1
|
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.
Collapse
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
| |
Collapse
|
2
|
Gaetani M, Parshuram CS, Redelmeier DA. Furosemide in pediatric intensive care: a retrospective cohort analysis. Front Pediatr 2024; 11:1306498. [PMID: 38293664 PMCID: PMC10824983 DOI: 10.3389/fped.2023.1306498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Furosemide is the most commonly used medication in pediatric intensive care. Growing data indicates improved hemodynamic stability and efficacy of furosemide infusions compared to intermittent injections, thereby suggesting furosemide infusions might be considered as first line therapy in critically ill, paediatric patients. The objective of this study is to examine furosemide treatment as either continuous infusions or intermittent injections and subsequent patient outcomes. Methods This is a retrospective cohort analysis of patients treated in a pediatric intensive care unit (ICU) over a nine year period (July 31st 2006 and July 31, 2015). Eligible patients were admitted to either the general pediatric or cardiac specific ICU for a duration of at least 6 hours and who received intravenous furosemide treatment. Results A total of 7,478 patients were identified who received a total of 118,438 furosemide administrations for a total of 113,951 (96%) intermittent doses and 4,487 (4%) infusions running for a total of 1,588,750 hours. A total of 5,996 (80%) patients received exclusively furosemide injections and 1,482 (20%) patients received at least one furosemide infusion. A total of 193 patients died during ICU admission, amounting to 87 (6%) of the 1,482 patients who received an infusion and 106 (2%) of the 5,996 who received intermittent injections. Multivariable regression analysis showed no statistically significant decrease in adjusted mortality for patients who received furosemide injections compared to furosemide infusions (aOR 1.20, CI 0.76-1.89). Discussion This retrospective study observed similar mortality for patients who received furosemide infusions compared to furosemide injections. More research on furosemide in the ICU could provide insights on fluid management, drug effectiveness, and pharmacologic stewardship for critically ill children.
Collapse
Affiliation(s)
- Melany Gaetani
- Child Health Evaluative Sciences, The Research Institute Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Center for Safety Research, Toronto, ON, Canada
| | - Christopher S. Parshuram
- Child Health Evaluative Sciences, The Research Institute Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Center for Safety Research, Toronto, ON, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Donald A. Redelmeier
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| |
Collapse
|
3
|
Maratta C, Hutchison K, Nicoll J, Bagshaw SM, Granton J, Kirpalani H, Stelfox HT, Ferguson N, Cook D, Parshuram CS, Moore GP. Overnight staffing in Canadian neonatal and pediatric intensive care units. Front Pediatr 2023; 11:1271730. [PMID: 38027260 PMCID: PMC10646373 DOI: 10.3389/fped.2023.1271730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Aim Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. Methods A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. Results We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Conclusion Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.
Collapse
Affiliation(s)
- Christina Maratta
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Kristen Hutchison
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Jessica Nicoll
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John Granton
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Haresh Kirpalani
- Department of Paediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine and O’Brien Institute for Public Health, University of Calgary & Alberta Health Services, Calgary, AB, Canada
| | - Niall Ferguson
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Deborah Cook
- Department of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - Christopher S. Parshuram
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Gregory P. Moore
- Division of Neonatology, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Research Unit, Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| |
Collapse
|
4
|
Proton Pump Inhibitor Use and Associated Infectious Complications in the PICU: Propensity Score Matching Analysis. Pediatr Crit Care Med 2022; 23:e590-e594. [PMID: 35994620 DOI: 10.1097/pcc.0000000000003063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We aimed to evaluate the association between proton pump inhibitor (PPI) exposure and nosocomial infection (NI) during PICU stay. DESIGN Propensity score matched analysis of a single-center retrospective cohort from January 1, 2017, to December 31, 2018. SETTING Tertiary medical and surgical PICU in France. PATIENTS Patients younger than 18 years old, admitted to the PICU with a stay greater than 48 hours. INTERVENTION Patients were retrospectively allocated into two groups and compared depending on whether they received a PPI or not. MEASUREMENTS AND MAIN RESULTS Seven-hundred fifty-four patients were included of which 231 received a PPI (31%). PPIs were mostly used for stress ulcer prophylaxis (174/231; 75%), but upper gastrointestinal bleed risk factors were rarely present (18%). In the unadjusted analyses, the rate of NI was 8% in the PPI exposed group versus 2% in the nonexposed group. After propensity score matching ( n = 184 per group), we failed to identify an association between PPI exposure and greater odds of NI (adjusted odds ratio 2.9 [95% CI, 0.9-9.3]; p = 0.082). However, these data have not excluded the possibility that there is up to nine-fold greater odds of NI. CONCLUSIONS This study highlights the prevalent use of PPIs in the PICU, and the potential association between PPIs and nine-fold greater odds of NI is not excluded.
Collapse
|
5
|
Effect of Early Nutritional Assessment and Nutritional Support on Immune Function and Clinical Prognosis of Critically Ill Children. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7100238. [PMID: 35035853 PMCID: PMC8759854 DOI: 10.1155/2022/7100238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/29/2021] [Accepted: 12/09/2021] [Indexed: 11/18/2022]
Abstract
The aim of this study was to study the effect of early nutritional assessment and nutritional support on immune function and clinical prognosis of critically ill children. 90 critically ill children at the same level of severity admitted to the pediatric intensive care unit (PICU) of our hospital (June 2019-June 2020) were chosen as the research objects and were equally separated into the experimental group and the control group by the random number table method. The children in the control group were admitted to the PICU according to the routine process, and the nutritional support was provided to the malnourished ones. After admission to the PICU, the children in the experimental group were given nutritional assessment, nutritional risk screening, and nutritional support according to the screening results. The PICU stay time and total hospitalization time of the experimental group were obviously shorter than those of the control group (P < 0.05), the hospitalization expenses of the experimental group were obviously lower than those of the control group (P < 0.05), the clinical outcomes and immune function of the experimental group were obviously better than those of the control group (P < 0.05), and the nutrition indicators of the experimental group were obviously higher than those of the control group (P < 0.05). Early nutritional assessment and nutritional support can effectively improve the immune function and reduce the incidence of adverse clinical outcomes of critically ill children, which are worthy of clinical application and promotion.
Collapse
|