Randomised controlled trial of colloid or crystalloid in hypotensive preterm infants

Neonatal fluid overload-ignorance is no longer bliss

Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.

Acute Cardiac Care for Neonatal Heart Disease

This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.

Use of Albumin in the NICU: An Evidence-based Review

Albumin is the most abundant protein in human blood with distinctive functions throughout the human body. Low albumin levels are a predictor of mortality as well as disease outcome in children and adults. However, the clinical significance of hypoalbuminemia and the role of albumin infusions in NICUs remain unclear and controversial.

A new physiologic-based integrated algorithm in the management of neonatal hemodynamic instability

Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.

Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn

The measurement of blood pressure in the very low birth weight newborn infant is not simple and may be erroneous because of numerous factors. Assessment of cardiovascular insufficiency in this population should be based on multiple parameters and not only on numeric blood pressure readings. The decision to treat cardiovascular insufficiency should be made after considering the potential complications of such treatment. There are numerous potential strategies to avoid or mitigate hypoperfusion states in the very low birth weight infant.

Know the Code: Medications for Resuscitation in Neonates

Resuscitations in the delivery room or the nursery cause significant stress for caregivers. Diligent preparation will improve the efficacy and safety of life-saving interventions and increase staff comfort. When establishment of an airway and delivery of positive pressure ventilation and chest compressions fail to result in return of spontaneous circulation, pharmacotherapeutic interventions should be considered. Epinephrine is first-line pharmacotherapy for severe bradycardia or cardiac arrest, increasing coronary arterial pressure and blood flow during chest compressions. Despite limited data regarding dosing and efficacy, the first dose of epinephrine may be delivered through the endotracheal tube during attainment of venous access (preferably a low-lying umbilical venous catheter in the delivery room). Intravenous dosing is preferred, and any facility caring for newborns must ensure optimized logistics including readily available dosing guidance and optimal flush volumes. After provision of epinephrine, additional medications may be considered, especially for resuscitations occurring outside of the immediate perinatal period, including normal saline, glucose, adenosine, atropine, and calcium. Clinicians must understand the indications, dosing, and monitoring parameters for these medications and ensure rapid availability for resuscitation. Every second truly counts in a neonatal resuscitation, and optimal understanding and preparation will ensure delivery of pharmacotherapy to optimize both patient outcomes and staff comfort.

Drugs in the delivery room

The need for cardiopulmonary resuscitation in newborns is quite rare, as most non-vigorous infants respond well to effective ventilation. For the minority of babies who do not respond to adequate ventilation, chest compressions are necessary using the preferred two thumb technique. Since effective ventilation remains a key component to successful resuscitation, chest compressions are coordinated with ventilations in a 3:1 ratio. If despite adequate ventilation and compressions, the heart rate remains below 60 beats per minute, epinephrine is indicated. The intravenous route is preferred over the endotracheal route and the recommended dose of epinephrine is 0.01-0.03 mg/kg. This can be repeated every 3-5 min until return of spontaneous circulation is achieved. In rare instances, when there is no response to these above measures and in infants who show evidence of significant hypovolemia, volume replacement should be considered.

Cardiopulmonary Bypass in Premature and Low Birth Weight Neonates - Implications for Postoperative Care From a Neonatologist/Intensivist Perspective

Prematurity and low weight remain significant risk factors for mortality after neonatal cardiac surgery despite steady gains in survival. Newer and lower weight thresholds for operability are constantly generated as surgeons gather proficiency, technical mastery, and experience in performing complex procedures on extremely small infants. Relationship between birth weight and survival after cardiac surgery is nonlinear with 2 kg being an inflection point below which marked decline in survival occurs. If strides toward improved survival in this weight category are to be made, understanding the inherent vulnerabilities of the premature and low birth weight infant is important in addition to acknowledging the vulnerabilities of the system in which care is delivered.

Successful Resuscitation in a Model of Asphyxia and Hemorrhage to Test Different Volume Resuscitation Strategies. A Study in Newborn Piglets After Transition

Background: Evidence for recommendations on the use of volume expansion during cardiopulmonary resuscitation in newborn infants is limited. Objectives: To develop a newborn piglet model with asphyxia, hemorrhage, and cardiac arrest to test different volume resuscitation on return of spontaneous circulation (ROSC). We hypothesized that immediate red cell transfusion reduces time to ROSC as compared to the use of an isotonic crystalloid fluid. Methods: Forty-four anaesthetized and intubated newborn piglets [age 32 h (12-44 h), weight 1,220 g (1,060-1,495g), Median (IQR)] were exposed to hypoxia and blood loss until asystole occurred. At this point they were randomized into two groups: (1) Crystalloid group: receiving isotonic sodium chloride (n = 22). (2) Early transfusion group: receiving blood transfusion (n = 22). In all other ways the piglets were resuscitated according to ILCOR 2015 guidelines [including respiratory support, chest compressions (CC) and epinephrine use]. One hour after ROSC piglets from the crystalloid group were randomized in two sub-groups: late blood transfusion and infusion of isotonic sodium chloride to investigate the effects of a late transfusion on hemodynamic parameters. Results: All animals achieved ROSC. Comparing the crystalloid to early blood transfusion group blood loss was 30.7 ml/kg (22.3-39.6 ml/kg) vs. 34.6 ml/kg (25.2-44.7 ml/kg), Median (IQR). Eleven subjects did not receive volume expansion as ROSC occurred rapidly. Thirty-three animals received volume expansion (16 vs. 17 in the crystalloid vs. early transfusion group). 14.1% vs. 10.5% of previously extracted blood volume in the crystalloid vs. early transfusion group was infused before ROSC. There was no significant difference in time to ROSC between groups [crystalloid group: 164 s (129-198 s), early transfusion group: 163 s (162-199 s), Median (IQR)] with no difference in epinephrine use. Conclusions: Early blood transfusion compared to crystalloid did not reduce time to ROSC, although our model included only a moderate degree of hemorrhage and ROSC occurred early in 11 subjects before any volume resuscitation occurred.

Uses and misuses of albumin during resuscitation and in the neonatal intensive care unit

Albumin is one of the most abundant proteins in plasma and serves many vital functions. Neonatal concentrations vary greatly with gestational and postnatal age. In critically ill neonates, hypoalbuminemia occurs due to decreased synthesis, increased losses or redistribution of albumin into the extravascular space, and has been associated with increased morbidities and mortality. For that reason, infusion of exogenous albumin as a volume expander has been proposed for various clinical settings including hypotension, delivery room resuscitation, sepsis and postoperative fluid management. Albumin is often prescribed in infants with hypoalbuminemia, hyperbilirubinemia, and protein-losing conditions. However, the evidence of these practices has not been reviewed or validated. Albumin infusion may initiate highly complex processes that vary according to the individual and disease pathophysiology. Indeed, it may be associated with harms when misused. In this review, we critically appraise the scientific evidence for administering albumin in most conditions encountered in the neonatal intensive care unit, while emphasizing the benefits and risks associated with their use.

Management of Neonatal Hypotension

Hypotension is a common problem in neonates with complex underlying pathophysiology. Although treatment of low blood pressure is common, clinicians must use all available information to target neonates with compromised perfusion. Pharmacotherapy should be tailored to the specific physiologic perturbations of the individual neonate. Dopamine is the most commonly utilized agent and may be the most appropriate agent for septic shock with low diastolic blood pressure. However, alternative therapies should be considered for other etiologies of hypotension, including milrinone and vasopressin for persistent pulmonary hypertension of the newborn and dobutamine for patent ductus arteriosus. Additional studies are required to refine the approach to neonatal hypotension and document the long-term outcomes of treated neonates.

Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge

Volume resuscitation (VR) for the treatment of newborn shock is a rare but potentially lifesaving intervention. Conducting clinical studies to assess the effectiveness of VR in the delivery room during newborn stabilization is challenging. We review the available literature and current management guidelines to determine which infants will benefit from VR, the frequency of VR, and the choice of agents used. In addition, the potential role for placental transfusion in the prevention of newborn shock is explored.

Comparison of the Effectiveness of Hydroxyethyl Starch (Voluven) Solution With Normal Saline in Hemorrhagic Shock Treatment in Trauma

BACKGROUND

Appropriate fluid therapy affects morbidity and mortality rates. A conclusion is yet to be reached on the role of crystalloids and colloids in immediate fluid therapy. This study was done to determine the suitable solution in immediate resuscitation of patients with hemorrhagic shock caused by tissue trauma.

METHODS

One hundred trauma patients with hemorrhagic shock, who underwent fluid therapy in the emergency unit, were assigned randomly to two groups of hydroxyethyl starch (Voluven) and normal saline. Before and after fluid therapy, 1 cc of blood was taken from all patients in order to determine and compare base excess levels.

RESULTS

In hydroxyethyl starch (Voluven) and normal saline groups, base excess level after solution therapy increased about 9.65 and 5.46 volumes, respectively, in which augmentation in hydroxyethyl starch (Voluven) group is significantly higher than normal saline group (P ≤ 0.001).

CONCLUSION

By using hydroxyethyl starch (Voluven) for fluid therapy in hemorrhagic shock caused by trauma, serum base excess decreases and results in improvement in tissue perfusion and better balance in acid-base status and it seems to be superior over normal saline administration, but the building block of the ideal fluid therapy should still remain with the physician's final clinical judgment.

Hemodynamic instability in the critically ill neonate: An approach to cardiovascular support based on disease pathophysiology

Hemodynamic disturbance in the sick neonate is common, highly diverse in underlying pathophysiology and dynamic. Dysregulated systemic and cerebral blood flow is hypothesized to have a negative impact on neurodevelopmental outcome and survival. An understanding of the physiology of the normal neonate, disease pathophysiology, and the properties of vasoactive medications may improve the quality of care and lead to an improvement in survival free from disability. In this review we present a modern approach to cardiovascular therapy in the sick neonate based on a more thoughtful approach to clinical assessment and actual pathophysiology. Targeted neonatal echocardiography offers a more detailed insight into disease processes and offers longitudinal assessment, particularly response to therapeutic intervention. The pathophysiology of common neonatal conditions and the properties of cardiovascular agents are described. In addition, we outline separate treatment algorithms for various hemodynamic disturbances that are tailored to clinical features, disease characteristics and echocardiographic findings.

Effect of synthetic colloid administration on hemodynamic and laboratory variables in healthy dogs and dogs with systemic inflammation

OBJECTIVE

To compare the effects of administering equal volumes of isotonic crystalloids and synthetic colloids on hemodynamic and laboratory variables in healthy dogs and dogs with systemic inflammation.

DESIGN

Randomized, placebo-controlled, blinded study.

SETTING

Comparative clinical research facility.

ANIMALS

Sixteen adult purpose-bred Beagles.

INTERVENTIONS

Dogs were first randomized to receive either lipopolysaccharide (LPS; 5 μg/kg, IV) or an equal volume of placebo (0.9% NaCl, IV). Dogs were then randomized into 1 of 2 groups receiving fluid resuscitation with either 40 mL/kg IV isotonic crystalloid (0.9% NaCl) or synthetic colloid (tetrastarch). After a 14-day washout, the study was repeated such that dogs received the opposite treatment (LPS or placebo) and the same resuscitation fluid regimen. Vital signs (heart rate (HR), oscillometric blood pressure) were measured and blood samples were collected for PCV, total plasma protein (TPP), serum lactate concentration, and colloid osmotic pressure (COP) measurements.

MEASUREMENTS AND MAIN RESULTS

Healthy (placebo) dogs had similar decreases in PCV and TPP after administration of either fluid. Tetrastarch administration was associated with a larger increase in HR, systolic blood pressure, and mean blood pressure. Dogs with systemic inflammation had similar increases in systolic blood pressure and decreases in PCV, TPP, and lactate after administration of either fluid. Tetrastarch administration caused greater immediate increase in HR and mean blood pressure compared to 0.9% NaCl. In all dogs, 0.9% NaCl administration decreased COP and tetrastarch administration increased COP.

CONCLUSIONS

Resuscitation with equal volumes of 0.9% NaCl and tetrastarch caused similar changes in hemodynamic and laboratory variables in dogs with LPS-induced systemic inflammation; however, larger increases in HR and blood pressure were seen within the first 2 hours following tetrastarch administration compared to 0.9% NaCl. Tetrastarch administration increased COP in all dogs, despite a decrease in TPP.

Diagnosis and management of hypotension in neonates

The diagnosis and management of hypotension in neonates is a frequently encountered issue in the intensive care setting. There is an ongoing debate as to the appropriateness of blood pressure monitoring as an indicator of organ perfusion and tissue hypoxia. These ultimately determine morbidity and mortality in the sick newborn. This article explores the methods available for the assessment of organ perfusion and speculates on other means that may become available in the future. Different modalities of treatment currently in use are discussed, with the aim of using information gained from perfusion monitoring techniques to determine the optimal choice of therapy.

Fluid homeostasis in the neonate

The physiology of the neonate is ideally suited to the transition to extrauterine life followed by a period of rapid growth and development. Intravenous fluids and electrolytes should be prescribed with care in the neonate. Sodium and water requirements in the first few days of life are low and should be increased after the postnatal diuresis. Expansion of the extracellular fluid volume prior to the postnatal diuresis is associated with poor outcomes, particularly in preterm infants. Newborn infants are prone to hypoglycemia and require a source of intravenous glucose if enteral feeds are withheld. Anemia is common, and untreated is associated with poor outcomes. Liberal versus restrictive transfusion practices are controversial, but liberal transfusion practices (accompanied by measures to minimize donor exposure) may be associated with improved long-term outcomes. Intravenous crystalloids are as effective as albumin to treat hypotension, and semi-synthetic colloids cannot be recommended at this time. Inotropes should be used to treat hypotension unresponsive to intravenous fluid, ideally guided by assessment of perfusion rather than blood pressure alone. Noninvasive methods of assessing cardiac output have been validated in neonates. More studies are required to guide fluid management in neonates, particularly in those with sepsis or undergoing surgery. A balanced salt solution such as Hartmann's or Plasmalyte should be used to replace losses during surgery (and blood or coagulation factors as indicated). Excessive fluid administration during surgery should be avoided.

Neonatal cardiac care, a perspective

Every year in the United States approximately 40,000 infants are born with congenital heart disease. Several of these infants require corrective or palliative surgery in the neonatal period. Mortality rates after cardiac surgery are highest amongst neonates, particularly those born prematurely. There are several reasons for the increased surgical mortality risk in neonates. This review outlines these risks, with particular emphasis on the relative immaturity of the organ systems in the term and preterm neonate.

Risk and protective factors of intraventricular hemorrhage in preterm babies in Wuhan, China

OBJECTIVE

The aim of this study is to identify prenatal and perinatal risk and protective factors for the development of IVH, using a retrospective and case-control clinical study.

METHODS

Prenatal and perinatal data were collected from three NICUs between January 2010 and December 2010. Univariate analysis was performed between case and control groups, and multivariate analysis was done to find out risk and protective factors for development of IVH. Further analysis of these variables was undertaken for gestational age strata <30, 30-34, and 35-37 weeks.

RESULTS

By univariate analysis, factors related with IVH were C-section, prenatal steroid, pregnancy-induced hypertension, transport from other hospital, hypothermia, Apgar score at 1 and 5 min < 4, luminal, pathological jaundice, RDS, hypotension, volume expansion/inotropics, PO(2), repeat suctioning, and mechanical ventilation (P < 0.05). Five variables remained significant in multivariate analysis. C-section and prenatal steroid use were protective variables while mechanical ventilation, hypotension, and transport from other hospital were risk factors. Further analysis of these variables was undertaken for gestational age strata <30, 30-34, and 35-37 weeks. Prenatal steroid use remained significant as a protective variable in gestational age less than 35 weeks; hypotension was shown to be a risk factor just in the time period between 30-34 weeks; transport from other hospital was a risk factor in gestational age more than 30 weeks; mechanical ventilation remained non-significant during the gestational age strata studied.

CONCLUSION

In the present study, factors that related to neonatal IVH included hypotension, prenatal steroid use, and transportation.

Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES

Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome.

PATIENTS AND METHODS

One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates.

RESULTS

Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4% and 92.0%, respectively), were similar for both phases.

CONCLUSIONS

The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Human albumin solution for resuscitation and volume expansion in critically ill patients

BACKGROUND

Human albumin solutions are used for a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, such as in burns and hypoproteinaemia. Human albumin solutions are more expensive than other colloids and crystalloids.

OBJECTIVES

To quantify the effect on mortality of human albumin and plasma protein fraction (PPF) administration in the management of critically ill patients.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register (searched 31 May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (Ovid) (1948 to week 3 May 2011), EMBASE (Ovid) (1980 to Week 21 2011), CINAHL (EBSCO) (1982 to May 2011), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to May 2011), ISI Web of Science: Conference Proceedings Citation Index - Science (CPCI-S) (1990 to May 2011), PubMed (www.ncbi.nlm.nih.gov/sites/entrez/) (searched 10 June 2011, limit: last 60 days). Reference lists of trials and review articles were checked, and authors of identified trials were contacted.

SELECTION CRITERIA

Randomised controlled trials comparing albumin or PPF with no albumin or PPF or with a crystalloid solution in critically ill patients with hypovolaemia, burns or hypoalbuminaemia.

DATA COLLECTION AND ANALYSIS

We collected data on the participants, albumin solution used, mortality at the end of follow up, and quality of allocation concealment. Analysis was stratified according to patient type.

MAIN RESULTS

We found 38 trials meeting the inclusion criteria and reporting death as an outcome. There were 1,958 deaths among 10,842 trial participants.For hypovolaemia, the relative risk of death following albumin administration was 1.02 (95% confidence interval (CI) 0.92 to 1.13). This estimate was heavily influenced by the results of the SAFE trial, which contributed 75.2% of the information (based on the weights in the meta-analysis). For burns, the relative risk was 2.93 (95% CI 1.28 to 6.72) and for hypoalbuminaemia the relative risk was 1.26 (95% CI 0.84 to 1.88). There was no substantial heterogeneity between the trials in the various categories (Chi(2) = 26.66, df = 31, P = 0.69). The pooled relative risk of death with albumin administration was 1.05 (95% CI 0.95 to 1.16).

AUTHORS' CONCLUSIONS

For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trials.

Human albumin solution for resuscitation and volume expansion in critically ill patients

BACKGROUND

Human albumin solutions are used for a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, such as in burns and hypoproteinaemia. Human albumin solutions are more expensive than other colloids and crystalloids.

OBJECTIVES

To quantify the effect on mortality of human albumin and plasma protein fraction (PPF) administration in the management of critically ill patients.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register (searched 31 May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (Ovid) (1948 to week 3 May 2011), EMBASE (Ovid) (1980 to Week 21 2011), CINAHL (EBSCO) (1982 to May 2011), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to May 2011), ISI Web of Science: Conference Proceedings Citation Index - Science (CPCI-S) (1990 to May 2011), PubMed (www.ncbi.nlm.nih.gov/sites/entrez/) (searched 10 June 2011, limit: last 60 days). Reference lists of trials and review articles were checked, and authors of identified trials were contacted.

SELECTION CRITERIA

Randomised controlled trials comparing albumin or PPF with no albumin or PPF or with a crystalloid solution in critically ill patients with hypovolaemia, burns or hypoalbuminaemia.

DATA COLLECTION AND ANALYSIS

We collected data on the participants, albumin solution used, mortality at the end of follow up, and quality of allocation concealment. Analysis was stratified according to patient type.

MAIN RESULTS

We found 38 trials meeting the inclusion criteria and reporting death as an outcome. There were 1,958 deaths among 10,842 trial participants.For hypovolaemia, the relative risk of death following albumin administration was 1.02 (95% confidence interval (CI) 0.92 to 1.13). This estimate was heavily influenced by the results of the SAFE trial, which contributed 75.2% of the information (based on the weights in the meta-analysis). For burns, the relative risk was 2.93 (95% CI 1.28 to 6.72) and for hypoalbuminaemia the relative risk was 1.26 (95% CI 0.84 to 1.88). There was no substantial heterogeneity between the trials in the various categories (Chi(2) = 26.66, df = 31, P = 0.69). The pooled relative risk of death with albumin administration was 1.05 (95% CI 0.95 to 1.16).

AUTHORS' CONCLUSIONS

For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trials.

Neonatal fluid management

Perioperative fluid management in paediatrics has been the subject of many controversies in recent years, but fluid management in the neonatal period has not been considered in most reviews and guidelines. The literature regarding neonatal fluid management mainly appears in the paediatric textbooks and few recent data are available, except for resuscitation and fluid loading during shock and major surgery. In the context of anaesthesia, many neonates requiring surgery within the first month of life have organ malformation and/or dysfunction. This article aims at reviewing basic physiological considerations important for neonatal fluid management and mainly focusses on fluid maintenance and replacement during surgery.

[Guidelines on therapy with blood components and plasma derivatives: human albumin. Recommendations of the scientific advisory board of the Medical Council]

Human albumin (HA) is by far the most expensive option for volume replacement and correction of hypoalbuminemia but is still widely used. The value of HA in the clinical setting continues to be controversial and it remains unclear whether there is still a place for using such a high-priced substance in the present cost-consciousness climate. Thus the Medical Council has presented some recommendations with regard to blood and plasma products including HA. There appear to be no indications for HA to correct hypovolemia either perioperatively or in the intensive care setting including children and patients undergoing cardiac or liver surgery. For maintaining colloid oncotic pressure (COP) cheaper modern synthetic colloids can be alternatively given and the value of HA for correcting hypoalbuminemia is also not clearly justified. Some small uncontrolled studies have shown that only patients with liver cirrhosis, spontaneous bacterial peritonitis and massive ascites drainage may profit from HA. Theoretical benefits such as oxygen radical scavenging or binding of toxic substances are no indications for using HA as beneficial clinical consequences have not yet been demonstrated. Experimental data from cell lines or animals must be viewed with skepticism because they do not mimic the clinical setting. According to the recommendations of the scientific advisory board of the Medical Council the use of HA should be considered very cautiously.

Neonatal resuscitation: Current issues

The following guidelines are intended for practitioners responsible for resuscitating neonates. They apply primarily to neonates undergoing transition from intrauterine to extrauterine life. The updated guidelines on Neonatal Resuscitation have assimilated the latest evidence in neonatal resuscitation. Important changes with regard to the old guidelines and recommendations for daily practice are provided. Current controversial issues concerning neonatal resuscitation are reviewed and argued in the context of the ILCOR 2005 consensus.

Use of albumin: an update

Human albumin (HA) is widely used for volume replacement or correction of hypoalbuminaemia. The value of HA in the clinical setting continues to be controversial, and it is unclear whether in today's climate of cost consciousness, there is still a place for such a highly priced substance. It is therefore appropriate to update our knowledge of the value of HA. With the exception of women in early pregnancy, there appears to be few indications for the use of HA to correct hypovolaemia. Some studies of traumatic brain injury and intensive care patients suggest negative effects on outcome and organ function of (hyperoncotic) HA. Modern synthetic colloids appear to be a cheaper alternative for maintaining colloid oncotic pressure. The value of using HA to correct hypoalbuminaemia has not been clearly justified. Theoretical and pharmacological benefits of HA, such as oxygen radical scavenging or binding of toxic substances, have not as yet been shown to have beneficial clinical consequences. Experimental data from cell lines or animals do not appear to mimic the clinical setting. Convincing data justifying the use of HA either for treating hypovolaemia or for correcting hypoalbuminaemia are still lacking. A restricted use of HA is recommended.

Hypotension and shock in the preterm neonate

While the methods of establishing and maintaining organ perfusion differ from one clinician to the next, the underlying physiological rationale remains constant. The gestalt for correcting circulatory compromise is generally performed in a stepwise manner; first ensuring that the vasculature is filled, then administering medications to tighten the vasculature, and lastly, compensating for an immature vasculature. This stepwise approach is reflected in the pharmacological interventions of providing fluid boluses (filling the pump), giving catecholamines (tightening the pump), and starting hydrocortisone (compensating for an immature pump). While the stepwise management approach may be familiar to some nurses, it is important to understand the evidence-based rationale that supports clinical decisions. This article will outline physiology unique to the neonate, clarify terminology that surrounds hypotension and shock, and explore various methods for the treatment of circulatory compromise in the preterm neonate.

Albumin versus normal saline for dehydrated term infants with metabolic acidosis due to acute diarrhea

To compare the efficacy of albumin to normal saline (NS) for initial hydration therapy for dehydrated term infants with severe metabolic acidosis due to acute diarrhea.

STUDY DESIGN

We randomized 33 infants presenting with moderate-to-severe dehydration and metabolic acidosis (pH <7.25 or base excess (BE) <-15) into two groups, an albumin group (n=15) and a NS group (n=18). For initial hydration treatment, the albumin group received 5% albumin (10 ml kg(-1)), whereas the NS group received NS (10 ml kg(-1)).

RESULT

After 3 h of treatment, both groups improved. However, the magnitude of improvement in the pH, BE and HCO(3)(-) levels were not different in comparisons between these two groups. In addition, there were no differences either in the body weight and weight gain 4 days after treatment or in the length of hospital stay.

CONCLUSION

Albumin was not more effective than NS for initial hydration treatment of dehydrated term infants with metabolic acidosis due to acute diarrhea.

The role of resuscitation drugs and placental transfusion in the delivery room management of newborn infants

Medications are used rarely in newborn resuscitations and are probably justifiable in less than 0.1% of births. Doses used are mainly extrapolated from animal and adult data. Despite this, the drugs used, their order and route of administration have all been sources of controversy for many years. There have been polarised views, often focusing upon adrenaline and sodium bicarbonate and more recently new drugs such as vasopressin have been suggested, once again extrapolating from adult experience. This article examines the sparse data behind the use of any medication at birth and the poor outcome data available. The appropriate decline in the indiscriminate use of volume expansion is considered and balanced by the increasing evidence in favour of delayed clamping of the umbilical cord. Focusing on the basic steps of resuscitation, improving the quality of their application and avoiding relative hypovolaemia, must improve the quality of outcome data. The place of medications in newborn resuscitation should be regarded as experimental and still requires evidence to justify their use especially in premature babies.

Bench-to-bedside review: Developmental influences on the mechanisms, treatment and outcomes of cardiovascular dysfunction in neonatal versus adult sepsis

Sepsis is a significant cause of morbidity and mortality in neonates and adults, and the mortality rate doubles in patients who develop cardiovascular dysfunction and septic shock. Sepsis is especially devastating in the neonatal population, as it is one of the leading causes of death for hospitalized infants. In the neonate, there are multiple developmental alterations in both the response to pathogens and the response to treatment that distinguish this age group from adults. Differences in innate immunity and cytokine response may predispose neonates to the harmful effects of pro-inflammatory cytokines and oxidative stress, leading to severe organ dysfunction and sequelae during infection and inflammation. Underlying differences in cardiovascular anatomy, function and response to treatment may further alter the neonate's response to pathogen exposure. Unlike adults, little is known about the cardiovascular response to sepsis in the neonate. In addition, recent research has demonstrated that the mechanisms, inflammatory response, response to treatment and outcome of neonatal sepsis vary not only from that of adults, but vary among neonates based on gestational age. The goal of the present article is to review key pathophysiologic aspects of sepsis-related cardiovascular dysfunction, with an emphasis on defining known differences between adult and neonatal populations. Investigations of these relationships may ultimately lead to 'neonate-specific' therapeutic strategies for this devastating and costly medical problem.

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.

A comparison of albumin-bolus therapy versus normal saline-bolus therapy for hypotension in neonates

OBJECTIVE

We compared responses to bolus infusion of 5% albumin (ALB) or normal saline (NS) for hypotension in neonates.

STUDY DESIGN

Hypotensive infants were given 10 ml kg(-1) of NS or ALB. A second bolus was given for persistent hypotension. Dopamine therapy was started for hypotension after the second bolus. The primary response was increase in arterial blood pressure toward normal range 1 h postinfusion. Secondary measures included duration of normotension, meeting criteria for second bolus, meeting criteria for vasopressor support and cost comparison.

RESULT

Those receiving ALB (N=49 ALB and 52 NS) were more likely to achieve a normotensive state (ALB=57.1%, NS=32.1% P=0.01) 1 h following the initial bolus therapy. Subsequently, the NS group was also more likely to qualify for vasopressor infusion (ALB=24.5%, NS=44.2% P=0.02). Overall cost for either therapy was equivalent.

CONCLUSION

In hypotensive neonates, ALB results in a greater likelihood of achieving normotension and decreased subsequent use of vasopressors when compared to NS.

Dopamine versus dobutamine in very low birthweight infants: endocrine effects

OBJECTIVES

To compare the endocrine effects of dopamine and dobutamine in hypotensive very low birthweight (VLBW) infants.

DESIGN

Non-blinded randomised prospective trial.

SETTING

Level III neonatal intensive care unit.

PATIENTS

35 hypotensive VLBW infants who did not respond to volume loading, assigned to receive dopamine or dobutamine.

MEASUREMENTS

Haemodynamic variables and serum levels of thyroid stimulating hormone (TSH), total thyroxine (T(4)), prolactin (PRL) and growth hormone were assessed during the first 72 h of treatment and the first 72 h after stopping treatment.

RESULTS

Demographic and clinical data did not significantly differ between the two groups. Necessary cumulative and mean drug doses and maximum infusion required to normalise blood pressure were significantly higher in the dobutamine than in the dopamine group (p<0.01). Suppression of TSH, T(4) and PRL was observed in dopamine-treated newborns from 12 h of treatment onwards, whereas levels of growth hormone reduced significantly only at 12 h and 36 h of treatment (p<0.01). TSH, T(4) and PRL rebound was observed from the first day onwards after stopping dopamine. Dobutamine administration did not alter the profile of any of the hormones and no rebound was observed after stopping treatment.

CONCLUSION

Dopamine and dobutamine both increase the systemic blood pressure, though dopamine is more effective. Dopamine reduces serum levels of TSH, T(4) and PRL in VLBW infants but such suppression is quickly reversed after treatment is stopped. Further research is required to assess if short-term iatrogenic pituitary suppression has longer-term consequences.

Evidence-based medicine in equine critical care

One of the fundamental skills required for practicing evidence-based medicine is the development of a well-built clinical question, which specifies the patient group or problem, intervention, and outcome of interest. For this purpose, various "levels of evidence" have been developed in the human literature, which rank the validity of evidence. Our established conclusions and advice are thus supported by specific "grades of recommendations," which are intended to give an indication of the "strength" of a clinical recommendation. This article was compiled with these principles in mind.

Treating hypotension in the preterm infant: when and with what: a critical and systematic review

A very large proportion of extremely preterm infants receive treatments for hypotension. There are, however, marked variations in indications for treatment, and in the interventions used, between neonatal intensive care units and between neonatologists.

METHODS

We performed systematic reviews of the literature in order to determine which preterm infants may benefit from treatment with interventions to elevate blood pressure (BP), and which interventions improve clinically important outcomes.

RESULTS

Our review was not able to define a threshold BP that was significantly predictive of a poor outcome, nor whether any interventions for hypotensive infants improved outcomes, nor which interventions were more likely to be beneficial.

CONCLUSIONS

There is a distinct lack of prospective research of this issue, which prevents good clinical care. It is possible that a simple BP threshold that indicates the need for therapy does not exist, and other factors, such as the clinical status or systemic blood flow measurements, may be much more informative. Such a paradigm shift will also require careful prospective study.

European consensus guidelines on the management of neonatal respiratory distress syndrome

Despite recent advances in the perinatal management of neonatal respiratory distress syndrome (RDS), controversies still exist. We report the recommendations of a European panel of expert neonatologists who developed consensus guidelines after critical examination of the most up-to-date evidence in 2007. Strong evidence exists for the role of antenatal steroids in RDS prevention, but it is not clear if repeated courses are safe. Many practices involved in preterm neonatal stabilization at birth are not evidence based, including oxygen administration and positive pressure lung inflation, and they may at times be harmful. Surfactant replacement therapy is crucial in management of RDS but the best preparation, optimal dose and timing of administration at different gestations is not always clear. Respiratory support in the form of mechanical ventilation may also be life saving but can cause lung injury, and protocols should be directed to avoiding mechanical ventilation where possible by using nasal continuous positive airways pressure. For babies with RDS to have the best outcome, it is essential that they have optimal supportive care, including maintenance of a normal body temperature, proper fluid management, good nutritional support, management of the ductus arteriosus and support of the circulation to maintain adequate blood pressure.

Randomized trial of volume infusion during resuscitation of asphyxiated neonatal piglets

Despite its use, there is little evidence to support volume infusion (VI) during neonatal cardiopulmonary resuscitation (CPR). This study compares 5% albumin (ALB), normal saline (NS), and no VI (SHAM) on development of pulmonary edema and restoration of mean arterial pressure (MAP) during resuscitation of asphyxiated piglets. Mechanically ventilated swine (n=37, age: 8 +/- 4 d, weight: 2.2 +/- 0.7 kg) were progressively asphyxiated until pH <7.0, Paco2 >100 mm Hg, heart rate (HR) <100 bpm, and MAP <20 mm Hg. After 5 min of ventilatory resuscitation, piglets were randomized blindly to ALB, NS, or SHAM infusion. Animals were recovered for 2 h before euthanasia and lung tissue sampled for wet-to-dry weight ratio (W/D) as a marker of pulmonary edema. SHAM MAP was similar to VI during resuscitation. At 2 h post-resuscitation, MAP of SHAM (48 +/- 13 mm Hg) and ALB (43 +/- 19 mm Hg) was higher than NS (29 +/- 10 mm Hg; p=0.003 and 0.023, respectively). After resuscitation, SHAM piglets had less pulmonary edema (W/D: 5.84 +/- 0.12 versus 5.98 +/- 0.19; p=0.03) and better dynamic compliance (Cd) compared with ALB or NS (Cd: 1.43 +/- 0.69 versus 0.97 +/- 0.37 mL/cm H2O, p=0.018). VI during resuscitation did not improve MAP, and acute recovery of MAP was poorer with NS compared with ALB. VI was associated with increased pulmonary edema. In the absence of hypovolemia, VI during neonatal resuscitation is not beneficial.

Resuscitation of the depressed newborn

The resuscitation of babies at birth is different from the resuscitation of all other age groups, and knowledge of the relevant physiology and pathophysiology is essential. Although the majority of babies will establish normal respiration and circulation without help after delivery, those babies who do not establish adequate regular normal breathing, or who have a heart rate of less than 100 beats per minute, require assistance. Despite the limitation of the available evidence, an international body of experts has provided guidelines for neonatal resuscitation.

Fluid resuscitation in neonatal and pediatric hypovolemic shock: a Dutch Pediatric Society evidence-based clinical practice guideline

OBJECTIVE

To develop a clinical practice guideline that provides recommendations for the fluid, i.e. colloid or crystalloid, used for resuscitation in critically ill neonates and children up to the age of 18 years with hypovolemia.

METHODS

The guideline was developed through a comprehensive search and analysis of the pediatric literature. Recommendations were formulated by a national multidisciplinary committee involving all stakeholders in neonatal and pediatric intensive care and were based on research evidence from the literature and, in areas where the evidence was insufficient or lacking, on consensus after discussions in the committee.

RESULTS

Because of the lack of evidence in neonates and children, trials conducted in adults were considered. We found several recent meta-analyses that show excess mortality in albumin-treated groups, compared with crystalloid-treated groups, and one recent large randomized controlled trial that found evidence of no mortality difference. We found no evidence that synthetic colloids are superior to crystalloid solutions.

CONCLUSIONS

Given the state of the evidence and taking all other considerations into account, the guideline-developing group and the multidisciplinary committee recommend that in neonates and children with hypovolemia the first-choice fluid for resuscitation should be isotonic saline.

Brain injury in the infant: the old, the new, and the uncertain

Although neonatal brain injury occurs most frequently after a perinatal hypoxic-ischemic insult, recently studies have noted that variable causes such as metabolic and reperfusion events can result in, or aggravate, a brain insult. Current data suggest that about 2 to 5 of 1,000 live births in the United States and more so in developing countries experience a brain injury Approximately 20% to 40% of infants who survive the brain injury develop significant neurological and developmental impairments. The resulting impact on the child, family, and society presents a formidable challenge to health care professionals. Although several important insights have been gained in the last several years about the epidemiology, diagnosis, and mechanism of brain injury, management remains mostly a cocktail of controversial trials. This article provides a comprehensive review of the pathology, clinical manifestations, and timely management of infants with brain injury.

Volume resuscitation: crystalloid versus colloid

Adequate circulating volume to maintain mean arterial blood pressure above a critical value is necessary to reverse bradycardia by positive-pressure ventilation during resuscitation after asphyxia. A variety of circumstances can lead to visible or occult blood loss in the perinatal period; however, distinguishing hypovolemic shock from asphyxial shock can be difficult in the delivery room. Small, randomized, controlled trials support the usefulness of isotonic crystalloid rather than albumin-containing solutions for acute volume expansion; ready availability, lower cost, and lesser risk of infectious complications favor the use of isotonic crystalloid as well. No trials have compared crystalloid and colloid for volume expansion in the setting of immediate resuscitation after birth. Further work is needed to refine the approach to infants in whom adequate positive-pressure ventilation fails and to better discriminate between shock on the basis of hypovolemia versus decreased myocardial function.

Influence of Volume Replacement with Colloids versus Crystalloids in Neonates on Venoarterial Extracorporeal Membrane Oxygenation on Fluid Retention, Fluid Balance, and ECMO Runtime

In this retrospective study, we compared the effects of colloid versus crystalloid fluid replacement on the clinical signs of capillary leakage syndrome in 30 neonates with pulmonary hypertension due to meconium aspiration syndrome on venoarterial membrane oxygenation (VA-ECMO). Before 2000, 15 neonates received volume replacement with a pasteurized plasma protein solution (3.8% albumin); after 2000, 15 neonates received normal saline. Patient characteristics and pre-ECMO values did not differ between the two groups. Total fluid balance was also equal. Diuretic use was significantly higher in the colloid group (p < 0.001). The chest wall soft-tissue index was significantly higher in the crystalloid group (p < 0.005), as were the ventilator settings at the end of the ECMO runtime (p < 0.05). Serum colloid osmotic pressure, albumin, urea nitrogen, and creatinine were significantly higher in the colloid group (p < 0.0001, < 0.0001, < 0.001, and < 0.05, respectively). Duration of VA-ECMO, of artificial ventilation after ECMO treatment, and the mortality rate did not differ between the two groups. We conclude that volume replacement with crystalloids in neonates on VA-ECMO aggravated the edema in a preexisting situation of capillary leakage syndrome, whereas volume replacement with colloids could impair the kidney function.