Albumin: saint or sinner?

Invasive meningococcal infection: analysis of 110 cases from a tertiary care centre in North East India

OBJECTIVES

To report an outbreak of invasive meningococcal disease from Meghalaya, in the north east India, from January 2008 through June 2009.

METHODS

Retrospective review of case sheets was done. One hundred ten patients with invasive meningococcal disease were included for the study.

RESULTS

Of the total patients, 61.8 % were boys and 38.2 % were girls (boy to girl ratio = 1.62:1). The average age of presentation was 8.48 ± 5.09 y. Meningococcal meningitis was seen in 61.8 % of cases, meningococcemia in 20 % and 18.2 % had both. Fever was the most common manifestation (100 %) followed by meningeal signs (78.2 %), headache (56.4 %), vomiting (53.6 %), shock (38.2 %), low Glasgow coma scale (GCS) (25.5 %), purpura and rashes (23.6 %), seizures (9.1 %), abdominal symptoms (4.5 %), irritability and excessive crying (4.5 %) and bulging anterior fontanalle (23 %) in those below 18 mo of age. Raised intracranial pressure (ICP) was the most common complication (28.2 %) followed by coagulopathy (16.4 %), hepatopathy (10 %), herpes labialis (9.1 %), syndrome of inappropriate ADH secretion (SIADH) (8 %), pneumonia (7 %), arthritis (6 %), purpura fulminans, respiratory failure, sixth nerve palsy and diabetes insipidus in 4.5 % each, subdural empyema, optic neuritis, ARDS and ARF in 1.8 % each, cerebral salt wasting syndrome, third nerve palsy, cerebritis and hearing impairment in 0.9 % each. Culture was positive in 35.5 %. Patients were treated initially with ceftriaxone and dexamethasone but later on with chloramphenicol due to clinical drug resistance. Mortality was 6.4 %.

CONCLUSIONS

This is the first epidemic report of invasive meningococcal disease from the north east India. Chloramphenicol acts well in areas with penicillin or cephalosporin resistance. Mortality reduces significantly with early diagnosis and prompt intervention.

HES 130/0.4 (Voluven) or human albumin in children younger than 2 yr undergoing non-cardiac surgery. A prospective, randomized, open label, multicentre trial

BACKGROUND AND OBJECTIVE

For perioperative volume therapy in infants and young children, human albumin has frequently been the colloid of choice. Recently, HES 130/0.4 (6% hydroxyethyl starch, Voluven; Fresenius Kabi, Bad Homburg, Germany) was developed, which demonstrated improved pharmacokinetics and a favourable safety profile in adults compared with hydroxyethyl starch products with a less rapid metabolization.

METHODS

Our prospective, controlled, randomized, open, multicentre pilot study was designed to obtain data on the effects of HES 130/0.4 compared with human albumin 5% with regard to haemodynamics in children <2 yr scheduled for elective non-cardiac surgery.

RESULTS

A total of 81 patients were treated. Comparable amounts of both study solutions (16.0 mL kg(-1) hydroxyethyl starch 130/0.4 vs. 16.9 mL kg(-1) human albumin 5%) as well as add-on crystalloids were used until 4-6 h postoperatively. No differences were detected between the two treatment groups regarding perioperative stabilization of haemodynamics, coagulation parameters, blood gas analyses or other laboratory values. Blood loss was 96 +/-143 mL for hydroxyethyl starch and 145+/- 290 mL for human albumin (P > 0.05). There were no relevant differences in the amount of red blood cells, fresh frozen plasma or platelet concentrates in both treatment groups. Median length of ICU stay was 3.5 days (range 1-57 days, mean +/- SD 7.6 +/- 11.5 days) in the hydroxyethyl starch group and 6.0 days (range 1-71 days; mean +/- SD 9.1 +/- 14.2 days) in the human albumin group. There was no difference for hospital stay (median: 12 days for both groups).

CONCLUSIONS

Both HES 130/0.4 and human albumin 5% were effective for haemodynamic stabilization in non-cardiac surgery of young infants with no adverse impact on coagulation or other safety parameters in our study population.

Solução concentrada de albumina eqüina na fluidoterapia em eqüinos com desidratação leve a moderada

Avaliou-se o efeito da solução concentrada de albumina eqüina diluída a 5% em solução fisiológica (SF) durante fluidoterapia em eqüinos, após indução de desidratação leve a moderada, utilizando-se cinco eqüinos adultos, sem alterações clínicas. Cada animal passou por dois protocolos de fluidoterapia: apenas com SF (metade sob pressão e metade em fluxo contínuo - grupo-controle); com solução de albumina eqüina e SF (apenas em fluxo contínuo - grupo experimental). Avaliaram-se peso, exame físico geral, hematócrito, osmolalidade plasmática, gasometria, proteína total, albumina, uréia, creatinina, Na, K, débito cardíaco e pressão arterial, e calcularam-se pressão oncótica e volume plasmático. Após a aplicação de metade da SF sob pressão nos animais do grupo-controle, as alterações no hematócrito, na proteína total, na albumina, na pressão arterial e na pressão oncótica foram semelhantes às encontradas nos do grupo experimental após aplicação apenas da solução de albumina. Conclui-se que a solução de albumina eqüina é de fácil preparação e aplicação, não demonstra efeitos deletérios na dose e velocidade utilizadas e é passível de ser utilizada como colóide na fluidoterapia na espécie eqüina.

Management of septic shock in childhood

OBJECTIVE

The object of this review is to discuss the recognition and treatment of septic shock in children based on principles of resuscitation, antibiotic use and recent therapeutic advances.

METHODS

A comprehensive literature search combining these

METHODS

on-line searches of Ovid, PubMed, and Medline; hand searches of 25 international journals; a trawl of 26 textbooks; searches of reference lists of pertinent articles; and scans of abstracts of recent international meetings. Various national and international units were contacted with regard to current research therapeutic strategies, both published and unpublished.

CONCLUSIONS

Septic shock remains a leading cause of morbidity and mortality in children. Early administration of empirical antibiotic therapy reduces mortality. The keystone of resuscitation is aggressive volume replacement. Adjunctive therapies to modulate the inflammatory response may further enhance outcome, but do not replace principles of resuscitation.

Meningococcal disease: how to prevent and how to manage

Meningococcal disease is a significant problem in the paediatric population. The diagnosis of meningococcal disease can be problematic and progression of the disease can rapidly lead to a life-threatening illness. Despite the success of antibiotic treatment, mortality rates remain high. The development of protein-polysaccharide conjugate vaccines has significantly improved the success of vaccination in reducing the incidence of meningococcal disease. However, a comprehensive vaccine conferring protection against disease-associated serogroups remains elusive. The aim of this review is to highlight recent significant improvements in the prevention and management of meningococcal disease.

Treating meningococcal infections in children

Aggressive early treatment of meningococcal disease in children can reduce mortality. This relies on prompt recognition of septicaemia and meningitis, and treatment of the complications of shock and raised intracranial pressure.

Controversies in the diagnosis and management of hypotension in the newborn infant

Although close to half of the newborns admitted to neonatal intensive care units receive treatment for "hypotension," the normal physiologic blood pressure range ensuring appropriate organ perfusion in the neonate is unknown. Thus, the decision to treat hypotension in the newborn is based on statistically defined gestational and postnatal age-dependent normative blood pressure values and physicians' beliefs rather than on data bearing physiologic reference. Dopamine is the most widely used sympathomimetic amine in the treatment of neonatal hypotension, and it is more effective than dobutamine in raising blood pressure. Volume administration is less effective in the immediate postnatal period, and its extensive use is associated with significant untoward effects, especially in preterm infants. During the course of their disease, some of the sickest hypotensive newborns become unresponsive to volume and pressor administration. This phenomenon is caused by the desensitization of the cardiovascular system to catecholamines by the critical illness and relative or absolute adrenal insufficiency. The findings that steroids rapidly up-regulate cardiovascular adrenergic receptor expression and serve as hormone substitution in cases of adrenal insufficiency explain their effectiveness in stabilizing the cardiovascular status and decreasing the requirement for pressor support in the critically ill newborn with volume-and pressor-resistant hypotension. Finally, despite recent advances in our understanding of the pathophysiology and management of neonatal hypotension, there are few data on the impact of the treatment on organ blood flow and tissue perfusion and on neonatal morbidity and mortality.

Circulatory support of the sick preterm infant

In the majority of preterm infants, especially during the immediate postnatal period, hypotension is primarily caused by abnormal peripheral vasoregulation and/or myocardial dysfunction and not by absolute hypovolemia. Therefore, aggressive volume resuscitation is not warranted and is potentially harmful. Volume support should be limited to 10-20 ml/kg of isotonic saline administration and, if sustained normalization of the blood pressure cannot be achieved, early initiation of cardiovascular pharmacological support is recommended. However, in preterm infants who present with an identifiable volume loss, the kind of fluid lost should first be replaced. Due to its beneficial cardiovascular and renal actions, dopamine is the drug of choice in the treatment of neonatal hypotension. Dobutamine may be added if myocardial dysfunction persists or develops during dopamine treatment. In some critically ill preterm infants, escalation of dopamine therapy or addition of epinephrine is necessary yet not always effective indicating the development of pressor resistant hypotension. Downregulation of cardiovascular adrenergic receptors and some degree of adrenal insufficiency may explain this phenomenon. In these patients, a brief course of steroid treatment may be successful in stabilizing the cardiovascular status and decreasing the requirement for pressor/inotrope support. However, well-designed randomized and controlled clinical trials are needed in the future to determine the effectiveness and potential short- and long-term side effects of steroid administration in preterm infants with pressor-resistant hypotension. In summary, management of the critically ill hypotensive preterm infant remains challenging and requires a better understanding of the pathophysiology of neonatal shock and improvements in our ability to evaluate cardiac output, organ blood flow, and tissue perfusion at the bedside.

Albumin in meningococcal disease

The management of acute meningococcal disease (MD) exemplifies what is best and worst about modern paediatric intensive care. The best because, in the face of well-staffed teams with centralized experience, survival has improved dramatically (clinical scoring systems such as the Glasgow Meningococcal Septicaemia Prognostic Score indicate that for the highest risk patients (score >12) the mortality has fallen from 100% (Thomson et al, 1991) to 37% (unpublished data, Peters et al, 2000)). The worst because there are no randomized trial data supporting many widely used interventions. This has caused problems in recent years as enthusiasts for novel therapies suggest that trials are now unethical because of improved outcome (Smith et al, 1997), while across the board outcomes are better than previously.

Recognition, treatment and complications of meningococcal disease

Meningococcal disease remains a major cause of death in young children. A decrease in mortality requires recognition and treatment of the disease at a number of stages in the illness. Life-threatening meningococcal disease usually presents as septicaemia rather than meningitis. The cardinal feature of meningococcal septicaemia is the purpuric rash. Many parents recognise the rash and seek medical advice because of it. When primary care physicians recognise the rash, the administration of parenteral penicillin may decrease mortality. However, antibacterials are not given promptly if there is no rash or if the disease presents in an atypical form. In hospital, antibacterial therapy with a third-generation cephalosporin should be given. Disease severity needs to be assessed by a valid method, such as the Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS). This can identify those patients who need intensive care and/or might benefit from new therapies. The 2 life-threatening complications are septic shock and meningoencephalitis with raised intracranial pressure. Despite numerous case reports of success with potential new treatments, none has been proven safe and/or effective by controlled trials. Although it is tempting to focus on new treatments, the early recognition of severe meningococcal disease by parents, primary care physicians and junior hospital doctors is equally, if not more, important as a potential means of decreasing mortality.

Emergency management of meningococcal disease

Meningococcal disease remains a major cause of mortality in children in the UK. Aggressive early volume resuscitation, meticulous attention to the normalisation of all physiological and laboratory parameters, and prompt referral to specialist paediatric intensive care may lead to a sharp reduction in mortality. Application of the management algorithm described in this article may be helpful to those involved in the early part of management of critically ill patients with meningococcal disease.