim JS, Brinton JT, Gist KM. Effect of a standardized fluid management algorithm on acute kidney injury and mortality in pediatric patients on extracorporeal support. Eur J Pediatr 2023; 182:581-590. [PMID: 36394647 DOI: 10.1007/s00431-022-04699-y] [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: 07/15/2022] [Revised: 11/03/2022] [Accepted: 11/05/2022] [Indexed: 11/18/2022]
Abstract
Acute kidney injury (AKI), fluid overload (FO), and mortality are common in pediatric patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study is to evaluate if using a fluid management algorithm reduced AKI and mortality in children supported by ECMO. We performed a retrospective study of pediatric patients aged birth to 25 years requiring ECMO at a quaternary level children's hospital from 2007 to 2019 In October 2017, a fluid management algorithm was implemented for protocolized fluid removal after deriving a daily fluid goal using a combination of diuretics and ultrafiltration. Daily algorithm compliance was defined as ≥ 12 h on the algorithm each day. The primary and secondary outcomes were AKI and mortality, respectively, and were assessed in the entire cohort and the sub-analysis of children from the era in which the algorithm was implemented. Two hundred and ninety-nine (median age 5.3 months; IQR: 0.2, 62.3; 45% male) children required ECMO (venoarterial in 85%). The fluid algorithm was applied in 74 patients. The overall AKI rate during ECMO was 38% (26% severe-stage 2/3). Both AKI incidence and mortality were significantly lower in patients managed on the algorithm (p = 0.02 and p = 0.05). After adjusting for confounders, utilization of the algorithm was associated with lower odds of AKI (aOR: 0.40, 95%CI: 0.21, 0.76; p = 0.005) but was not associated with a reduction in mortality. In the sub-analysis, algorithm compliance of 80-100% was associated with a 54% reduction in mortality (ref: < 60% compliant; aOR:0.46, 95%CI:0.22-1.00; p = 0.05). Conclusion: Among the entire cohort, the use of a fluid management algorithm reduced the odds of AKI. Better compliance on the algorithm was associated with lower mortality. Multicenter studies that implement systematic fluid removal may represent an opportunity for improving ECMO-related outcomes. What is Known: • Acute kidney injury and fluid overload are associated with morbidity and mortality in children supported by extracorporeal membrane oxygenation. What is New: • A systematic and protocolized approach to fluid removal in children supported by extracorporeal membrane oxygenation reduces acute kidney injury incidence. • Greater adherence to a protocolized fluid removal algorithm is associated with a reduction in mortality.
Collapse
Affiliation(s)
- Megan M SooHoo
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA.
| | - Ananya Shah
- University of Colorado-Denver Campus, Denver, CO, 80045, USA
| | - Anthony Mayen
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - M Hank Williams
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - Robert Hyslop
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - Shannon Buckvold
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - Rajit K Basu
- Department of Pediatrics, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John S Kim
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - John T Brinton
- Department of Biostatistics and Epidemiology, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
34
|
Muacevic A, Adler JR, Alqahtani AM, Alsomali FA, Alrasheed MA, Alhafi MM, Alqirnas MQ, Alhamied FA, Albaqami FM, Almosa AS, Othman F, Naeem M. The Association of Corticosteroid Therapy With Mortality and Length of Stay Among Children With Septic Shock: A Retrospective Cohort Study. Cureus 2023; 15:e33267. [PMID: 36741650 PMCID: PMC9891713 DOI: 10.7759/cureus.33267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/04/2023] Open
Abstract
Introduction Septic shock remains a leading cause of mortality in pediatric patients. Corticosteroids have been used in the management of sepsis and septic shock, but there is conflicting evidence on the potential benefit of corticosteroid therapy. This study assessed the risk of mortality and length of stay in the pediatric intensive care unit (PICU) among pediatric patients admitted with a septic shock diagnosis. Method A retrospective cohort study was conducted among pediatric patients (up to 14 years old) admitted with a septic shock diagnosis to the PICU of King Abdullah Specialist Children's Hospital in Riyadh from January 2016 to December 2021. The clinical outcomes of patients receiving corticosteroid therapy were compared to those of control patients who were not given corticosteroids. Electronic medical records provided clinical data, severity scores, and the management given for each patient. The patients were followed up from the date of sepsis diagnosis to hospital discharge. Proportional hazard ratios (HRs) were calculated to compare the risk of mortality, length of PICU stay, and length of hospital stay. Results A total of 182 pediatric patients were included in the study, and 86 (47%) received corticosteroid therapy. The median age of the study population was 15 months (interquartile range [IQR]: 2-72 months). Compared to the controls, the patients who received corticosteroids had a higher total Sequential Organ Failure Assessment (SOFA) score (mean±SD: 5.5±3 vs. 7.1±3.3, respectively; p <0.01) and required more ventilation support (72% vs. 28%, respectively) and the use of inotropes and vasopressors (74% vs. 34% and 32% vs. 6%, respectively). In-hospital mortality did not significantly differ between the groups (adjusted HR: 2.66; 95% confidence interval [CI]: 0.66-10.28). Those patients who received corticosteroids had 42% less risk of staying in the PICU for over six days than those not receiving steroids (HR: 0.35; 95% CI: 0.13-0.98) Conclusion After adjusting for baseline characteristics, severity scores, and medical intervention, no association was found between receiving corticosteroids and mortality (p=0.492). Furthermore, patients who received corticosteroids had less risk of a prolonged stay in the PICU than those who did not.
Collapse
|
35
|
Desphpande SR, Bearl DW, Eghtesady P, Henderson HT, Auerbach S, Jeewa A, Bansal N, Amdani S, Richmond ME, Sacks LD, Shih R, Townsend M, Conway J. Clinical approach to vasoplegia in the transplant patient from the Pediatric Heart Transplant Society. Pediatr Transplant 2022; 26:e14392. [PMID: 36377326 DOI: 10.1111/petr.14392] [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: 04/21/2022] [Revised: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022]
Abstract
This manuscript outlines a clinical approach to vasoplegia incorporating the current state of knowledge regarding vasoplegia in pediatric patients immediately post-transplant and to identify modifiable factors both pre- and post-transplant that may reduce post-operative morbidity, end-organ dysfunction, and mortality. Centers participating in the Pediatric Heart Transplant Society (PHTS) were asked to provide their internal protocols and rationale for vasoplegia management, and applicable adult and pediatric data were reviewed. The authors synthesized the above protocols and literature into the following description of clinical approaches to vasoplegia highlighting areas of both broad consensus and of significant practice variation.
Collapse
Affiliation(s)
- Shriprasad R Desphpande
- Department of Cardiology and Cardiovascular Surgery, Children's National Hospital, The George Washington University, Washington, DC, USA
| | - David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital and School of Medicine, Washington University, St Louis, Michigan, USA
| | - Heather T Henderson
- Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott Auerbach
- Pediatrics, Division of Cardiology, University of Colorado, Denver Anschutz Medical Campus, Children's Hospital Colorado Aurora, Aurora, Colorado, USA
| | - Aamir Jeewa
- Department of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Neha Bansal
- Children's Hospital at Montefiore, Bronx, New York, USA
| | | | - Marc E Richmond
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University College of Physician and Surgeons, Morgan Stanley Children's Hospital, New York, New York, USA
| | - Loren D Sacks
- Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Renata Shih
- Congenital Heart Center, Division of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA
| | | | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
36
|
de Almeida CB, Leite HP, Lopes Junior E, Konstantyner T, Franco MDCP. Erythrocyte and plasma selenium in children with acute inflammatory response. J Trace Elem Med Biol 2022; 74:127068. [PMID: 36162157 DOI: 10.1016/j.jtemb.2022.127068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/20/2022] [Accepted: 09/08/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Plasma selenium may not reflect selenium status in critically ill patients because it transiently decreases inversely with the magnitude of the systemic inflammatory response. The decision to supplement selenium should ideally be based on laboratory measurements that reliably reflect selenium status. We hypothesized that erythrocyte selenium, unlike plasma selenium, is not affected by the systemic inflammatory response in critically ill children. METHODS In a prospective study of 109 critically ill children, plasma and erythrocyte selenium concentrations were evaluated on admission, and plasma selenoprotein P was evaluated on days 1, 2, and 3 of the ICU stay. The main outcome was the effect of systemic inflammation on the erythrocyte and plasma selenium concentrations. The magnitude of the systemic inflammatory response was measured using serum C-reactive protein (CRP) and procalcitonin levels. The covariates were age, sex, anthropometric nutritional status, diagnosis of severe sepsis/septic shock, and clinical severity on admission. Multiple linear regression and generalized estimating equations were used for statistical analysis. RESULTS Erythrocyte selenium levels were not influenced by the magnitude of the inflammatory response or by the patient's clinical severity. Procalcitonin (β coefficient=-0.99; 95%CI: -1.64; -0.34, p = 0.003) and clinical severity (β coefficient= -11.13; 95%CI: -21.6; -0.63), p = 0.038) on admission were associated with decreased plasma selenium concentrations. Erythrocyte selenium was associated with selenoprotein P in the first three days of ICU stay (β coefficient=0.32; 95%CI: 0.20; 0.44, p < 0.001). CONCLUSION Unlike plasma selenium, erythrocyte selenium does not change in children with an acute systemic inflammatory response and is associated with selenoprotein P concentrations. Erythrocyte selenium is probably a more reliable marker than plasma selenium for evaluating the selenium status in critically ill children.
Collapse
Affiliation(s)
- Cláudia Bezerra de Almeida
- Discipline of Pediatric Nutrition, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Heitor Pons Leite
- Discipline of Pediatric Nutrition, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Emilio Lopes Junior
- Discipline of Pediatric Nutrition, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Tulio Konstantyner
- Discipline of Pediatric Nutrition, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, Brazil.
| | | |
Collapse
|
37
|
Demirhan S, Topcuoglu S, Karadag N, Ozalkaya E, Karatekin G. Vasoactive inotropic score as a predictor of mortality in neonatal septic shock. J Trop Pediatr 2022; 68:6833201. [PMID: 36399355 DOI: 10.1093/tropej/fmac100] [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] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although many improvements in neonatal care have been achieved, mortality rates for sepsis and septic shock in newborns are still high. The vasoactive inotropic score (VIS) was designed and studied to predict mortality in different settings. There are currently no data on the predictive ability of the VIS for mortality in newborn patients with septic shock. METHODS Patients with late-onset neonatal sepsis who required inotropes because of fluid-refractory septic shock during the study period were included in the study. Four distinct VIS values were calculated for each septic shock episode after inotropic treatment had begun, that is, at the initiation of inotropic treatment and at 24 and 48 h after inotropic treatment had begun, and the highest VIS (VISmax) at any time after initiation of inotropic agents. RESULTS The 98 episodes studied were divided into two groups according to the outcomes of their sepsis episodes as survivors (n = 39) or nonsurvivors (n = 59). The areas under the curve of the VIS values for the prediction of mortality were the VISmax (0.819, p < 0.001), followed by the VIS48 (0.802, p < 0.001), VIS24 (0.762, p = 0.001) and VIS0 (0.699, p = 0.015). Patients with a VISmax of greater than 20 had significantly higher odds of mortality (p < 0.001, β = 14.7, 95% confidence interval [4.7-45.9]). CONCLUSION We found that the VISmax was an easy-to-use and helpful tool for predicting a poor outcome in neonatal sepsis. Physicians should be aware that the prognosis is poor for any newborn with a VIS of 20 or greater at any point after the onset of sepsis.
Collapse
Affiliation(s)
- Salih Demirhan
- Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul, Turkey
| | - Sevilay Topcuoglu
- Divison of Neonatology, Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul, Turkey
| | - Nilgun Karadag
- Divison of Neonatology, Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul, Turkey
| | - Elif Ozalkaya
- Divison of Neonatology, Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul, Turkey
| | - Guner Karatekin
- Divison of Neonatology, Department of Pediatrics, University of Health Sciences, Zeynep Kamil Maternity and Children's Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
38
|
Hou SK, Lin HA, Tsai HW, Lin CF, Lin SF. Monocyte Distribution Width in Children With Systemic Inflammatory Response: Retrospective Cohort Examining Association With Early Sepsis. Pediatr Crit Care Med 2022; 23:698-707. [PMID: 35704311 DOI: 10.1097/pcc.0000000000003019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the association between increased monocyte distribution width (MDW) and pediatric sepsis in the emergency department (ED). DESIGN Retrospective cohort study. SETTING A single academic hospital study. PATIENTS Patients from birth to the age of 18 years who presented at the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were consecutively enrolled. Sepsis was diagnosed using the International Pediatric Surviving Sepsis Campaign criteria. INTERVENTIONS Antibiotic treatment was administrated once infection was suspected. MEASUREMENTS AND MAIN RESULTS Routine complete blood cell count, neutrophil-to-lymphocyte ratio (NLR), and MDW, a new inflammatory biomarker, were evaluated in the ED. Logistic regression models were used to explore associations with early pediatric sepsis. We included 201 patients with sepsis and 1,050 without sepsis. In the multivariable model, MDW greater than 23 U (odds ratio [OR], 4.97; 95% CI, 3.42-7.22; p < 0.0001), NLR greater than 6 (OR, 2.06; 95% CI, 1.43-2.94; p = 0.0001), WBC greater than 11,000 cells/µL (OR, 6.52; 95% CI, 4.45-9.53; p < 0.0001), and the SIRS score (OR, 3.42; 95% CI, 2.57-4.55; p < 0.0001) were associated with pediatric sepsis. In subgroup analysis, MDW greater than 23 U remained significantly associated with sepsis for children 6-12 years old (OR, 6.76; 95% CI, 2.60-17.57; p = 0.0001) and 13-18 years (OR, 17.49; 95% CI, 7.69-39.76; p = 0.0001) with an area under the receiver operating curve of 0.8-0.9. CONCLUSIONS MDW greater than 23 U at presentation is associated with the early diagnosis of sepsis in children greater than or equal to 6 years old. This parameter should be considered as a stratification variable in studies of pediatric sepsis.
Collapse
Affiliation(s)
- Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hung-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chiou-Feng Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Feng Lin
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
39
|
Fustiñana A, Yock-Corrales A, Casson N, Galvis L, Iramain R, Lago P, Da Silva APP, Paredes F, Zamarbide MP, Aprea V, Kohn-Loncarica G. Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America. Pediatr Emerg Care 2022; 38:e1496-e1502. [PMID: 35802481 DOI: 10.1097/pec.0000000000002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.
Collapse
|
40
|
Mullan PC, Pruitt CM, Levasseur KA, Macias CG, Paul R, Depinet H, Nguyen ATH, Melendez E. Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:375-384. [PMID: 35924031 PMCID: PMC9342868 DOI: 10.2147/oaem.s368442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients and Methods Results Conclusion
Collapse
Affiliation(s)
- Paul C Mullan
- Department of Pediatrics, Division of Emergency Medicine, Eastern Virginia Medical School, Children’s Hospital of the King’s Daughters, Norfolk, VA, USA
- Correspondence: Paul C Mullan, Email
| | - Christopher M Pruitt
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly A Levasseur
- Pediatric Emergency Medicine, Beaumont Children’s Hospital, Royal Oak, MI, USA
| | - Charles G Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies and Children’s, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raina Paul
- Department of Emergency Medicine, Advocate Children’s Hospital, Park Ridge, IL, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Anh Thy H Nguyen
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Elliot Melendez
- Division of Pediatric Critical Care, Connecticut Children’s Medical Center, University of Connecticut, Hartford, CT, USA
| |
Collapse
|
41
|
Morin L, Hall M, de Souza D, Guoping L, Jabornisky R, Shime N, Ranjit S, Gilholm P, Nakagawa S, Zimmerman JJ, Sorce LR, Argent A, Kissoon N, Tissières P, Watson RS, Schlapbach LJ. The Current and Future State of Pediatric Sepsis Definitions: An International Survey. Pediatrics 2022; 149:188114. [PMID: 35611643 DOI: 10.1542/peds.2021-052565] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Definitions for pediatric sepsis were established in 2005 without data-driven criteria. It is unknown whether the more recent adult Sepsis-3 definitions meet the needs of providers caring for children. We aimed to explore the use and applicability of criteria to diagnose sepsis and septic shock in children across the world. METHODS This is an international electronic survey of clinicians distributed across international and national societies representing pediatric intensive care, emergency medicine, pediatrics, and pediatric infectious diseases. Respondents stated their preferences on a 5-point Likert scale. RESULTS There were 2835 survey responses analyzed, of which 48% originated from upper-middle income countries, followed by high income countries (38%) and low or lower-middle income countries (14%). Abnormal vital signs, laboratory evidence of inflammation, and microbiologic diagnoses were the criteria most used for the diagnosis of "sepsis." The 2005 consensus definitions were perceived to be the most useful for sepsis recognition, while Sepsis-3 definitions were stated as more useful for benchmarking, disease classification, enrollment into trials, and prognostication. The World Health Organization definitions were perceived as least useful across all domains. Seventy one percent of respondents agreed that the term sepsis should be restricted to children with infection-associated organ dysfunction. CONCLUSIONS Clinicians around the world apply a myriad of signs, symptoms, laboratory studies, and treatment factors when diagnosing sepsis. The concept of sepsis as infection with associated organ dysfunction is broadly supported. Currently available sepsis definitions fall short of the perceived needs. Future diagnostic algorithms should be pragmatic and sensitive to the clinical settings.
Collapse
Affiliation(s)
- Luc Morin
- Université Paris-Saclay, AP-HP, Pediatric Intensive Care, Bicêtre Hospital, DMU 3 Santé de l'Enfant et de l'Adolescent, Le Kremlin-Bicêtre, France
| | - Mark Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Daniela de Souza
- Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Lu Guoping
- Children's Hospital of Fudan University, Shanghai, China
| | - Roberto Jabornisky
- Universidad Nacional del Nordeste, Corrientes, Argentina.,Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Japan
| | | | - Patricia Gilholm
- Child Health Research Centre, and Paediatric Intensive Care Unit, The University of Queensland, and Queensland Children`s Hospital, Brisbane, Australia
| | | | - Jerry J Zimmerman
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Lauren R Sorce
- Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,University of Cape Town, Cape Town, South Africa
| | - Niranjan Kissoon
- British Columbia Women and Children's Hospital, Vancouver, British Columbia, Canada.,The University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Tissières
- Université Paris-Saclay, AP-HP, Pediatric Intensive Care, Bicêtre Hospital, DMU 3 Santé de l'Enfant et de l'Adolescent, Le Kremlin-Bicêtre, France.,Institute of Integrative Biology of the Cell, CNRS, CEA, Paris Saclay University, Gif-sur-Yvette, France
| | - R Scott Watson
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Luregn J Schlapbach
- Child Health Research Centre, and Paediatric Intensive Care Unit, The University of Queensland, and Queensland Children`s Hospital, Brisbane, Australia.,Department of Intensive Care and Neonatology, and Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland
| | | |
Collapse
|
42
|
Mora J, Chan GC, Morgenstern DA, Nysom K, Bear MK, Tornøe K, Kushner BH. Outpatient administration of naxitamab in combination with granulocyte-macrophage colony-stimulating factor in patients with refractory and/or relapsed high-risk neuroblastoma: Management of adverse events. Cancer Rep (Hoboken) 2022; 6:e1627. [PMID: 35579862 PMCID: PMC9875606 DOI: 10.1002/cnr2.1627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/21/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Naxitamab is a humanized GD2-binding monoclonal antibody that received accelerated approval from the U.S. Food and Drug Administration for refractory or relapsed high-risk neuroblastoma limited to bone or bone marrow. Trial 201 (NCT03363373) is an ongoing global clinical trial to evaluate the efficacy and safety of naxitamab in combination with granulocyte-macrophage colony-stimulating factor in this population. AIMS Here, we review the safety profile and adverse event (AE) management associated with naxitamab administration in a pediatric population, based on Trial 201 protocol guidelines and clinical trial experience. METHODS AND RESULTS At least 50% of patients experienced pain, hypotension, bronchospasm, cough, vomiting, diarrhea, nausea, and tachycardia, with the following reported at grade ≥3 AEs for at least 10% of patients: pain, hypotension, urticaria, and bronchospasm. These AEs were generally manageable in the outpatient setting using premedications, supportive therapies, and appropriate monitoring post-infusion. Algorithms were established for infusion-related AEs, including hypotension and bronchospasm, to provide guidance to investigators for early recognition and timely intervention, including medication and infusion rate modification or interruption, or treatment discontinuation, based on AE severity. Educating patients and caregivers on what to expect regarding premedication at home, experience during the infusion cycle, and post-infusion monitoring helps optimize naxitamab treatment and supportive therapies and may reduce treatment burden. CONCLUSION This article highlights the protocol-based recommendations for the management of acute AEs associated with outpatient naxitamab treatment in Trial 201. The authors recommend close monitoring and timely implementation of measures to ensure that patients can remain on treatment and obtain maximum clinical benefit from naxitamab therapy.
Collapse
Affiliation(s)
- Jaume Mora
- Pediatric Cancer Center BarcelonaHospital Sant Joan de DéuBarcelonaSpain
| | | | | | - Karsten Nysom
- Department of Pediatrics and Adolescent MedicineRigshospitaletCopenhagenDenmark
| | - Melissa K. Bear
- Pediatric Hematology and OncologyRiley Hospital for ChildrenIndianapolisIndianaUSA
| | - Karen Tornøe
- Medical DirectorYmabs TherapeuticsHørsholmDenmark
| | - Brian H. Kushner
- Department of PediatricsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| |
Collapse
|
43
|
Zha Y, Yuan J, Bao J, Fang M, Liu N, Huang R, Wang C, Chen S, Shao M. Veno-venous extracorporeal membrane oxygenation for septic shock patients with pulmonary infection: A propensity score matching-based retrospective study. Artif Organs 2022; 46:2304-2312. [PMID: 35491962 DOI: 10.1111/aor.14278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate whether septic shock patients with pulmonary infection and life-threatening hypoxemia can benefit from V-V ECMO. METHODS Retrospective clinical data analysis on patients who suffered septic shock with pulmonary infection, categorized into V-V ECMO and control groups.The propensity score matching (PSM) method was used to screen patients matched for age, gender, and disease severity.The primary outcome was 30- and 90-day mortality after diagnosis of septic shock. RESULTS After PSM, 31 pairs of patients were enrolled in this study, and there were no significant differences between the two groups in terms of gender, age, chronic disease, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score. Within 28 days after the diagnosis of septic shock, the median time of renal replacement therapy-free days was longer in the V-V ECMO group than in the control group (27 days versus 9 days ; P=0.044).Kaplan-Meier analysis showed that 30-day mortality was lower in the V-V ECMO group than in the control group (38.7% versus 61.3%; HR 0.488; 95% CI 0.240-0.992; P=0.043,by Log-rank test); 90-day mortality was not significantly different between the two groups (51.6% versus 67.7%; P=0.097). CONCLUSION Patients receiving V-V ECMO support had lower 30-day mortality and faster recovery of renal function within 28 days compared with those receiving conventional therapy. However, V-V ECMO did not improve 90-day survival in septic shock patients with pulmonary infection.
Collapse
Affiliation(s)
- Yutao Zha
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Jun Yuan
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Junjie Bao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Ming Fang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Nian Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Rui Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Cui Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Shi Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Min Shao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| |
Collapse
|
44
|
Burgunder L, Heyrend C, Olson J, Stidham C, Lane RD, Workman JK, Larsen GY. Medication and Fluid Management of Pediatric Sepsis and Septic Shock. Paediatr Drugs 2022; 24:193-205. [PMID: 35307800 DOI: 10.1007/s40272-022-00497-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 01/02/2023]
Abstract
Sepsis is a life-threatening response to infection that contributes significantly to neonatal and pediatric morbidity and mortality worldwide. The key tenets of care include early recognition of potential sepsis, rapid intervention with appropriate fluids to restore adequate tissue perfusion, and empiric antibiotics to cover likely pathogens. Vasoactive/inotropic agents are recommended if tissue perfusion and hemodynamics are inadequate following initial fluid resuscitation. Several adjunctive therapies have been suggested with theoretical benefit, though definitive recommendations are not yet supported by research reports. This review focuses on the recommendations for medication and fluid management of pediatric sepsis and septic shock, highlighting issues related to antibiotic choices and antimicrobial stewardship, selection of intravenous fluids for resuscitation, and selection and use of vasoactive/inotropic medications. Controversy remains regarding resuscitation fluid volume and type, antibiotic choices depending upon infectious risks in the patient's community, and adjunctive therapies such as vitamin C, corticosteroids, intravenous immunoglobulin, and methylene blue. We include best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.
Collapse
Affiliation(s)
- Lauren Burgunder
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Caroline Heyrend
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA
| | - Jared Olson
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chanelle Stidham
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA
| | - Roni D Lane
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| |
Collapse
|
45
|
Safety of Vasopressor Medications through Peripheral Line in Pediatric Patients in PICU in a Resource-Limited Setting. Crit Care Res Pract 2022; 2022:6160563. [PMID: 35402044 PMCID: PMC8991380 DOI: 10.1155/2022/6160563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/10/2021] [Accepted: 02/12/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Central venous catheter (CVC) placement in children in resource-limited settings (RLSs) can be a difficult task. Timely administration of vasopressor medications (VMs) through peripheral intravenous line (PIV) can help overcome this limitation. We aim to determine the safety of administration of vasopressor medications through PIVs in children admitted to pediatric intensive care unit (PICU) in a RLS. Design Prospective observational study. Setting. An eight-bedded PICU of a tertiary care hospital. Patients. Children aged 1 month to 18 years admitted to the PICU. Intervention. None. Measurements and Main Results. All children (aged 1 month–18 years) who received VMs through PIV line from January 2019 to December 2019 were prospectively followed for the development of extravasation, conversion to CVC, duration of infusion, maximum dose of VMs used, maximum vasopressor inotropic score (VIS), and coadministration of vasopressor medication through PIV line. Results are presented as means with standard deviation and frequency with percentages. A total of 369 patients were included in the study, 221 (59.9%) were males, and the median age of the study population was 24 months (IQR; 6–96). Epinephrine was the most frequently used vasopressor medication (n = 279, 75.6%), followed by milrinone (n = 93, 25.2%), norepinephrine (n = 42, 11.4%), and dopamine (n = 32, 8.7%). The maximum dose of vasopressor medication was 0.25 µg/kg/min (epinephrine), 0.2 µg/kg/min (norepinephrine), 15 µg/kg/min (dopamine), and 0.8 µg/kg/min (milrinone). Extravasation was observed in 8 (2.2%) patients, while PIV line was converted to CVC in 127 (34.4%) children. Maximum dose of epinephrine, norepinephrine, VIS score, and PRISM Score was associated with conversion to CVC (p < 0.001), while none of them was associated with risk for extravasation. Conclusion Vasopressor medication through PIV line is a safe option in patients admitted to the PICU.
Collapse
|
46
|
Lee EP, Lin JJ, Hsia SH, Chan OW, Jan SL, Wu HP. Cutoff Values of Hemodynamic Parameters in Pediatric Refractory Septic Shock. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030303. [PMID: 35327675 PMCID: PMC8947105 DOI: 10.3390/children9030303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022]
Abstract
Background: Refractory septic shock can cause severe morbidities and mortalities in children. Resuscitation based on hemodynamics is important in children with critical illness. Thus, this study aimed to identify the hemodynamics of refractory septic shock associated with poor prognosis at an early stage to allow for timely interventions. Methods: We evaluated children with refractory septic shock admitted to a pediatric intensive care unit (PICU) and monitored their hemodynamics using a pulse index continuous cardiac output (PiCCO) system. The serial cardiac index (CI), systemic vascular resistance index (SVRI), and vasoactive−inotropic score (VIS) were recorded during the first 72 h after PICU admission. Results: Thirty-three children with refractory septic shock were enrolled. The SVRI and VIS were both associated with fatality from septic shock. The non-survivors had lower serial SVRI and higher VIS (both p < 0.05). Based on the area under the ROC curve, the SVRI was the predictor during the early resuscitative stage (first 36 h) in pediatric refractory septic shock. Conclusions: Both SVRI and VIS are predictors of mortality in children with refractory septic shock, and the SVRI is the powerful predictor of mortality in the early resuscitative stage. A low serial SVRI may allow for the early awareness of disease severity and strategies for adjusting vasoactive−inotropic agents to increase the SVRI.
Collapse
Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan 333, Taiwan; (E.-P.L.); (J.-J.L.); (S.-H.H.); (O.-W.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan 333, Taiwan; (E.-P.L.); (J.-J.L.); (S.-H.H.); (O.-W.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan 333, Taiwan; (E.-P.L.); (J.-J.L.); (S.-H.H.); (O.-W.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan 333, Taiwan; (E.-P.L.); (J.-J.L.); (S.-H.H.); (O.-W.C.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Sheng-Ling Jan
- Department of Pediatrics, Children’s Medical Center, Taichung Veterans General Hospital, Taichung City 407, Taiwan
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei City 112, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Correspondence: (S.-L.J.); (H.-P.W.); Tel.: +886-4-23592525 (S.-L.J.); +886-4-22052121 (H.-P.W.)
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, Children’s Hospital, China Medical University, Taichung 406040, Taiwan
- Department of Medical Research, Children’s Hospital, China Medical University, Taichung 406040, Taiwan
- Department of Medicine, School of Medicine, China Medical University, Taichung 406040, Taiwan
- Correspondence: (S.-L.J.); (H.-P.W.); Tel.: +886-4-23592525 (S.-L.J.); +886-4-22052121 (H.-P.W.)
| |
Collapse
|
47
|
Association of selenium status with endothelial activation during acute systemic inflammation in children. Clin Nutr ESPEN 2022; 47:367-374. [DOI: 10.1016/j.clnesp.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/07/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022]
|
48
|
Yang Y, Xiao Z, Huang J, Gong L, Lu X. Role of Extracorporeal Membrane Oxygenation in Adults and Children With Refractory Septic Shock: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 9:791781. [PMID: 35127592 PMCID: PMC8814621 DOI: 10.3389/fped.2021.791781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The benefits of extracorporeal membrane oxygenation in patients with refractory septic shock remain controversial. Current guidelines on the management of refractory septic shock recommend the consideration of extracorporeal membrane oxygenation as a salvage therapy. The difference between adults and children with septic refractory shock treated with extracorporeal membrane oxygenation has not been previously analyzed. We aimed to review peer-reviewed publications on the role of extracorporeal membrane oxygenation in adults and children with refractory septic shock. METHODS Studies reporting on mortality in both adults and children with refractory septic shock supported with extracorporeal membrane oxygenation published in PubMed, Cochrane Library, and Embase databases were included in the meta-analysis. Study eligibility was independently assessed by two authors, and disagreements were resolved by a third author. The outcome measure was survival at discharge. Subgroup analysis included the adult and pediatric groups. RESULTS Of the 293 articles screened, 14 original articles were identified for systematic review and meta-analysis. The cumulative estimate of survival (14 studies, 535 patients) in the cohort was 39% (95% confidence interval [CI]: 27-51%). During the subgroup analysis, the cumulative estimate of survival at discharge in the adult group (6 studies, 276 patients) in the cohort was 18% (95% CI: 10-27%), and that in the pediatric group (8 studies, 259 patients) was 53% (95% CI: 47-59%). CONCLUSIONS The survival rate of adults with refractory septic shock requiring extracorporeal membrane oxygenation was 18%, and children with refractory septic shock requiring extracorporeal membrane oxygenation had a higher survival rate (53%) than adults.
Collapse
Affiliation(s)
| | | | | | | | - Xiulan Lu
- Department of Intensive Care Unit of Hunan Children's Hospital, Changsha, China
| |
Collapse
|
49
|
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]
|
50
|
Comparison of vena cava distensibility index and pulse pressure variation for the evaluation of intravascular volume in critically ill children. J Pediatr (Rio J) 2022; 98:99-103. [PMID: 34052225 PMCID: PMC9432067 DOI: 10.1016/j.jped.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE In this study, the authors aimed to evaluate the effectiveness of the vena cava distensibility index and pulse pressure variation as dynamic parameters for estimating intravascular volume in critically ill children. METHODS Patients aged 1 month to 18 years, who were hospitalized in the present study's pediatric intensive care unit, were included in the study. The patients were divided into two groups according to central venous pressure: hypovolemic (< 8 mmHg) and non-hypovolemic (central venous pressure ≥ 8 mmHg) groups. In both groups, vena cava distensibility index was measured using bedside ultrasound and pulse pressure variation. Measurements were recorded and evaluated under arterial monitoring. RESULTS In total, 19 (47.5%) of the 40 subjects included in the study were assigned to the central venous pressure ≥ 8 mmHg group, and 21 (52.5%) to the central venous pressure < 8 mmHg group. A moderate positive correlation was found between pulse pressure variation and vena cava distensibility index (r = 0.475, p < 0.01), while there were strong negative correlations of central venous pressure with pulse pressure variation and vena cava distensibility index (r = -0.628, p < 0.001 and r = -0.760, p < 0.001, respectively). In terms of predicting hypovolemia, the predictive power for vena cava distensibility index was > 16% (sensitivity, 90.5%; specificity, 94.7%) and that for pulse pressure variation was > 14% (sensitivity, 71.4%; specificity, 89.5%). CONCLUSION Vena cava distensibility index has higher sensitivity and specificity than pulse pressure variation for estimating intravascular volume, along with the advantage of non-invasive bedside application.
Collapse
|