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Duron VP, Ichinose R, Stewart LA, Porigow C, Fan W, Rubsam JM, Stylianos S, Dorrello NV. Pilot randomized controlled trial of restricted versus liberal crystalloid fluid management in pediatric post-operative and trauma patients. Pilot Feasibility Stud 2023; 9:185. [PMID: 37941073 PMCID: PMC10631167 DOI: 10.1186/s40814-023-01408-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Intravenous (IV) fluid therapy is essential in the treatment of critically ill pediatric surgery and trauma patients. Recent studies have suggested that aggressive fluids may be detrimental to patients. Prospective studies are needed to compare liberal to restricted fluid management in these patients. The primary objective of this pilot trial is to test study feasibility-recruitment and adherence to the study treatment algorithm. METHODS We conducted a two-part pilot randomized controlled trial (RCT) comparing liberal to restricted crystalloid fluid management in 50 pediatric post-operative (1-18 years) and trauma (1-15 years) patients admitted to our pediatric intensive care unit (PICU). Patients were randomized to a high (liberal) volume or low (restricted) volume algorithm using unblinded, blocked randomization. A revised treatment algorithm was used after the 29th patient for the second part of the RCT. The goal of the trial was to determine the feasibility of conducting an RCT at a single site for recruitment and retention. We also collected data on the safety of study interventions and clinical outcomes, including pulmonary, infectious, renal, post-operative, and length of stay outcomes. RESULTS Fifty patients were randomized to either liberal (n = 26) or restricted (n = 24) fluid management strategy. After data was obtained on 29 patients, a first study analysis was performed. The volume of fluid administered and triggers for intervention were adapted to optimize the treatment effect and clarity of outcomes. Updated and refined fluid management algorithms were created. These were used for the second part of the RCT on patients 30-50. During this second study period, 54% (21/39, 95% CI 37-70%) of patients approached were enrolled in the study. Of the patients enrolled, 71% (15/21, 95% CI 48-89%) completed the study. This met our a priori recruitment and retention criteria for success. A data safety monitoring committee concluded that no adverse events were related to study interventions. Although the study was not powered to detect differences in outcomes, after the algorithm was revised, we observed a non-significant trend towards improved pulmonary outcomes in patients on the restricted arm, including decreased need for and time on oxygen support and decreased need for mechanical ventilation. CONCLUSION We demonstrated the feasibility and safety of conducting a single-site RCT comparing liberal to restricted crystalloid fluid management in critically ill pediatric post-operative and trauma patients. We observed trends in improved pulmonary outcomes in patients undergoing restricted fluid management. A definitive multicenter RCT comparing fluid management strategies in these patients is warranted. TRIAL REGISTRATION ClinicalTrials.gov, NCT04201704 . Registered 17 December 2019-retrospectively registered.
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Affiliation(s)
- Vincent P Duron
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA.
| | - Rika Ichinose
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Latoya A Stewart
- Columbia University Vagelos College of Physicians and Surgeons, 630W 168Th Street, New York, NY, 10032, USA
| | - Chloe Porigow
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Weijia Fan
- Department of Biostatistics, Columbia University Mailman School of Public Health, 722W 168Th Street, New York, NY, 10032, USA
| | - Jeanne M Rubsam
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Steven Stylianos
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital/New York-Presbyterian, Columbia University College of Physicians & Surgeons, , 3959 Broadway, CHN 215, New York, NY, 10032, USA
| | - Nicolino V Dorrello
- Department of Pediatric Critical Care, CUIMC/New York-Presbyterian Morgan Stanley Children's Hospital, New York City, USA
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James V, Chong SL, Shetty SS, Ong GY. Early coagulopathy in children with isolated blunt head injury is associated with mortality and poor neurological outcomes. J Neurosurg Pediatr 2020; 25:663-669. [PMID: 32114542 DOI: 10.3171/2019.12.peds19531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is the leading cause of long-term disability and death in children and adolescents globally. Long-term adverse outcomes, including physical, cognitive, and behavioral sequelae, have been reported after TBI in a significant number of pediatric patients. In this study the authors sought to investigate the epidemiology of TBI-associated coagulopathy and its association with mortality and poor neurological outcome in a pediatric population with isolated moderate to severe blunt head injury treated at the authors' institution. METHODS This retrospective study was conducted in the children's emergency department between January 2010 and December 2016. Children < 18 years old who presented with isolated moderate to severe blunt head injury were included in the study. The authors collected data on patient demographics, clinical presentation, and TBI management. Outcomes studied were death and poor neurological outcome defined by a score of < 7 (death, moderate to severe neurological disability) at 6 months postinjury on the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds). RESULTS In 155 pediatric patients who presented with isolated moderate to severe blunt head injury, early coagulopathy was observed in 33 (21.3%) patients during the initial blood investigations done in the emergency department. The mean (SD) age of the study group was 7.03 (5.08) years and the predominant mechanism of injury was fall from height (65.2%). The median Abbreviated Injury Scale of the head (AIS head) score was 4 and the median GCS score was 13 (IQR 12-15). TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 (p = 0.02, adjusted OR 6.07, 95% CI 1.32-27.83). The overall mortality rate was 5.8%. After adjusting for confounders, only AIS head score and hypotension at triage remained significantly associated with TBI-associated coagulopathy. CONCLUSIONS TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 at 6 months postinjury. Larger prospective studies are needed to investigate the use of TBI-associated coagulopathy to prognosticate these critical clinical outcomes.
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Kuo SCH, Kuo PJ, Hsu SY, Rau CS, Chen YC, Hsieh HY, Hsieh CH. The use of the reverse shock index to identify high-risk trauma patients in addition to the criteria for trauma team activation: a cross-sectional study based on a trauma registry system. BMJ Open 2016; 6:e011072. [PMID: 27329440 PMCID: PMC4916635 DOI: 10.1136/bmjopen-2016-011072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/26/2016] [Accepted: 05/27/2016] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES The presentation of decrease blood pressure with tachycardia is usually an indicator of significant blood loss. In this study, we used the reverse shock index (RSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), to evaluate the haemodynamic status of trauma patients. As an SBP lower than the HR (RSI<1) may indicate haemodynamic instability, the objective of this study was to assess whether RSI<1 can help to identify high-risk patients with potential shock and poor outcome, even though these patients do not yet meet the criteria for multidisciplinary trauma team activation (TTA). DESIGN Cross-sectional study. SETTING Taiwan. PARTICIPANTS We retrospectively reviewed the data of 20 106 patients obtained from the trauma registry system of a level I trauma centre for trauma admissions from January 2009 through December 2014. Patients for whom a trauma team was not activated (regular patients) and who had RSI<1 were compared with regular patients with RSI≥1. The ORs of the associated conditions and injuries were calculated with 95% CIs. MAIN OUTCOME MEASURES In-hospital mortality. RESULTS Among regular patients with RSI<1, significantly more patients had an Injury Severity Score (ISS) ≥25 (OR 2.4, 95% CI 1.58 to 3.62; p<0.001) and the mortality rate was also higher (2.1% vs 0.5%; OR 3.9, 95% CI 2.10 to 7.08; p<0.001) than in regular patients with RSI≥1. The intensive care unit length of stay was longer in regular patients with RSI<1 than in regular patients with RSI≥1. CONCLUSIONS Among patients who did not reach the criteria for TTA, RSI<1 indicates a potentially worse outcome and a requirement for more attention and aggressive care in the emergency department.
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Affiliation(s)
- Spencer C H Kuo
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiao-Yun Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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