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Wang L, Dixon C, Nhan J, Kakajiwala A. A balancing act: drifting away from the reflexive use of "ab"normal saline. Pediatr Nephrol 2024; 39:2325-2335. [PMID: 38233719 DOI: 10.1007/s00467-023-06271-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.
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Affiliation(s)
- Linda Wang
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA.
| | - Celeste Dixon
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Jennifer Nhan
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
| | - Aadil Kakajiwala
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
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2
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Brossier DW, Goyer I, Morice C, Alsohime F, Mayberry HF, Porcheret F, Tume LN, Valla FV. How to follow the guidelines, when the appropriate fluid is missing? Eur J Pediatr 2024; 183:2797-2803. [PMID: 38498239 PMCID: PMC11098858 DOI: 10.1007/s00431-024-05514-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. Recently paediatric societies have produced evidence-based practice guidelines that recommend the use of balanced isotonic fluid when prescribing IV-MFT in both acute and critical paediatric care. Unfortunately, the applicability of these guidelines could be called into question when a ready-to-use glucose-containing balanced isotonic fluid is not available. The main objective of this study was to describe the availability of glucose-containing balanced isotonic fluids in European and Middle Eastern paediatric acute and critical care settings. This work is an ancillary study of the survey dedicated to IV-MFT practices in the paediatric acute and critical care settings in Europe and Middle East, a cross-sectional electronic 27-item survey, emailed in April-May 2021 to paediatric critical care physicians across 34 European and Middle East countries. The survey was developed by an expert multi-professional panel within the European Society of Peadiatric and Neonatal Intensive Care (ESPNIC). Balanced isotonic fluid with glucose 5% was available for only 32/153 (21%) responders. Balanced isotonic fluid with glucose 5% was consistently available in the UK (90%) but not available in France, Greece, The Netherlands and Turkey. Conclusion: Ready-to-use isotonic balanced IV solutions containing glucose in sufficient amount exist but are inconsistently available throughout Europe. National and European Medication Safety Incentives should guarantee the availability of the most appropriate and safest IV-MFT solution for all children. What is Known: • Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. • Balanced isotonic fluid is recommended when prescribing IV-MFT in both acute and critical paediatric care. What is New: • Balanced isotonic fluid with glucose 5% is available for less than 25% of the prescribers in Europe and the Middle East. Availability of balanced isotonic fluid with glucose 5% varies from one country to another but can also be inconsistent within the same country. • Clinicians who have access to a ready-to-use balanced isotonic fluid with glucose 5% are more likely to consider its use than clinicians who do not have access to such an IV solution.
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Affiliation(s)
- David W Brossier
- CHU de Caen, Pediatric Intensive Care Unit, 14000, Caen, France.
- Medical School, Université Caen Normandie, 14000, Caen, France.
- Université de Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, 59000, Lille, France.
- CHU Sainte Justine Research Center, Montréal, Canada.
| | - Isabelle Goyer
- CHU de Caen, Department of Pharmacy, 14000, Caen, France
| | - Claire Morice
- Pediatric Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Fahad Alsohime
- Pediatric Intensive Care, Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Huw F Mayberry
- Pediatric Intensive Care Unit, Alder Hey Childrens Hospital, Liverpool, UK
| | - Florence Porcheret
- Department of Pediatric Nephrology, CHU de Nantes, 44000, Nantes, France
| | - Lyvonne N Tume
- Pediatric Intensive Care Unit, Alder Hey Childrens Hospital, Liverpool, UK
- Faculty of Heath Social Care & Medicine, Edge Hill University, Ormskirk, UK
| | - Frederic V Valla
- Faculty of Heath Social Care & Medicine, Edge Hill University, Ormskirk, UK
- Hospices Civils de Lyon, Pediatric Intensive Care, 69000, Lyon, France
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3
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Duan H, Li N, Qi J, Li X, Zhou K. Cullin-3 proteins be a novel biomarkers and therapeutic targets for hyperchloremia induced by oral poisoning. Sci Rep 2024; 14:8597. [PMID: 38615119 PMCID: PMC11016057 DOI: 10.1038/s41598-024-59264-4] [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: 11/19/2023] [Accepted: 04/08/2024] [Indexed: 04/15/2024] Open
Abstract
Oral poisoning can trigger diverse physiological reactions, determined by the toxic substance involved. One such consequence is hyperchloremia, characterized by an elevated level of chloride in the blood and leads to kidney damage and impairing chloride ion regulation. Here, we conducted a comprehensive genome-wide analysis to investigate genes or proteins linked to hyperchloremia. Our analysis included functional enrichment, protein-protein interactions, gene expression, exploration of molecular pathways, and the identification of potential shared genetic factors contributing to the development of hyperchloremia. Functional enrichment analysis revealed that oral poisoning owing hyperchloremia is associated with 4 proteins e.g. Kelch-like protein 3, Serine/threonine-protein kinase WNK4, Serine/threonine-protein kinase WNK1 and Cullin-3. The protein-protein interaction network revealed Cullin-3 as an exceptional protein, displaying a maximum connection of 18 nodes. Insufficient data from transcriptomic analysis indicates that there are lack of information having direct associations between these proteins and human-related functions to oral poisoning, hyperchloremia, or metabolic acidosis. The metabolic pathway of Cullin-3 protein revealed that the derivative is Sulfonamide which play role in, increasing urine output, and metabolic acidosis resulted in hypertension. Based on molecular docking results analysis it found that Cullin-3 proteins has the lowest binding energies score and being suitable proteins. Moreover, no major variations were observed in unbound Cullin-3 and all three peptide bound complexes shows that all systems remain compact during 50 ns simulations. The results of our study revealed Cullin-3 proteins be a strong foundation for the development of potential drug targets or biomarker for future studies.
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Affiliation(s)
- Hui Duan
- Department of Emergency Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Na Li
- Department of Vascular Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jia Qi
- Department of Hematology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xi Li
- Department of Ophthalmology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Kun Zhou
- Department of Physical Examination Center, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
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4
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Brossier DW, Goyer I, Verbruggen SCAT, Jotterand Chaparro C, Rooze S, Marino LV, Schlapbach LJ, Tume LN, Valla FV. Intravenous maintenance fluid therapy in acutely and critically ill children: state of the evidence. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:236-244. [PMID: 38224704 DOI: 10.1016/s2352-4642(23)00288-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 01/17/2024]
Abstract
Intravenous maintenance fluid therapy (IV-MFT) is one of the most prescribed, yet one of the least studied, interventions in paediatric acute and critical care settings. IV-MFT is not typically treated in the same way as drugs with specific indications, contraindications, compositions, and associated adverse effects. In the last decade, societies in both paediatric and adult medicine have issued evidence-based practice guidelines for the use of intravenous fluids in clinical practice. The main objective of this Viewpoint is to summarise and compare the rationales on which these international expert guidelines were based and how these recommendations affect IV-MFT practices in paediatric acute and critical care. Although these guidelines recommend the use of isotonic fluids as a standard in IV-MFT, some discrepancies and uncertainties remain regarding the systematic use of balanced fluids, glucose and electrolyte requirements, and appropriate fluid volume. IV-MFT should be considered in the same way as any other prescription drug and none of the components of IV-MFT prescription should be overlooked (ie, choice of drug, dosing rate, duration of treatment, and de-escalation). Furthermore, most evidence that was used to inform the guidelines comes from high-income countries. Although some principles of IV-MFT are universal, the direct relevance to and feasibility of implementing the guidelines in low-income and middle-income countries is uncertain.
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Affiliation(s)
- David W Brossier
- Paediatric Intensive Care Unit, Centre Hospitalier Universitaire, Caen, France; Medical School, Université Caen Normandie, Caen, France; Centre Hospitalier Universitaire, Université de Lille, ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.
| | - Isabelle Goyer
- Department of Pharmacy, University Hospital of Caen, Caen, France
| | - Sascha C A T Verbruggen
- Paediatric Intensive Care Unit, Department of Neonatal and Paediatric Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, Netherlands
| | - Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Shancy Rooze
- Paediatric Intensive Care, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Luise V Marino
- University Hospital Southampton, National Health Service Foundation Trust, Southampton, UK
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, and Children's Research Centre, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lyvonne N Tume
- Paediatric Intensive Care Unit Alder Hey Children's Hospital, Liverpool, UK; Faculty of Health Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Frederic V Valla
- Faculty of Health Social Care and Medicine, Edge Hill University, Ormskirk, UK; Paediatric Intensive Care, Hospices Civils de Lyon, Lyon, France
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5
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Atreya MR, Piraino G, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Thomas NJ, Baines T, Haileselassie B, Zingarelli B. SERUM HUMANIN IN PEDIATRIC SEPTIC SHOCK-ASSOCIATED MULTIPLE-ORGAN DYSFUNCTION SYNDROME. Shock 2024; 61:83-88. [PMID: 37917869 PMCID: PMC10842252 DOI: 10.1097/shk.0000000000002266] [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] [Indexed: 11/04/2023]
Abstract
ABSTRACT Background: Multiple-organ dysfunction syndrome disproportionately contributes to pediatric sepsis morbidity. Humanin (HN) is a small peptide encoded by mitochondrial DNA and thought to exert cytoprotective effects in endothelial cells and platelets. We sought to test the association between serum HN (sHN) concentrations and multiple-organ dysfunction syndrome in a prospectively enrolled cohort of pediatric septic shock. Methods: Human MT-RNR2 ELISA was used to determine sHN concentrations on days 1 and 3. The primary outcome was thrombocytopenia-associated multiorgan failure (TAMOF). Secondary outcomes included individual organ dysfunctions on day 7. Associations across pediatric sepsis biomarker (PERSEVERE)-based mortality risk strata and correlation with platelet and markers of endothelial activation were tested. Results: One hundred forty subjects were included in this cohort, of whom 39 had TAMOF. The concentration of sHN was higher on day 1 relative to day 3 and among those with TAMOF phenotype in comparison to those without. However, the association between sHN and TAMOF phenotype was not significant after adjusting for age and illness severity in multivariate models. In secondary analyses, sHN was associated with presence of day 7 sepsis-associated acute kidney injury ( P = 0.049). Furthermore, sHN was higher among those with high PERSEVERE-mortality risk strata and correlated with platelet counts and several markers of endothelial activation. Conclusion: Future investigation is necessary to validate the association between sHN and sepsis-associated acute kidney injury among children with septic shock. Furthermore, mechanistic studies that elucidate the role of HN may lead to therapies that promote organ recovery through restoration of mitochondrial homeostasis among those critically ill.
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Affiliation(s)
| | - Giovanna Piraino
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, 45229, OH, USA
| | | | | | - Scott L Weiss
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, Orange, CA 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN 55404, USA
| | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA 17033, USA
| | - Torrey Baines
- University of Florida Health Shands Children's Hospital, Gainesville, FL 32610, USA
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6
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Wang P, Huang Y, Li J, Cao D, Chen B, Chen Z, Li J, Wang R, Liu L. Balanced crystalloid solutions versus normal saline in intensive care units: a systematic review and meta-analysis. Int Urol Nephrol 2023; 55:2829-2844. [PMID: 37017820 PMCID: PMC10560196 DOI: 10.1007/s11255-023-03570-9] [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: 12/26/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Intravenous fluid therapy is important for pediatric and adult patients in intensive care units (ICUs). However, medical professionals continue to struggle to determine the most appropriate fluids to obtain the best possible outcomes for each patient. OBJECTIVE We conducted a meta-analysis involving cohort studies and randomized controlled trials (RCTs) to compare the influence of balanced crystalloid solutions and normal saline among patients in ICUs. PATIENTS AND METHODS Studies that compared balanced crystalloid solutions and saline in ICU patients from databases including PubMed, Embase, Web of Science, and Cochrane Library were systematically searched up to July 25, 2022. The primary outcomes were mortality and renal-related outcomes, which included major adverse kidney events within 30 days (MAKE30), acute kidney injury (AKI), new receipt of renal replacement therapy (RRT), maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline. Service utilization including length of hospital stay, ICU stay, ICU-free days and ventilator-free days were also reported. RESULTS A total of 13 studies (10 RCTs and 3 cohort studies) involving 38,798 patients in ICUs met the selection criteria. Our analysis revealed that each subgroup had no significant difference in mortality outcomes among ICU patients between balanced crystalloid solutions and normal saline. A significant difference was detected between the adult groups (odds ratio [OR], 0.92; 95% confidence interval [CI], [0.86, 1.00]; p = 0.04) indicating that the AKI in the balanced crystalloid solutions group was lower than that in the normal saline group. Other renal-related outcomes, such as MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline showed no significant difference between the two groups. Regarding secondary outcomes, the balanced crystalloid solution group had a longer ICU stay time (WMD, 0.02; 95% CI, [0.01, 0.03]; p = 0.0004 and I2 = 0%; p = 0.96) than the normal saline group among adult patients. Furthermore, children treated with balanced crystalloid solution had a shorter hospital stay time (WMD, - 1.10; 95% CI, [- 2.10, - 0.10]; p = 0.03 and I2 = 17%; p = 0.30) than those treated with saline. CONCLUSIONS Compared with saline, balanced crystalloid solutions could not reduce the risk of mortality and renal-related outcomes, including MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline, but the solutions may reduce total AKI incidence among adult patients in ICUs. For service utilization outcomes, balanced crystalloid solutions were associated with a longer length of ICU stay in the adult group and shorter length of hospital stay in the pediatric group.
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Affiliation(s)
- Puze Wang
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Yin Huang
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Jin Li
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Dehong Cao
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Bo Chen
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Zeyu Chen
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Jinze Li
- Department of Urology, West China Hospital of Medicine, Chengdu, China
| | - Ruyi Wang
- Department of Urology, West China Hospital of Medicine, Chengdu, China
- Department of Urology, Hospital of Chengdu University, Chengdu, China
| | - Liangren Liu
- Department of Urology, West China Hospital of Medicine, Chengdu, China.
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7
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Luglio M, de Carvalho WB, Tannuri U, Tannuri ACA, Matsura RH, Morais França G, Delgado AF. Effects of serum sodium and chloride levels in the outcome of critically ill pediatric patients in the post-operative period of liver transplantation. BMC Nephrol 2023; 24:141. [PMID: 37217877 DOI: 10.1186/s12882-023-03195-1] [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: 06/29/2022] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Sodium and chloride disturbances have attracted increasing attention in recent years. Many pathophysiological effects are associated with hyperchloremia, including reduction in mean arterial pressure and acute renal disease. Pediatric patients undergoing liver transplantation are at risk of developing various electrolyte and biochemical abnormalities, with an impact on their postoperative outcomes. OBJECTIVE To analyze the impacts of serum sodium and chloride levels on prognosis of Pediatric Liver Transplant receptors. METHODS This was a retrospective analytical observational study performed in a single transplant reference center in Sao Paulo, Brazil. Included patients were pediatric patients who underwent liver transplantation between January 2015 and July 2019. Statistical regression analysis and General Estimating Equations analysis were performed to evaluate the impacts of sodium and chloride disturbances on the development of acute renal failure and mortality. RESULTS A total of 143 patients were included in this study. The main diagnosis was Biliary Atresia (62.9%). Twenty-seven patients died (18.9%), and graft dysfunction was the main cause of death (29.6%). The only variable individually associated with 28-days mortality was PIM-3 score (HR 1.59, CI 95% 1.165-2.177, p = 0.004). Forty-one patients (28.6%) developed moderate or severe AKI. PIM-3 score (OR 3.052, 95% CI 1.56-5.97, p = 0.001), hypernatremia (OR 3.49, 95% CI 1.32-9.23, p = 0.012), and hyponatremia (OR 4.24, 95% CI 1.52-11.85, p = 0.006) were independently associated with the development of moderate/severe AKI. CONCLUSIONS In pediatric patients after liver transplantation, PIM-3 score, and abnormal serum sodium levels were correlated with AKI development.
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Affiliation(s)
- Michele Luglio
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Werther B de Carvalho
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Uenis Tannuri
- Pediatric Surgery and Liver Transplant Team, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ana Cristina A Tannuri
- Pediatric Surgery and Liver Transplant Team, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Hideki Matsura
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gardenia Morais França
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Artur F Delgado
- Pediatric Critical Care Center, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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8
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Barhight MF, Selewski DT. Hyperchloremia and acute kidney injury: chicken or the egg? Pediatr Nephrol 2023:10.1007/s00467-023-05895-0. [PMID: 36752931 DOI: 10.1007/s00467-023-05895-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 428 MSC 608, Charleston, SC, 29425, USA.
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9
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Stanski NL, Gist KM, Pickett K, Brinton JT, Sadlowski J, Wong HR, Mourani P, Soranno DE, Kendrick J, Stenson EK. Electrolyte derangements in critically ill children receiving balanced versus unbalanced crystalloid fluid resuscitation. BMC Nephrol 2022; 23:388. [PMID: 36474179 PMCID: PMC9727874 DOI: 10.1186/s12882-022-03009-w] [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] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adult studies have demonstrated potential harm from resuscitation with 0.9% sodium chloride (0.9%NaCl), resulting in increased utilization of balanced crystalloids like lactated ringers (LR). The sodium and potassium content of LR has resulted in theoretical safety concerns, although limited data exists in pediatrics. We hypothesized that use of LR for resuscitation would not be associated with increased electrolyte derangements compared to 0.9%NaCl. METHODS A prospective, observational cohort study of critically ill children who received ≥ 20 ml/kg of fluid resuscitation and were admitted to two pediatric intensive care units from November 2017 to February 2020. Fluid groups included patients who received > 75% of fluids from 0.9%NaCl, > 75% of fluids from LR, and a mixed group. The primary outcome was incidence of electrolyte derangements (sodium, chloride, potassium) and acidosis. RESULTS Among 559 patients, 297 (53%) received predominantly 0.9%NaCl, 74 (13%) received predominantly LR, and 188 (34%) received a mixture. Extreme hyperkalemia (potassium ≥ 6 mmol/L) was more common in 0.9%NaCl group (5.8%) compared to LR group (0%), p 0.05. Extreme acidosis (pH > 7.1) was more common in 0.9%NaCl group (11%) compared to LR group (1.6%), p 0.016. CONCLUSIONS LR is associated with fewer electrolyte derangements compared to 0.9%NaCl. Prospective interventional trials are needed to validate these findings.
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Affiliation(s)
- Natalja L. Stanski
- grid.239573.90000 0000 9025 8099Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Katja M. Gist
- grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA ,grid.239573.90000 0000 9025 8099Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Kaci Pickett
- grid.430503.10000 0001 0703 675XDepartment of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - John T. Brinton
- grid.430503.10000 0001 0703 675XDepartment of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Jennifer Sadlowski
- grid.413957.d0000 0001 0690 7621Research Informatics, Children’s Hospital Colorado, Aurora, CO USA
| | - Hector R. Wong
- grid.239573.90000 0000 9025 8099Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Peter Mourani
- grid.241054.60000 0004 4687 1637Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR USA ,grid.239305.e0000 0001 2157 2081Division of Critical Care Medicine, Arkansas Children’s Hospital, Little Rock, AR USA
| | - Danielle E. Soranno
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA ,grid.430503.10000 0001 0703 675XSection of Nephrology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jessica Kendrick
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Erin K. Stenson
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA ,grid.430503.10000 0001 0703 675XSection of Critical Care, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Avenue, MS8414, Aurora, CO 80045 USA
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10
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Bhowmick R. Normal Anion Gap Metabolic Acidosis in Pediatric Acute Diarrhea: A Menace or an Innocent Bystander? Indian J Crit Care Med 2022; 26:1235-1236. [PMID: 36755625 PMCID: PMC9886017 DOI: 10.5005/jp-journals-10071-24371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
How to cite this article: Bhowmick R. Normal Anion Gap Metabolic Acidosis in Pediatric Acute Diarrhea: A Menace or an Innocent Bystander? Indian J Crit Care Med 2022;26(12):1235-1236.
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Affiliation(s)
- Rohit Bhowmick
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Kalyani, West Bengal, India
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11
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Hyperchloremia and association with acute kidney injury in critically ill children. Pediatr Nephrol 2022:10.1007/s00467-022-05823-8. [PMID: 36409366 DOI: 10.1007/s00467-022-05823-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/30/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyperchloremia has been associated with acute kidney injury (AKI) in critically ill adult patients. Data is limited in pediatric patients. Our study sought to determine if an association exists between hyperchloremia and AKI in pediatric patients admitted to the intensive care unit (PICU). METHODS This is a single-center retrospective cohort study of pediatric patients admitted to the PICU for greater than 24 h and who received intravenous fluids. Patients were excluded if they had a diagnosis of kidney disease or required kidney replacement therapy (KRT) within 6 h of admission. Exposures were hyperchloremia (serum chloride ≥ 110 mmol/L) within the first 7 days of PICU admission. The primary outcome was the development of AKI using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Secondary outcomes included time on mechanical ventilation, new KRT, PICU length of stay, and mortality. Outcomes were analyzed using multivariate logistic regression. RESULTS There were 407 patients included in the study, 209 in the hyperchloremic group and 198 in the non-hyperchloremic group. Univariate analysis demonstrated 108 (51.7%) patients in the hyperchloremic group vs. 54 (27.3%) in the non-hyperchloremic group (p = < .001) with AKI. On multivariate analysis, the odds ratio of AKI with hyperchloremia was 2.24 (95% CI 1.39-3.61) (p = .001). Hyperchloremia was not associated with increased odds of mortality, need for KRT, time on mechanical ventilation, or length of stay. CONCLUSION Hyperchloremia was associated with AKI in critically ill pediatric patients. Further pediatric clinical trials are needed to determine the benefit of a chloride restrictive vs. liberal fluid strategy. A higher resolution version of the Graphical abstract is available as Supplementary information.
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12
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Fluid bolus therapy in pediatric sepsis: a narrative review. Eur J Med Res 2022; 27:246. [DOI: 10.1186/s40001-022-00885-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/04/2022] [Indexed: 11/14/2022] Open
Abstract
AbstractLeading cause of death in children under five, pediatric sepsis remains a significant global health threat. The 2020 Surviving Sepsis Campaign guidelines revised the management of septic shock and sepsis-associated organ dysfunction in children. In addition to empiric broad-spectrum antibiotics, fluid bolus therapy is one of the cornerstones of management, due to theoretical improvement of cardiac output, oxygen delivery and organ perfusion. Despite a very low level of evidence, the possible benefit of balanced crystalloids in sepsis resuscitation has led to discussion on their position as the ideal fluid. However, the latest adult data are not consistent with this, and the debate is still ongoing in pediatrics. We provide here the current state of knowledge on fluid bolus therapy in pediatric sepsis with emphasis on balanced crystalloids.
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Scioscia A, Horvat C, Moritz ML, Fuhrman D. Balanced Crystalloids versus Normal Saline in Children with Critical Asthma. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1480. [PMID: 36291416 PMCID: PMC9601181 DOI: 10.3390/children9101480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 01/03/2023]
Abstract
There is little known about the impact of maintenance fluid choice in children with critical asthma on clinical outcomes. Our primary study objectives were to determine the differences in the serum chloride and bicarbonate levels based on the receipt of 0.9% saline or a balanced solution. The secondary study objectives included differences in acute kidney injury (AKI) and intensive care unit (ICU)/hospital length of stay (LOS). In this retrospective cohort study, we included 1166 patients admitted to a quaternary children's hospital with critical asthma between 2017 and 2019. The patients were stratified based on if they received 0.9% saline or a balanced solution (Lactated Ringer's or Plasma-lyte) for maintenance therapy. The study outcomes were determined using independent sample t-tests, multivariable logistic regression, and negative binomial regression. The patients who received 0.9% saline maintenance therapy had a significantly higher increase in their serum chloride levels when compared to those who received balanced solutions (0.9% saline: +4 mMol/L, balanced: +2 mMol/L, p = 0.002). There was no difference in the decrease in the serum bicarbonate levels (0.9% saline: -0.4 mMol/L, balanced: -0.5 mMol/L, p = 0.830). After controlling for age, race, sex, and the Pediatric Logistic Organ Dysfunction (PELOD-2) score, there was no association between the type of fluid received and the development of AKI (OR 0.87, 95% CI: 0.46-1.63, p = 0.678). Additionally, there was no association between the type of fluid and hospital or ICU LOS. Thus, despite higher serum chloride levels in the patients that received 0.9% saline, the choice of fluid therapy did not have an impact on the serum bicarbonate values, the development of AKI or hospital and ICU LOS, suggesting there is little difference between 0.9% saline and balanced solutions as maintenance therapy in children with critical asthma.
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Affiliation(s)
- Andrea Scioscia
- Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH 44106, USA
| | - Christopher Horvat
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Michael L. Moritz
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Dana Fuhrman
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
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14
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Zhu X, Xue J, Liu Z, Dai W, Xiang J, Xu H, Zhou Q, Zhou Q, Chen W. Association between serum chloride levels with mortality in critically ill patients with acute kidney injury: An observational multicenter study employing the eICU database. PLoS One 2022; 17:e0273283. [PMID: 35998143 PMCID: PMC9398007 DOI: 10.1371/journal.pone.0273283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The effect of the serum chloride (Cl) level on mortality in critically ill patients with acute kidney injury (AKI) remains unknown. We sought an association between mortality and serum Cl. Methods We identified AKI patients in the eICU Collaborative Research Database from 2014 to 2015 at 208 US hospitals. The outcomes included in-hospital and intensive care unit (ICU) mortality. Time-varying covariates Cox regression models and the Kaplan-Meier (K-M) curves were used to assess the association between serum Cl levels and mortality. Multivariable adjusted restricted cubic spline models were used to analyze the potential nonlinear relationship between mortality and serum Cl. Results In total, 4,234 AKI patients were included in the study. Compared with normochloremia (98≤chloride<108mEq/L), hypochloremia (Cl<98mEq/L) was associated with mortality (adjusted hazard ratio [HR] for in-hospital mortality 1.46, 95% confidence interval [CI] 1.20–1.80, P = 0.0003; adjusted HR for ICU mortality 1.37, 95% CI 1.05–1.80, P = 0.0187). Hyperchloremia showed no significant difference in mortality compared to normochloremia (adjusted HR for in-hospital mortality 0.89, 95% CI 0.76–1.04, P = 0.1438; adjusted HR for ICU mortality 0.87, 95% CI 0.72–1.06, P = 0.1712). Smoothing curves revealed continuous non-linear associations between serum Cl levels and mortality. The K-M curve showed that patients with hypochloremia presented with a lower survival rate. Conclusions Lower serum Cl levels after ICU admission was associated with increased in-hospital and ICU mortality in critically ill patients with AKI. The results should be verified in well-designed prospective studies.
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Affiliation(s)
- Xu Zhu
- Department of Epidemiology and Health Statistics, College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jing Xue
- Department of Scientific Research, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zheng Liu
- Department of Anesthesiology, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated with Shandong First Medical University, Ji’nan, Shandong, China
| | - Wenjie Dai
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Jingsha Xiang
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Hui Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qiaoling Zhou
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Quan Zhou
- Department of Science and Education, The First People’s Hospital of Changde City, Changde, Hunan, China
| | - Wenhang Chen
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Movement System Injury and Repair Research Center, Xiangya Hospital, Central South University, Changsha, Hunan, China
- * E-mail:
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15
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Bledsoe J, Peltan ID, Bunnell RJ, Brown SM, Jephson A, Groat D, Levin NM, Wilson E, Newbold J, Fontaine GV, Frandsen J, Hasleton D, Krakovitz P, Brunisholz K, Allen T. Order Substitutions and Education for Balanced Crystalloid Solution Use in an Integrated Health Care System and Association With Major Adverse Kidney Events. JAMA Netw Open 2022; 5:e2210046. [PMID: 35503217 PMCID: PMC9066288 DOI: 10.1001/jamanetworkopen.2022.10046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/10/2022] [Indexed: 11/25/2022] Open
Abstract
Importance Trials comparing balanced crystalloids with normal saline have yielded mixed results regarding reductions in kidney complications and mortality for hospitalized patients receiving intravenous fluids. Objective To evaluate the association of a multifaceted implementation program encouraging the preferential use of lactated Ringer solution with patient outcomes and intravenous fluid-prescribing practices in a large, multilevel health care system. Design, Setting, and Participants This type 2 hybrid implementation and comparative effectiveness study enrolled all patients 18 years or older who received 1 L or more of intravenous fluids while admitted to an emergency department and/or inpatient unit at 1 of 22 hospitals in Idaho and Utah between November 1, 2018, and February 29, 2020. An interrupted time series analysis was used to assess study outcomes before and after interventions to encourage use of lactated Ringer solution. Exposures Implementation program combining order set modification, electronic order entry alerts, and sequential clinician-targeted education to encourage prescribing of lactated Ringer solution instead of normal saline. Main Outcomes and Measures The primary implementation outcome was the patient-level proportion of intravenous fluids that was balanced crystalloids. The primary effectiveness outcome was the incidence of major adverse kidney events (MAKE30)-a composite of new persistent kidney dysfunction, new initiation of dialysis, and death-at 30 days. Results Among 148 423 patients (median [IQR] age, 47 [30-67] years; 91 302 women [61%]), the proportion of total fluids received that was lactated Ringer solution increased from 28% to 75% in the first week vs the last week of the study (immediate implementation effect odds ratio [OR], 3.44; 95% CI, 2.79-4.24). The estimated MAKE30 absolute risk reduction was 2.2% (95% CI, 1.3%-3.3%) based on interrupted time series analysis showing a decrease in the week-on-week trend for MAKE30 (OR difference, 0.03; 95% CI, 0.03-0.03, P < .001). The immediate postimplementation OR for MAKE30 was 0.88 (95% CI, 0.76-1.01), with a decrease in persistent kidney dysfunction (OR, 0.80; 95% CI, 0.69-0.93) and mortality (OR, 0.78; 95% CI, 0.65-0.93) but not dialysis (OR, 1.00; 95% CI, 0.76-1.32). Conclusions and Relevance In this comparative effectiveness study, an implementation program was associated with an increase in the proportion of fluids administered as lactated Ringer solution compared with normal saline and was associated with a reduction in MAKE30 events among patients treated in a large integrated health care system.
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Affiliation(s)
- Joseph Bledsoe
- Department of Emergency Medicine, Intermountain Healthcare, Salt Lake City, Utah
- Department of Emergency Medicine, Stanford Medicine, Palo Alto, California
| | - Ithan D. Peltan
- Intermountain Medical Center, Salt Lake City, Utah
- Division of Pulmonary/Critical Care, Department of Medicine, University of Utah, Salt Lake City
| | - R. J. Bunnell
- Department of Medicine, Intermountain Healthcare, Salt Lake City, Utah
| | - Samuel M. Brown
- Intermountain Medical Center, Salt Lake City, Utah
- Division of Pulmonary/Critical Care, Department of Medicine, University of Utah, Salt Lake City
| | - Al Jephson
- Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City
| | - Danielle Groat
- Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City
| | - Nicholas M. Levin
- Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City
| | - Emily Wilson
- Divisions of Epidemiology and Infectious Disease, Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | - Jon Newbold
- Department of Pharmacy, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Joe Frandsen
- Care Transformation Information Services, Intermountain Healthcare, Salt Lake City, Utah
| | - David Hasleton
- Department of Emergency Medicine, Intermountain Healthcare, Salt Lake City, Utah
- Specialty Based Care, Intermountain Healthcare, Salt Lake City, Utah
| | - Paul Krakovitz
- Specialty Based Care, Intermountain Healthcare, Salt Lake City, Utah
| | - Kim Brunisholz
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Todd Allen
- Office of Quality and Patient Safety, The Queens Healthcare Systems, Honolulu, Hawaii
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16
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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.
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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.
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17
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Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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18
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Lehr AR, Rached-d'Astous S, Barrowman N, Tsampalieros A, Parker M, McIntyre L, Sampson M, Menon K. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2022; 23:181-191. [PMID: 34991134 PMCID: PMC8887852 DOI: 10.1097/pcc.0000000000002890] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The ideal crystalloid fluid bolus therapy for fluid resuscitation in children remains unclear, but pediatric data are limited. Administration of 0.9% saline has been associated with hyperchloremic metabolic acidosis and acute kidney injury. The primary objective of this systematic review was to compare the effect of balanced versus unbalanced fluid bolus therapy on the mean change in serum bicarbonate or pH within 24 hours in critically ill children. DATA SOURCES We searched MEDLINE including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, CENTRAL Trials Registry of the Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. STUDY SELECTION Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guidelines, we retrieved all controlled trials and observational cohort studies comparing balanced and unbalanced resuscitative fluids in critically ill children. The primary outcome was the change in serum bicarbonate or blood pH. Secondary outcomes included the prevalence of hyperchloremia, acute kidney injury, renal replacement therapy, and mortality. DATA EXTRACTION Study screening, inclusion, data extraction, and risk of bias assessments were performed independently by two authors. DATA SYNTHESIS Among 481 references identified, 13 met inclusion criteria. In the meta-analysis of three randomized controlled trials with a population of 162 patients, we found a greater mean change in serum bicarbonate level (pooled estimate 1.60 mmol/L; 95% CI, 0.04-3.16; p = 0.04) and pH level (pooled mean difference 0.03; 95% CI, 0.00-0.06; p = 0.03) after 4-12 hours of rehydration with balanced versus unbalanced fluids. No differences were found in chloride serum level, acute kidney injury, renal replacement therapy, or mortality. CONCLUSIONS Our systematic review found some evidence of improvement in blood pH and bicarbonate values in critically ill children after 4-12 hours of fluid bolus therapy with balanced fluid compared with the unbalanced fluid. However, a randomized controlled trial is needed to establish whether these findings have an impact on clinical outcomes before recommendations can be generated.
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Affiliation(s)
- Anab Rebecca Lehr
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Soha Rached-d'Astous
- Division of Emergency Medicine, Department of Pediatrics, University of Montreal, CHU Sainte Justine, Montreal, QC, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Melissa Parker
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
- Division of Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Margaret Sampson
- Library Services, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Kusum Menon
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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19
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Martínez RM, Viñas T, Manrique G, López-Herce J. Hyperchloremia and hypernatremia in critically ill children. Med Intensiva 2021; 45:e59-e61. [PMID: 34776404 DOI: 10.1016/j.medine.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Affiliation(s)
- R M Martínez
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - T Viñas
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - G Manrique
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain; Red de Salud Maternoinfantil y del Desarrollo (RedSAMID), RETICS financiada por el PN I+D+I 2013-2016, ISCIII-Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022/0007
| | - J López-Herce
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain; Red de Salud Maternoinfantil y del Desarrollo (RedSAMID), RETICS financiada por el PN I+D+I 2013-2016, ISCIII-Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022/0007.
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20
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Trepatchayakorn S, Sakunpunphuk M, Samransamruajkit R. Balanced Salt Solution Versus Normal Saline in Resuscitation of Pediatric Sepsis: A Randomized, Controlled Trial. Indian J Pediatr 2021; 88:921-924. [PMID: 34110580 PMCID: PMC8189839 DOI: 10.1007/s12098-021-03808-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/10/2021] [Indexed: 11/27/2022]
Abstract
Current evidences in resuscitation of adult sepsis have pointed to the importance of types of crystalloid fluid-related complications on resuscitation outcomes, but evidences are lacking in pediatric populations. In this study, the authors aimed to compare outcomes of pediatric sepsis resuscitation with different types of crystalloid. They randomly assigned pediatric sepsis patients requiring fluid bolus into three groups to receive either normal saline solution (NSS), Ringer lactate solution (RLS), or Sterofundin as fluid bolus therapy. Forty-two patients were included in the study. Median age was 29 mo and, weight 13 kg. After fluid bolus, the complications were not different among groups. However, in the RLS group, the patients who received large dose of the fluid showed significant reduction in urinary neutrophil gelatinase-associated lipocalin (uNGAL) level. It is concluded that fluid bolus therapy with different types of crystalloid solution did not result in different outcomes but large dose of RLS was associated with greater reduction of uNGAL level, compared to other fluids.Trial Registration: Thai Clinical Trial Registry (TCTR) identification number TCTR20170605001 (retrospectively registered on 1st June 2017). https://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task20=search&task2=view1&id=2576.
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Affiliation(s)
- Sirawut Trepatchayakorn
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathum Wan, Bangkok, 10330, Thailand.
| | - Manee Sakunpunphuk
- Department of Nursing, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathum Wan, Bangkok, 10330, Thailand
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21
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Willems A, De Groote F, Schmartz D, Fils JF, Van der Linden P. Does a balanced colloid decrease perioperative blood loss in paediatric cardiac surgery: A double-blinded randomized controlled trial? Eur J Anaesthesiol 2021; 38:923-931. [PMID: 33966019 DOI: 10.1097/eja.0000000000001526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Unbalanced fluid solutions cause metabolic acidosis and could be associated with impaired coagulation and increased blood loss. OBJECTIVE To investigate whether the use of a balanced colloid compared with a saline colloid for peri-operative fluid therapy in children undergoing cardiac surgery is associated with decreased blood loss and exposure to blood products. DESIGN Double-blinded randomised controlled trial. SETTING Tertiary children's hospital from 2013 to 2016. PATIENTS Children older than 29 days and younger than 3 years admitted for cardiac surgery with cardiopulmonary bypass (CPB). Exclusion criteria were emergency cardiac surgery, moribund (American Society of Anesthesiologists 5), Jehovah's witnesses, coagulopathy, renal failure, liver injury, intracranial haemorrhage and electrolyte disturbances. From the 128 patients eligible, 88 were included in the study. INTERVENTION Random assignment of patients to either a saline colloid (6% hydroxyethyl starch 130/0.4 in 0.9% NaCl) or a balanced-electrolyte colloid (6% hydroxyethyl starch 130/0.4 in an isotonic solution) for CPB priming and intra- and postoperative fluid therapy during the first postoperative 48 h. MAIN OUTCOME MEASURE The primary outcome measure was calculated blood loss until the third postoperative day (POD3). RESULTS A total of 44 patients were included in each study arm. Calculated blood loss at POD3 was not significantly different between the groups (saline colloid 19.9 [IQR 13.8 to 26.1] ml kg-1 versus balanced colloid 15.9 [IQR 9.0 to 25.3 ml kg-1], P = 0.409). Secondary outcomes related to bleeding, exposure to blood products and coagulation were not different between groups. There was also no difference in length of mechanical ventilation, intensive care and hospital length of stay between groups. CONCLUSION The use of a balanced colloid for peri-operative fluid therapy compared with a saline one is not associated with decreased blood loss or exposure to blood products. TRIAL REGISTRATION EudraCT identifier: 2012-006034-17 and ClinicalTrial.gov identifier: NCT02584868.
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Affiliation(s)
- Ariane Willems
- From the Paediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands (AW), Department of Anaesthesiology, University Hospital Brugmann and Queen Fabiola University Children's Hospital, Brussels, Belgium (F-DG, DS, P-VdL) and Ars Statistica, Nivelles, Belgium (JF-F)
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22
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Barhight MF, Nelson D, Moran T, Christiano J, Sanchez-Pinto LN. Association between the use of balanced fluids and outcomes in critically ill children: a before and after study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:266. [PMID: 34325729 PMCID: PMC8319885 DOI: 10.1186/s13054-021-03705-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/24/2021] [Indexed: 12/29/2022]
Abstract
Background Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU). Methods A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities. Results Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (n = 130) and a mortality rate of 2.8% (n = 79) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65–1.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%, p = < 0.0001) and hyperkalemia (pre 3.2% vs. post 1.4%, p = 0.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%, p = < 0.0001) and hypokalemia (pre 38.2% vs. post 47.2%, p = < 0.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS. Conclusions Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03705-3.
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Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA. .,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Delphine Nelson
- Division of Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Thomas Moran
- Department of Pharmacy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jessica Christiano
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - L Nelson Sanchez-Pinto
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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23
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Sensing W, Wenker M, Whitney E. Maintenance fluid management in pediatrics: Current practice and quality improvement achievements. Curr Probl Pediatr Adolesc Health Care 2021; 51:100996. [PMID: 34092514 DOI: 10.1016/j.cppeds.2021.100996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The long-standing use of hypotonic fluids in pediatric maintenance fluids has been challenged in recent years due to concerns over iatrogenic hyponatremia causing morbidity and mortality. Newer research has highlighted the safety of isotonic fluid alternatives. The American Academy of Pediatrics published an evidenced-based Clinical Practice Guideline in December of 2018 (Feld et al., 2018) to support the routine use of isotonic solutions in pediatric maintenance fluids. This article will also highlight relevant history, current practice, and a quality improvement project to standardize isotonic fluid use in the inpatient pediatric setting.
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Affiliation(s)
- Wendla Sensing
- Dayton Children's Hospital, Boonshoft School of Medicine at Wright State University, United States.
| | - Megan Wenker
- Dayton Children's Hospital, Boonshoft School of Medicine at Wright State University, United States
| | - Eric Whitney
- Dayton Children's Hospital, Boonshoft School of Medicine at Wright State University, United States
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24
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Fernández-Sarmiento J, Alcalá-Lozano C, Barrera PA, Erazo Vargas SC, Gómez Cortes LB, Reyes C M. Association Between Unbalanced Solutions and Acute Kidney Injury During Fluid Resuscitation in Children With Sepsis. J Intensive Care Med 2021; 37:625-632. [PMID: 33926299 DOI: 10.1177/08850666211004453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients with sepsis-associated organ dysfunction and septic shock who receive fluid resuscitation with balanced and unbalanced solutions in a middle-income country. DESIGN An observational, analytical cohort study with propensity score matching (PSM) in children admitted to a pediatric intensive care unit (PICU). Patients from one month to 17 years old who required fluid boluses due to hemodynamic instability were included. The primary outcome was the presence of acute kidney injury and the secondary outcomes were the need to begin continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay and mortality. MEASUREMENTS AND MAIN RESULTS Out of the 1,074 admissions to the PICU during the study period, 99 patients had sepsis-associated organ dysfunction and septic shock. Propensity score matching was performed including each patient´s baseline characteristics. The median age was 9.9 months (IQR 4.9-22.2) with 55.5% of the patients being male. Acute kidney injury was seen less frequently in children who received a balanced solution than in those who received an unbalanced solution (20.3% vs 25.7% P = 0.006 ORa, 0.75; 95% CI, 0.65-0.87), adjusted for disease severity. In addition, the group that received balanced solutions had less need for CRRT (3.3 % vs 6.5%; P = 0.02 ORa 0.48; 95% CI, 0.36-0.64) and a shorter PICU stay (6 days IQR 4.4-20.2 vs 10.2 days IQR 4.7-26; P < 0.001) than the group with unbalanced solutions. We found no difference in the frequency of metabolic acidosis (P = 0.37), hyperchloremia (P = 0.11) and mortality (P = 0.25) between the 2 groups. CONCLUSION In children with sepsis-associated organ dysfunction and septic shock, the use of unbalanced solutions for fluid resuscitation is associated with a higher frequency of acute kidney injury, a greater need for continuous renal support and a longer PICU stay compared to the use of balanced solutions, in a middle-income country.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Pediatrics and Intensive Care, Universidad de la Sabana, 42705Fundación Cardioinfantil-Instituto de Cardiología, Universidad CES Graduate School, Bogotá, Colombia
| | - Catalina Alcalá-Lozano
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfanti-Instituto de Cardiología, Universidad el Rosario, Bogotá, Colombia
| | - Pedro Alexander Barrera
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfantil-Instituto de Cardiología, Research Department, Fundación Santafé de Bogotá, Bogotá, Colombia
| | - Sofía Camila Erazo Vargas
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfanti-Instituto de Cardiología, Universidad el Rosario, Bogotá, Colombia
| | - Laura Bibiana Gómez Cortes
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfanti-Instituto de Cardiología, Universidad el Rosario, Bogotá, Colombia
| | - Martha Reyes C
- Department of Pediatric Cardiology and Pediatric Cardiovascular Intensive Care, 42705Fundación CardioInfantil-Instituto de Cardiología, Bogotá, Colombia
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25
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Banerjee S, Mohammed A, Wong HR, Palaniyar N, Kamaleswaran R. Machine Learning Identifies Complicated Sepsis Course and Subsequent Mortality Based on 20 Genes in Peripheral Blood Immune Cells at 24 H Post-ICU Admission. Front Immunol 2021; 12:592303. [PMID: 33692779 PMCID: PMC7937924 DOI: 10.3389/fimmu.2021.592303] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 01/28/2021] [Indexed: 01/08/2023] Open
Abstract
A complicated clinical course for critically ill patients admitted to the intensive care unit (ICU) usually includes multiorgan dysfunction and subsequent death. Owing to the heterogeneity, complexity, and unpredictability of the disease progression, ICU patient care is challenging. Identifying the predictors of complicated courses and subsequent mortality at the early stages of the disease and recognizing the trajectory of the disease from the vast array of longitudinal quantitative clinical data is difficult. Therefore, we attempted to perform a meta-analysis of previously published gene expression datasets to identify novel early biomarkers and train the artificial intelligence systems to recognize the disease trajectories and subsequent clinical outcomes. Using the gene expression profile of peripheral blood cells obtained within 24 h of pediatric ICU (PICU) admission and numerous clinical data from 228 septic patients from pediatric ICU, we identified 20 differentially expressed genes predictive of complicated course outcomes and developed a new machine learning model. After 5-fold cross-validation with 10 iterations, the overall mean area under the curve reached 0.82. Using a subset of the same set of genes, we further achieved an overall area under the curve of 0.72, 0.96, 0.83, and 0.82, respectively, on four independent external validation sets. This model was highly effective in identifying the clinical trajectories of the patients and mortality. Artificial intelligence systems identified eight out of twenty novel genetic markers (SDC4, CLEC5A, TCN1, MS4A3, HCAR3, OLAH, PLCB1, and NLRP1) that help predict sepsis severity or mortality. While these genes have been previously associated with sepsis mortality, in this work, we show that these genes are also implicated in complex disease courses, even among survivors. The discovery of eight novel genetic biomarkers related to the overactive innate immune system, including neutrophil function, and a new predictive machine learning method provides options to effectively recognize sepsis trajectories, modify real-time treatment options, improve prognosis, and patient survival.
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Affiliation(s)
- Shayantan Banerjee
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, India
| | - Akram Mohammed
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Nades Palaniyar
- Translational Medicine, Peter Gilgan Center for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
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26
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Pollack MM, Chamberlain JM, Patel AK, Heneghan JA, Rivera EAT, Kim D, Bost JE. The Association of Laboratory Test Abnormalities With Mortality Risk in Pediatric Intensive Care. Pediatr Crit Care Med 2021; 22:147-160. [PMID: 33258574 PMCID: PMC7855885 DOI: 10.1097/pcc.0000000000002610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To determine the bivariable associations between abnormalities of 28 common laboratory tests and hospital mortality and determine how mortality risks changes when the ranges are evaluated in the context of commonly used laboratory test panels. DESIGN A 2009-2016 cohort from the Health Facts (Cerner Corporation, Kansas City, MO) database. SETTING Hospitals caring for children in ICUs. PATIENTS Children cared for in ICUs with laboratory data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 2,987,515 laboratory measurements in 71,563 children. The distribution of laboratory test values in 10 groups defined by population percentiles demonstrated the midrange of tests was within the normal range except for those measured predominantly when significant abnormalities are suspected. Logistic regression analysis at the patient level combined the population-based groups into ranges with nonoverlapping mortality odds ratios. The most deviant test ranges associated with increased mortality risk (mortality odds ratios > 5.0) included variables associated with acidosis, coagulation abnormalities and blood loss, immune function, liver function, nutritional status, and the basic metabolic profile. The test ranges most associated with survival included normal values for chloride, pH, and bicarbonate/total Co2. When the significant test ranges from bivariable analyses were combined in commonly used test panels, they generally remained significant but were reduced as risk was distributed among the tests. CONCLUSIONS The relative importance of laboratory test ranges vary widely, with some ranges strongly associated with mortality and others strongly associated with survival. When evaluated in the context of test panels rather than isolated tests, the mortality odds ratios for the test ranges decreased but generally remained significant as risk was distributed among the components of the test panels. These data are useful to develop critical values for children in ICUs, to identify risk factors previously underappreciated, for education and training, and for future risk score development.
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Affiliation(s)
- 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
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - 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
| | - Julia A Heneghan
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eduardo A Trujillo Rivera
- Biomedical Informatics Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Dongkyu Kim
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E Bost
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
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27
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Affiliation(s)
- H.D. O'Reilly
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - K. Menon
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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28
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Fernández-Sarmiento J, Pérez A, Echeverri MA, Jimenez P, Joachim MA, Andrés-Jagua. Association Between Hyponatremia and Maintenance Intravenous Solutions in Critically Ill Children: A Retrospective Observational Study. Front Pediatr 2021; 9:691721. [PMID: 34295861 PMCID: PMC8290911 DOI: 10.3389/fped.2021.691721] [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: 04/06/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
Objetive: We sought to determine the association between maintenance intravenous solutions and the presence of hyponatremia in children in pediatric intensive care (PICU). Materials and Methods: An analytical observational study in children hospitalized in the PICU between January 2015 and December 2018. Patients who received maintenance fluids within the first 48 h after admission and who had at least two serum sodium levels drawn during this time were included. Measurements and Main Results: A total of 1,668 patients were admitted to the PICU during the study period, 503 of whom met the inclusion criteria. The median age was 24 months (IQR 8-96) and 50.9% were female. Altogether, 24.1% of the children developed hyponatremia; it was more frequent in those who received hypotonic solutions (63 vs. 37%; OR 1.41 95% CI 0.92, 2.15 p = 0.106), who also had a longer hospital stay (20 vs. 14 days, difference in means 8 days, 95% CI 2.67, 13.3, p = 0.001). Children who received loop diuretics and those who were post-operative had a greater risk of developing hyponatremia if they received hypotonic solutions (aOR 2.1 95% CI 1.41, 3.0, p = 0.000). Those with balanced isotonic solutions had a lower risk of developing hyponatremia (aOR 0.59 95% CI 0.35, 0.99, p = 0.004) and hyperchloremia (aOR 0.51 95% CI 0.34, 0.77, p = 0.000), adjusted for disease severity. A greater risk of death was found in the group with severe hyponatremia <130 mEq/L (aOR 9.75 95% CI 1.64-58.15; p = 0.01). Conclusions: Hyponatremia associated with the use of hypotonic maintenance solutions occurs in one out of four children in intensive care. The use of these solutions is associated with a longer hospital stay, and the main risk groups are post-operative patients and those who receive loop diuretics. Clinical studies are needed to determine which maintenance solutions have the greatest efficacy and safety in critically ill children.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Departament of Pediatrics and Intensive Care, Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia
| | - Andrea Pérez
- Departament of Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Universidad El Rosario, Bogotá, Colombia
| | - Maria Alejandra Echeverri
- Departament of Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Universidad El Rosario, Bogotá, Colombia
| | - Paola Jimenez
- Department of Pediatrics and Intensive Care, Universidad de La Sabana, Bogotá, Colombia
| | | | - Andrés-Jagua
- Departament of Research, Universidad Nacional de Colombia, Bogotá, Colombia
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29
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Martínez RM, Viñas T, Manrique G, López-Herce J. Hyperchloremia and hypernatremia in critically ill children. Med Intensiva 2020; 45:S0210-5691(20)30332-6. [PMID: 33279262 DOI: 10.1016/j.medin.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 09/25/2020] [Accepted: 10/12/2020] [Indexed: 10/22/2022]
Affiliation(s)
- R M Martínez
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - T Viñas
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - G Manrique
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (RedSAMID), RETICS financiada por el PN I+D+I 2013-2016, ISCIII-Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022/0007
| | - J López-Herce
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (RedSAMID), RETICS financiada por el PN I+D+I 2013-2016, ISCIII-Subdirección General de Evaluación y Fomento de la Investigación y el Fondo Europeo de Desarrollo Regional (FEDER), ref. RD16/0022/0007.
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30
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Khan AH, Gai J, Faruque F, Bost JE, Patel AK, Pollack MM. Pediatric Mortality and Acute Kidney Injury Are Associated with Chloride Abnormalities in Intensive Care Units in the United States: A Multicenter Observational Study. J Pediatr Intensive Care 2020; 11:91-99. [DOI: 10.1055/s-0040-1719172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/28/2020] [Indexed: 01/19/2023] Open
Abstract
AbstractOur objective was to determine in children in the intensive care unit (ICU) the incidence of hyperchloremia (>110 mmol/L) and hypochloremia (<98 mmol/L), the association of diagnoses with chloride abnormalities, and the associations of mortality and acute kidney injury (AKI) with chloride abnormalities. We analyzed the initial, maximum, and minimum chloride measurements of 14,684 children in the ICU with ≥1 chloride measurement in the Health Facts database between 2009 and 2016. For hyperchloremia and hypochloremia compared with normochloremia, mortality rates increased three to fivefold and AKI rates increased 1.5 to threefold. The highest mortality rate (7.7%; n = 95/1,234) occurred with hyperchloremia in the minimum chloride measurement group and the highest AKI rate (7.7%; n = 72/930) occurred with hypochloremia in the initial chloride measurement group. The most common diagnostic categories associated with chloride abnormalities were injury and poisoning; respiratory; central nervous system; infectious and parasitic diseases; and endocrine, nutritional, metabolic, and immunity disorders. Controlled for race, gender, age, and diagnostic categories, mortality odds ratios, and AKI odds ratios were significantly higher for hyperchloremia and hypochloremia compared with normochloremia. In conclusion, hyperchloremia and hypochloremia are independently associated with mortality and AKI in children in the ICU.
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Affiliation(s)
- Aamer H. Khan
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Jiaxing Gai
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Farhana Faruque
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - James E. Bost
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Anita K. Patel
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Murray M. Pollack
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
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31
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Barhight MF, Brinton JT, Soranno DE, Faubel S, Mourani PM, Gist KM. Effects of hyperchloremia on renal recovery in critically ill children with acute kidney injury. Pediatr Nephrol 2020; 35:1331-1339. [PMID: 32152726 DOI: 10.1007/s00467-020-04513-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/14/2020] [Accepted: 02/19/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Serum chloride derangements are associated with poor clinical outcomes, including acute kidney injury (AKI) and mortality. We sought to determine the association between persistent hyperchloremia and renal recovery in critically ill children with AKI. METHODS We performed a retrospective cohort study of all patients with day 2 AKI admitted to a large academic pediatric intensive care unit from January 2014 to December 2015. After applying exclusion criteria, 348 patients were categorized as (1) hyperchloremia on both day 2 and day 7 (PersistentCl), (2) hyperchloremia on day 2 with normochloremia on day 7 (RecoveredCl), (3) normochloremia on day 2 with hyperchloremia on day 7 (DelayedCl), and (4) no hyperchloremia on day 2 nor day 7 (NormalCl). Hyperchloremia was defined as ≥ 110 mEq/L. The primary outcome was renal recovery on day 7, defined as the absence of AKI criteria. Secondary outcomes included discharge renal recovery, mortality, duration of mechanical ventilation, and hospital length of stay. RESULTS Day 7 renal recovery rates for PersistentCl, RecoveredCl, DelayedCl, and NormalCl were 37%, 66%, 71%, and 52% respectively. PersistentCl had lower odds of day 7 renal recovery (aOR = 0.29; 95% CI, 0.14 to 0.60; p = 0.0009), lower odds of discharge renal recovery (aOR = 0.22; 95% CI, 0.11 to 0.48; p = 0.0001), and higher odds of mortality (aOR = 3.50; 95% CI, 1.11 to 11.10; p = 0.03) when compared with RecoveredCl after adjusting for confounders. CONCLUSIONS Persistent hyperchloremia is independently associated with impaired renal recovery as well as higher mortality. Prospective studies are indicated to determine if serum chloride represents a modifiable risk factor for poor outcomes. Graphical abstract.
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Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - John T Brinton
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Danielle E Soranno
- Division of Pediatric Nephrology, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Peter M Mourani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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32
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Son J, Jang Y, Kim W, Lee S, Jeong JS, Lee SK, Seo JM. Thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: is it a safe procedure in infants weighing less than 2000 g? Surg Endosc 2020; 35:1597-1601. [PMID: 32323019 PMCID: PMC7222104 DOI: 10.1007/s00464-020-07538-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/31/2020] [Indexed: 11/28/2022]
Abstract
Background Since Rothenberg first performed thoracoscopic repair for esophageal atresia with distal tracheoesophageal fistula (EA/TEF) successfully in 2000, thoracoscopic repair has achieved status as a routine procedure worldwide. Previously, an international multicenter study reported that this procedure was not inferior to conventional open surgery. However, thoracoscopic surgery is a highly difficult operation for surgeons and anesthesiologists; as a result, the safety and efficacy of the surgery is still under debate. Considering these circumstances, the purpose of this study was to analyze the results of single-center thoracoscopic surgery and to compare the outcomes relative to the patient’s weight at the time of surgery. Methods We retrospectively analyzed patients with EA/TEF who underwent thoracoscopic surgery in a single center between October 2008 and February 2017. Results In total, 41 cases of thoracoscopic repair of EA/TEF were performed. Upon subgrouping by over and under 2000 g of body weight at the time of operation, 34 were found to be over 2000 g and seven were under 2000 g. Intraoperative factors and events were not significantly different between the two groups. Additionally, most of the postoperative outcomes, including the rate of postoperative leakage and strictures, showed no difference. On the other hand, the under 2000 g group had more gastroesophageal reflux requiring fundoplication than did the heavier group (P = 0.04). Conclusions The results of this center’s thoracoscopic repair of EA/TEF were not inferior to other centers’ outcomes. Additionally, the intraoperative and postoperative outcomes were similar despite differences in weight at operation. Therefore, thoracoscopic repair might be a feasible surgical option for infants weighing less than 2000 g when performed by a surgeon and anesthesiologist team who are experienced in pediatric thoracoscopic surgery.
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Affiliation(s)
- Joonhyuk Son
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Yerang Jang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Wontae Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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El-Mekkawy MS, Ellahony DM, Khalifa KAE, Abd Elsattar ES. Plasma lactate can improve the accuracy of the Pediatric Sequential Organ Failure Assessment Score for prediction of mortality in critically ill children: A pilot study. Arch Pediatr 2020; 27:206-211. [PMID: 32278589 DOI: 10.1016/j.arcped.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/03/2020] [Accepted: 03/28/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Plasma lactate has been used to predict the prognosis of critically ill children, but mortality risk scores appear to be more appealing, particularly in resource-limited countries. OBJECTIVE To assess the prognostic utility of lactate compared with the pediatric Sequential Organ Failure Assessment (pSOFA) score among the general pediatric intensive care unit (PICU) population. METHODS This was a prospective observational study including 78 children admitted to a tertiary-level PICU. Plasma lactate was measured upon admission and repeated 24h later. pSOFA score, Pediatric Risk of Mortality, and Pediatric Index of Mortality-2 (PIM2) were calculated. The primary outcome was 30-day mortality. RESULTS In total, 47.4% of patients had hyperlactatemia at admission. Among these, 20.5% had persistent hyperlactatemia. No significant difference in admission lactate level was found between survivors and nonsurvivors. The 24-h, peak, and average lactate levels were higher among nonsurvivors (P=0.005, 0.035, and 0.019, respectively). The 24-h lactate level and pSOFA score were independent predictors of mortality (adjusted odds ratio and 95% confidence interval=1.12 [1.02-1.23] and 1.80 [1.23-2.64], respectively]. The 24-h lactate level showed positive correlations with pSOFA, PRISM, and PIM2 (Spearman correlation coefficient=0.31, 0.23, 0.43; P=0.006, P=0.047, P<0.001, respectively). The 24-h lactate level had an area under the receiver operating characteristic curve (AUC) of 0.77 (P=0.013) for mortality prediction, while admission, peak, and average lactate level had an AUC of 0.69, 0.69, 0.71 (P=0.086, P=0.035, P=0.019), respectively. PIM2, PRISM, and pSOFA score had an AUC of 0.80, 0.78, 0.82 (P=0.001, P=0.001, and P<0.001), respectively. Combining 24-h lactate level with pSOFA demonstrated superior performance (AUC=0.88). CONCLUSION Both 24-h lactate level and pSOAF are useful for prediction of mortality. Incorporating the 24-h lactate level into the pSOFA Score achieved superior prognostic utility.
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Affiliation(s)
- M S El-Mekkawy
- Department of Pediatrics, Faculty of Medicine, Menoufia University, 32511 Menoufia, Egypt.
| | - D M Ellahony
- Department of Pediatrics, Faculty of Medicine, Menoufia University, 32511 Menoufia, Egypt
| | - K A E Khalifa
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
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Hughes K, Buenger L. Select topics in the management of critically ill children. Am J Health Syst Pharm 2020; 76:1532-1543. [PMID: 31532504 DOI: 10.1093/ajhp/zxz167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The purpose of this review article is to discuss considerations for the critically ill child presenting to an emergency department (ED) with pharmacists who have minimal to no pediatric training. SUMMARY In 2015, 17% of all children visited an ED, constituting 30 million visits. The majority of these children were treated at community hospitals where pediatric care resources, including a pediatric-trained pharmacist, may be limited. Because of the complex array of ages and disease states, the care of critically ill children in the ED creates many concerns for adult and community hospitals. This article will focus on several common disease states seen in the pediatric ED, including septic shock, trauma, status epilepticus, and diabetic ketoacidosis. CONCLUSION Critically ill children admitted to a community or adult ED provide therapeutic dilemmas and medication safety concerns. A pharmacist with training or experience in pediatrics can have a major impact in patient outcomes in many of the disease states seen in these pediatric patients. This article highlights several key differences between critically ill pediatric and adult patients to better prepare all pharmacists to care for these vulnerable patients.
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Affiliation(s)
- Kaitlin Hughes
- Riley Hospital for Children, Indiana University Health, Indianapolis, IN
| | - Lauren Buenger
- Riley Hospital for Children, Indiana University Health, Indianapolis, IN
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Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Abbadessa MK, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med 2019; 26:1346-1356. [PMID: 31183919 PMCID: PMC7302266 DOI: 10.1111/acem.13815] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/17/2019] [Accepted: 05/26/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment. However, the optimal type of crystalloid fluid is unknown. We aimed to determine the feasibility of conducting a pragmatic randomized trial to compare balanced (lactated Ringer's [LR]) with 0.9% normal saline (NS) fluid resuscitation in children with suspected septic shock. METHODS Open-label pragmatic randomized controlled trial at a single academic children's hospital from January to August 2018. Eligible patients were >6 months to <18 years old who were treated in the emergency department for suspected septic shock, operationalized as blood culture, parenteral antibiotics, and fluid resuscitation for abnormal perfusion. Screening, enrollment, and randomization were carried out by the clinical team as part of routine care. Patients were randomized to receive either LR or NS for up to 48 hours following randomization. Other than fluid type, all treatment decisions were at the clinical team's discretion. Feasibility outcomes included proportion of eligible patients enrolled, acceptability of enrollment via the U.S. federal exception from informed consent (EFIC) regulations, and adherence to randomized study fluid administration. RESULTS Of 59 eligible patients, 50 (85%) were enrolled and randomized. Twenty-four were randomized to LR and 26 to NS. Only one (2%) of 44 patients enrolled using EFIC withdrew before study completion. Total median (interquartile range [IQR]) crystalloid fluid volume received during the intervention window was 107 (60 to 155) mL/kg and 98 (63 to 128) mL/kg in the LR and NS arms, respectively (p = 0.50). Patients randomized to LR received a median (IQR) of only 20% (13 to 32) of all study fluid as NS compared to 99% (64% to 100%) of study fluid as NS in the NS arm (absolute difference = 79%, 95% CI = 48% to 85%). CONCLUSIONS A pragmatic study design proved feasible to study comparative effectiveness of LR versus NS fluid resuscitation for pediatric septic shock.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Marlena Kittick
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter McBride
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ashley L. Woodford
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicole Vestal
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mary Kate Abbadessa
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Melissa Metheney
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Katherine Smith
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Natalie J. Atkin
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jill M. Baren
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis Health, Sacramento, CA
| | - Scott L. Weiss
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Canepa-Escaro F, Neyra JA. Is dyschloremia a marker of critical illness or euchloremia an interventional target to improve outcomes? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S264. [PMID: 32015983 PMCID: PMC6976500 DOI: 10.21037/atm.2019.12.48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/02/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Fabrizio Canepa-Escaro
- Department of Internal Medicine, Division of Hospital Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Javier A. Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, KY, USA
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Fluid management in the critically ill. Kidney Int 2019; 96:52-57. [DOI: 10.1016/j.kint.2018.11.047] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 11/20/2018] [Accepted: 11/28/2018] [Indexed: 12/30/2022]
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Bulfon AF, Alomani HL, Anton N, Comrie BT, Rochwerg B, Stef SA, Thabane L, Vanniyasingam T, Choong K. Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia? J Pediatr Intensive Care 2019; 8:218-225. [PMID: 31673457 DOI: 10.1055/s-0039-1692413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/04/2019] [Indexed: 12/12/2022] Open
Abstract
Our objective is to evaluate intravenous (IV) fluid prescription practice patterns in critically ill children in the first 72 hours of pediatric intensive care unit (PICU) admission and to evaluate the incidence and predictors of hyperchloremic metabolic acidemia (HCMA) and the association between HCMA and adverse outcomes. This retrospective cohort study was conducted in two tertiary-care Canadian PICUs. Children aged 0 to 18 years admitted to the PICU between January 2015 and January 2016 who received at least 50% of their calculated maintenance fluid requirements parenterally during the first 24 hours of admission were included. Children with known preexisting conditions associated with HCMA, such as renal tubular acidosis and gastrointestinal bicarbonate losses, were excluded. Of the 771 children screened, 543 met eligibility criteria and were included. The commonest prescribed maintenance fluid was 0.9% NaCl (72.9%) followed by lactated Ringer's solution (19.6%) and hypotonic solutions (4.6%). Balanced salt solutions (i.e., lactated Ringer's and Plasma-Lyte) were as commonly administered as unbalanced solutions (0.9% NaCl) for volume expansion (49.6 vs. 48.5%, respectively). Medications contributed to a significant proportion of total daily intake, in excess of bolus fluids. The incidence of hyperchloremia and HCMA was 94.9% (95% confidence interval [CI]: 93.2-96.9; 470/495) and 38.9% (95% CI: 34.6-43.2; 196/504), respectively. Predictors of HCMA were increasing combined bolus and maintenance 0.9% NaCl intake (odds ratio: 1.13; 95% CI: 1.04-1.23) and increasing severity of illness. HCMA was not associated with an increased risk of acute kidney injury, feeding intolerance, or PICU-acquired weakness. Isotonic fluids, specifically 0.9% NaCl, were the most commonly administered maintenance IV fluid in critically ill children. Sources of chloride load are not isolated to resuscitation fluids as previously suggested. Maintenance fluids and fluids administered with medications and IV flushes (fluid creep) are under-recognized significant sources of fluid and electrolyte intake in critically ill children. HCMA is common, and further prospective research is required to determine whether HCMA is indeed harmful in children. However, all significant sources of fluid should be accounted for in the design of future trials comparing balanced and unbalanced salt solutions.
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Affiliation(s)
- Adrian F Bulfon
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Hakem L Alomani
- Department of Pediatrics (Critical Care), McMaster University, London, Ontario, Canada
| | - Natalie Anton
- Department of Pediatrics, Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brooke T Comrie
- Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Bram Rochwerg
- McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sorina A Stef
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thuva Vanniyasingam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Karen Choong
- Department of Pediatrics (Critical Care), McMaster University, London, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Morin L, Pierre A, Tissieres P, Miatello J, Durand P. Actualités sur le sepsis et le choc septique de l’enfant. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’incidence du sepsis de l’enfant augmente en réanimation pédiatrique. La définition du sepsis et du choc septique de l’enfant est amenée à évoluer à l’instar de celle du choc septique de l’adulte pour détecter les patients nécessitant une prise en charge urgente et spécialisée. La prise en charge d’un patient septique repose sur une oxygénothérapie, une expansion volémique au sérum salé isotonique, une antibiothérapie et un transfert dans un service de réanimation ou de surveillance continue pédiatrique. Le taux et la cinétique d’élimination du lactate plasmatique est un bon critère diagnostic et pronostic qui permet de guider la prise en charge. La présence de plusieurs défaillances d’organes ou une défaillance circulatoire aiguë signe le diagnostic de sepsis encore dit sévère, et leur persistance et/ou la non-correction de l’hypotension artérielle malgré un remplissage vasculaire d’au moins 40 ml/kg définit le choc septique chez l’enfant. Dans ce cas, la correction rapide de l’hypotension artérielle persistante repose sur la noradrénaline initiée sur une voie intraveineuse périphérique dans l’attente d’un accès veineux central. L’échographie cardiaque est un examen clé de l’évaluation hémodynamique du patient, pour guider la poursuite de l’expansion volémique ou détecter une cardiomyopathie septique. Des thérapeutiques additionnelles ont été proposées pour prendre en charge certains patients avec des défaillances d’organes particulières. L’immunomonitorage et la modulation sont un ensemble de techniques qui permettent la recherche et le traitement de certaines complications. La Surviving Sepsis Campaign a permis d’améliorer la prise en charge de ces patients par l’implémentation d’algorithmes de détection et de prise en charge du sepsis de l’enfant. Une révision pédiatrique de cette campagne est attendue prochainement.
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Iwaki T, Bennion BG, Stenson EK, Lynn JC, Otinga C, Djukovic D, Raftery D, Fei L, Wong HR, Liles WC, Standage SW. PPARα contributes to protection against metabolic and inflammatory derangements associated with acute kidney injury in experimental sepsis. Physiol Rep 2019; 7:e14078. [PMID: 31102342 PMCID: PMC6525329 DOI: 10.14814/phy2.14078] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/02/2019] [Accepted: 04/04/2019] [Indexed: 01/05/2023] Open
Abstract
Sepsis-associated acute kidney injury (AKI) is a significant problem in critically ill children and adults resulting in increased morbidity and mortality. Fundamental mechanisms contributing to sepsis-associated AKI are poorly understood. Previous research has demonstrated that peroxisome proliferator-activated receptor α (PPARα) expression is associated with reduced organ system failure in sepsis. Using an experimental model of polymicrobial sepsis, we demonstrate that mice deficient in PPARα have worse kidney function, which is likely related to reduced fatty acid oxidation and increased inflammation. Ultrastructural evaluation with electron microscopy reveals that the proximal convoluted tubule is specifically injured in septic PPARα deficient mice. In this experimental group, serum metabolomic analysis reveals unanticipated metabolic derangements in tryptophan-kynurenine-NAD+ and pantothenate pathways. We also show that a subgroup of children with sepsis whose genome-wide expression profiles are characterized by repression of the PPARα signaling pathway has increased incidence of severe AKI. These findings point toward interesting associations between sepsis-associated AKI and PPARα-driven fatty acid metabolism that merit further investigation.
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Affiliation(s)
- Takuma Iwaki
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashington
- Department of PediatricsUniversity HospitalFaculty of MedicineKagawa UniversityKagawaJapan
| | - Brock G. Bennion
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashington
- Department of Pathology and ImmunologyWashington University School of MedicineSt. LouisMissouri
| | - Erin K. Stenson
- Department of PediatricsSection of Critical CareUniversity of Colorado School of MedicineAnschutz Medical CenterChildren's Hospital ColoradoAuroraColorado
- Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhio
| | - Jared C. Lynn
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashington
| | - Cynthia Otinga
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashington
| | - Danijel Djukovic
- Department of Chemistry and BiochemistryUniversity of ColoradoBoulderColorado
- Department of Anesthesiology and Pain MedicineUniversity of Washington School of MedicineSeattleWashington
| | - Daniel Raftery
- Department of Anesthesiology and Pain MedicineUniversity of Washington School of MedicineSeattleWashington
| | - Lin Fei
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOhio
- Department of PediatricsUniversity of CincinnatiCincinnatiOhio
| | - Hector R. Wong
- Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhio
- Department of PediatricsUniversity of CincinnatiCincinnatiOhio
| | - W. Conrad Liles
- Department of MedicineUniversity of Washington School of MedicineSeattleWashington
| | - Stephen W. Standage
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashington
- Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhio
- Department of PediatricsUniversity of CincinnatiCincinnatiOhio
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Lima MF, Neville IS, Cavalheiro S, Bourguignon DC, Pelosi P, Malbouisson LMS. Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children Undergoing Neurosurgery: A Randomized Clinical Trial. J Neurosurg Anesthesiol 2019; 31:30-35. [PMID: 29912723 DOI: 10.1097/ana.0000000000000515] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. METHODS In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. RESULTS Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [-1.0; 3.0] mmol/L; P<0.001). Saline use also resulted in increased post-preopΔBE (-4.4 [-5.0; -2.3] vs. -0.4 [-2.7; 1.3] mmol/L; P<0.001) and hyperchloremic acidosis incidence (6/25 [24%] vs. 0; P=0.022) compared with balanced crystalloid. Brain relaxation score was comparable between groups. CONCLUSIONS In children undergoing brain tumor resection, saline infusion increased variation in serum chloride compared with balanced crystalloid. These findings support the use of balanced crystalloid solutions in children undergoing brain tumor resection.
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Affiliation(s)
- Mariana F Lima
- Departments of Anesthesiology.,Department of Anesthesiology
| | - Iuri S Neville
- Neurosurgery, Hospital das Clínicas, University of São Paulo
| | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy
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Abstract
OBJECTIVES To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists. DESIGN A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive and Critical Care Societies website, and World Federation of Pediatric Intensive and Critical Care Societies newsletter using the electronic survey distribution and collection system Research Electronic Data Capture. SETTING PICUs around the world. SUBJECTS Pediatric intensivists managing children after surgery for congenital heart disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-hundred eight responses from 18 countries and six continents were received. The most common prescribed fluids for IV maintenance are isotonic solutions, mainly NaCl 0.9% (42%); followed by hypotonic fluids (33%) and balanced crystalloids solutions (14%). The majority of the respondents limit total fluid intake to 50% during the first 24 hours after cardiac surgery. The most frequently used fluid as first choice for resuscitation is NaCl 0.9% (44%), the second most frequent choice are colloids (27%). Furthermore, 64% of respondents switch to a second fluid for ongoing resuscitation, 76% of these choose a colloid. Albumin 5% is the most commonly used colloid (61%). Almost all respondents (96%) agree there is a need for research on this topic. CONCLUSIONS Our survey demonstrates great variation in fluid management practices, not only for maintenance fluids but also for volume resuscitation. Despite the lack of evidence, colloids are frequently administered. The results highlight the need for further research and evidence-based guidelines on this topic.
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Ab-normal saline in abnormal kidney function: risks and alternatives. Pediatr Nephrol 2019; 34:1191-1199. [PMID: 29987459 PMCID: PMC6531391 DOI: 10.1007/s00467-018-4008-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
Abstract
Intravenous 0.9% saline has saved countless lives since it was introduced over a century ago. It remains the most widespread crystalloid in both adult and pediatric practice. However, in recent years, evidence of deleterious effects is accruing. These include increased mortality, acute kidney injury (AKI), metabolic acidosis, and coagulopathy. The predominant cause for these sequelae appears to be the excess chloride concentration of 0.9% saline relative to plasma. This has led to development of balanced isotonic solutions such as PlasmaLyte. This review summarizes current evidence for adverse effects of chloride-rich intravenous fluid and considers whether 0.9% saline should still be used in 2018 or abandoned as a historical treatment in favor of balanced crystalloid solutions.
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Watkins LA. Interventions for Pediatric Sepsis and Their Impact on Outcomes: A Brief Review. Healthcare (Basel) 2018; 7:E2. [PMID: 30597866 PMCID: PMC6473772 DOI: 10.3390/healthcare7010002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/13/2018] [Accepted: 12/24/2018] [Indexed: 12/28/2022] Open
Abstract
In the current era, pediatric sepsis remains a public health problem of significant prevalence and impact. With mortality rates practically unchanged over the years, this review hopes to briefly summarize the epidemiology and the current interventions for pediatric sepsis and point towards possible areas of improvement. Most pediatric studies of sepsis are either small, retrospective or observational. Given information technology spreading across country, and a stronger presence of clinical networks, development of multicenter prospective studies over the next decade should enable better treatments for pediatric sepsis, and improved outcomes.
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Affiliation(s)
- Laura A Watkins
- Department of Pediatrics/Critical Care, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 667, Rochester, NY 14642, USA.
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45
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Patel A, Hulton SA. QUESTION 1: Do balanced fluids have benefits over 0.9% sodium chloride? Arch Dis Child 2018; 103:1178-1180. [PMID: 30262508 DOI: 10.1136/archdischild-2018-315782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/13/2018] [Accepted: 08/28/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Ashish Patel
- Department of Paediatric Nephrology, Birmingham Woman's and Children's NHS Foundation Trust, Birmingham, UK
| | - Sally-Ann Hulton
- Department of Paediatric Nephrology, Birmingham Woman's and Children's NHS Foundation Trust, Birmingham, UK
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46
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Weiss SL, Babl FE, Dalziel SR, Balamuth F. Is chloride worth its salt? Intensive Care Med 2018; 45:275-277. [PMID: 30488168 DOI: 10.1007/s00134-018-5477-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/19/2018] [Indexed: 01/23/2023]
Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, Pediatric Sepsis Program, and the Center for Mitochondrial and Epigenomic Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Wood Building Suite 6026A, Philadelphia, PA, 19104, USA.
| | - Franz E Babl
- Department of Pediatrics, University of Melbourne, Melbourne, Australia
- Emergency Department, Royal Children's Hospital, Melbourne, Australia
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Pediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Fran Balamuth
- Department of Pediatrics and Pediatric Sepsis Program, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Barhight MF, Brinton J, Stidham T, Soranno DE, Faubel S, Griffin BR, Goebel J, Mourani PM, Gist KM. Increase in chloride from baseline is independently associated with mortality in critically ill children. Intensive Care Med 2018; 44:2183-2191. [PMID: 30382307 DOI: 10.1007/s00134-018-5424-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children. METHODS We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90 days or > 18 years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96 mEq/L; normochloraemia, 96-109 mEq/L; and hyperchloraemia, ≥ 110 mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5 mEq/L, ≥ 5 mEq/L). Our primary outcome was in-hospital mortality. RESULTS A total of 1935 patients [55% female, median age 6.3 years IQR (1.9-13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5 mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5 mEq/L was associated with a 2.3 (95% CI 1.03-5.21) greater odds of mortality. CONCLUSIONS An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.
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Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
| | - John Brinton
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy Stidham
- Division of Critical Care, Kalispell Regional Healthcare, Kalispell, MT, USA
| | - Danielle E Soranno
- Sections of Nephrology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin R Griffin
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Jens Goebel
- Sections of Nephrology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Sections of Critical Care, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Katja M Gist
- Sections of Cardiology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
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Hyperchloremia is associated with acute kidney injury in pediatric patients with septic shock. Intensive Care Med 2018; 44:2004-2005. [PMID: 30324289 DOI: 10.1007/s00134-018-5368-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
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Vidrine R, Atreya MR, Stalets EL. Continuum of care in pediatric sepsis: a prototypical acute care delivery model. Transl Pediatr 2018; 7:253-261. [PMID: 30460176 PMCID: PMC6212391 DOI: 10.21037/tp.2018.10.01] [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: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 11/06/2022] Open
Abstract
Sepsis is a burdensome public health problem and a leading cause of infant and child morbidity and mortality across the world. Few proven therapies exist to treat septic shock and the mainstay of management remains judicious fluid resuscitation and timely antibiotics. In its most recent iteration, the American College of Critical Care Medicine (ACCM) guidelines on hemodynamic support in pediatric septic shock recommends an institutional approach to the management of septic shock rather than one aimed at the individual practitioner. The acute care delivery model has been proposed as a way to guide quality improvement in emergency care and to improve care delivery. In this review, we summarize current recommendations in the management of pediatric patients with septic shock, and highlight opportunities to provide seamless care by application of the acute care model.
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Affiliation(s)
- Rhea Vidrine
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mihir R. Atreya
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Erika L. Stalets
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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