1
|
Khowaja R, Karimi F. Comparison of clinical outcomes between culture-positive and culture-negative sepsis or septic shock pediatrics patients: A systematic review and meta-analysis. Qatar Med J 2024; 2024:32. [PMID: 39131794 PMCID: PMC11311758 DOI: 10.5339/qmj.2024.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/09/2024] [Indexed: 08/13/2024] Open
Abstract
Introduction Comparatively, culture-negative septic shock or septic shock (CNSS) is frequently observed among pediatric patients, contrasting with the more distinct clinical profile and prognosis of post-surgical septic shock (CPSS). However, limited data are available on the outcomes of CNSS in comparison to CPSS in pediatric patients. This study seeks to conduct a systematic review and meta-analysis of existing literature to comprehensively compare outcomes between CNSS and CPSS in pediatric patients. Methods Electronic databases, such as PubMed, CINAHIL, and EMBASE, were systematically searched up to January 15, 2024, using predefined terms. We included all studies that compared outcomes between CPSS and CNSS in pediatric patients. The primary outcome evaluated in this study was all-cause mortality. Secondary outcomes included length of hospitalization, length of intensive care unit (ICU) stay, and duration of mechanical ventilation (all measured in days). Results Among the initially identified 1328 articles, six studies involving 2511 pediatric patients met the inclusion criteria and were part of this meta-analysis study. The pooled analysis revealed no significant differences in all-cause mortality (odds ratio: 1.26, 95% confidence interval (CI): 0.93 to 1.70, p = 0.14), length of ICU stay (mean difference (MD): 0.18, 95% CI: -0.33 to 0.68, p = 0.50), and duration of mechanical ventilation (MD: -0.74, 95% CI: -2.46 to 0.98, p-value = 0.40) between CPSS and CNSS. However, the length of hospital stay was longer in CPSS compared to CNSS (MD: 7.38, 95% CI: 5.50 to 9.27, p < 0.0001). Conclusion Approximately 26.56% of pediatric septic cases were culture-positive. There were no statistically significant differences in mortality, ICU stay, and duration of mechanical ventilation between CPSS and CNSS. However, hospital stay was prolonged by more than 7 days in culture-positive cases. Further multicenter studies are warranted to validate these findings and explore additional presentation characteristics.
Collapse
Affiliation(s)
- Rahil Khowaja
- School of Medicine, Swansea University, Swansea, United Kingdom *
| | - Fazila Karimi
- School of Public Health, SZABIST University, Karachi, Pakistan
| |
Collapse
|
2
|
Suárez MDP, Fernández-Sarmiento J, González LE, Rico MP, Barajas JS, Amaya RG. Evaluation of the Renal Angina Index to Predict the Development of Acute Kidney Injury in Children With Sepsis Who Live in Middle-Income Countries. Pediatr Emerg Care 2024; 40:208-213. [PMID: 37079697 DOI: 10.1097/pec.0000000000002951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
OBJECTIVE The renal angina index (RAI) provides a clinically feasible and applicable tool to identify critically ill children at risk of severe acute kidney injury (AKI) in high-income countries. Our objective was to evaluate the performance of the RAI as a predictor of the development of AKI in children with sepsis in a middle-income country and its association with unfavorable outcomes. METHODS This is a retrospective cohort study in children with sepsis hospitalized in the pediatric intensive care unit (PICU) between January 2016 and January 2020. The RAI was calculated 12 hours after admission to predict the development of AKI and at 72 hours to explore its association with mortality, the need for renal support therapy, and PICU stay. RESULTS We included 209 PICU patients with sepsis with a median age of 23 months (interquartile range, 7-60). We found that 41.1% of the cases (86/209) developed de novo AKI on the third day of admission (KDIGO 1, 24.9%; KDIGO 2, 12.9%; and KDIGO 3, 3.3%).Overall mortality was 8.1% (17/209), higher in patients with AKI (7.7% vs 0.5%, P < 0.01). The RAI on admission was able to predict the presence of AKI on day 3 (area under the curve (AUC), 0.87; sensitivity, 94.2%; specificity, 100%; P < 0.01), with a negative predictive value greater than 95%. An RAI greater than 8 at 72 hours was associated with a greater risk of mortality (adjusted odds ratio [aOR], 2.6; 95% confidence interval [CI], 2.0-3.2; P < 0.01), a need for renal support therapy (aOR, 2.9; 95% CI, 2.3-3.6; P < 0.01), and a PICU stay of more than 10 days (aOR, 1.54; 95% CI, 1.1-2.1; P < 0.01). CONCLUSIONS The RAI on the day of admission is a reliable and accurate tool for predicting the risk of developing AKI on day 3, in critically ill children with sepsis in a limited resource context. A score greater than eight 72 hours after admission is associated with a higher risk of death, the need for renal support therapy, and PICU stay.
Collapse
Affiliation(s)
| | - Jaime Fernández-Sarmiento
- Pediatrics and Intensive Care Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | | | - Mayerly Prada Rico
- From the Departments of Pediatrics and Pediatric Nephrology, Universidad del Bosque
| | - Juan Sebastián Barajas
- Pediatrics and Intensive Care Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | | |
Collapse
|
3
|
Liu Y, Zhao K, Liu Y, Sun YH, Li MX, Yu M, Zhu LQ, Wang XD. Bone and joint infection complicated with sepsis in neonates and infants under three months of age. J Pediatr (Rio J) 2024; 100:156-162. [PMID: 37837994 PMCID: PMC10943287 DOI: 10.1016/j.jped.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 10/16/2023] Open
Abstract
OBJECTIVE Studies focusing on bone and joint infections (BJIs) in young infants are rare. Some cases of BJI are accompanied by sepsis. This study aimed to identify the clinical and bacteriological features of sepsis in neonates and young infants with BJIs. METHODS Neonates and infants younger than 3 months diagnosed with BJI in the present institution from 2014 to 2021 were retrospectively reviewed. Patient characteristics, clinical data, and outcomes were documented and compared between those with and without sepsis. RESULTS Twenty-five patients with a mean age of 34.8 days were included. Nine BJI cases had concomitant sepsis (group A), and 16 had BJI without sepsis (group B). Within group A, staphylococcus aureus was the major pathogenic germ (5 cases, of which 4 were of the methicillin-resistant staphylococcus aureus (MRSA) type). There was no statistical difference in male-to-female ratio, age, history of hospitalization, anemia, birth asphyxia, peripheral leukocyte counts, C-reactive protein on admission, and sequelae between groups. Univariate analyses indicated a significant difference in the incidence of septic arthritis (SA) combined with osteomyelitis (OM) (88.9% vs 37.5%), congenital deformities (44.4% vs 0%), and mean duration of symptoms (2.83 days vs 9.21 days) in comparisons between groups A and B. CONCLUSION Staphylococcus aureus is the main pathogenic bacteria in BJI cases complicated with sepsis in neonates and young infants. Among infants younger than 3 months diagnosed with BJI, those with concurrent SA and OM, MRSA infection, or congenital deformities are more likely to develop sepsis.
Collapse
Affiliation(s)
- Yao Liu
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Kai Zhao
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Ya Liu
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Yu-Han Sun
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Meng-Xia Li
- Children's Hospital of Soochow University, Pediatrics Research Institute, Suzhou, Jiangsu Province, China
| | - Min Yu
- Children's Hospital of Soochow University, Department of Neonatology, Suzhou, Jiangsu Province, China
| | - Lun-Qing Zhu
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Xiao-Dong Wang
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China.
| |
Collapse
|
4
|
Fernández-Sarmiento J, Lamprea S, Barrera S, Acevedo L, Duque C, Trujillo M, Aguirre V, Jimenez C. The association between prolonged capillary refill time and microcirculation changes in children with sepsis. BMC Pediatr 2024; 24:68. [PMID: 38245695 PMCID: PMC10799439 DOI: 10.1186/s12887-024-04524-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/01/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUNDS In children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis. METHODS This was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]-a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes. RESULTS A total of 132 children with sepsis were included, with a median age of two years (IQR 0.6-12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09-6.34; p = 0.02) and fewer 4-6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06-6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO2 difference (DCO2) had an abnormal PBR (aOR 1.13, 95% CI 1.01-1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64-0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58-1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94-0.99; p < 0.05). CONCLUSIONS We found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.
Collapse
Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia.
| | - Shirley Lamprea
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Sofia Barrera
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Catalina Duque
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Manuela Trujillo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Valeria Aguirre
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Carolina Jimenez
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| |
Collapse
|
5
|
Fernández-Sarmiento J, Sierra-Zuñiga MF, Salazar González MP, Lucena N, Soares Lanziotti V, Agudelo S. Association between fluid overload and mortality in children with sepsis: a systematic review and meta-analysis. BMJ Paediatr Open 2023; 7:e002094. [PMID: 37989355 PMCID: PMC10668252 DOI: 10.1136/bmjpo-2023-002094] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/29/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Sepsis is one of the main causes of morbidity and mortality worldwide. Fluid resuscitation is among the most common interventions and is associated with fluid overload (FO) in some patients. The objective of this systematic review and meta-analysis was to summarise the available evidence on the association between FO and morbimortality in children with sepsis. METHODS A systematic search was carried out in PubMed/Medline, Embase, Cochrane and Google Scholar up to December 2022 (PROSPERO 408148), including studies in children with sepsis which reported more than 10% FO 24 hours after admission to intensive care. The risk of bias was assessed using the Newcastle-Ottawa scale. Heterogeneity was assessed using I2, considering it absent if <25% and high if >75%. A sensitivity analysis was run to explore the impact of the methodological quality on the size of the effect. Mantel-Haenszel's model of random effects was used for the analysis. The primary outcome was to determine the risk of mortality associated with FO and the secondary outcomes were the need for mechanical ventilation (MV), multiple organ dysfunction syndrome (MODS) and length of hospital stay associated with FO. RESULTS A total of 9 studies (2312 patients) were included, all of which were observational. Children with FO had a higher mortality than patients without overload (46% vs 26%; OR 5.06; 95% CI 1.77 to 14.48; p<0.01). We found no association between %FO and the risk of MODS (OR: 0.97; 95% CI 0.13 to 7.12; p=0.98). Children with FO required MV more often (83% vs 47%; OR: 4.78; 95% CI 2.51 to 9.11; p<0.01) and had a longer hospital stay (8 days (RIQ 6.5-13.2) vs 7 days (RIQ 6.1-11.5); p<0.01). CONCLUSION In children with sepsis, more than 10% FO 24 hours after intensive care admission is associated with higher mortality, the need for MV and length of hospital stay.
Collapse
Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Bogotá, Colombia
| | - Marco Fidel Sierra-Zuñiga
- Department of Critical Care Medicine and Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Bogotá, Colombia
| | - María Paula Salazar González
- Department of Critical Care Medicine and Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Bogotá, Colombia
| | - Natalia Lucena
- Department of Critical Care Medicine and Pediatrics, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Bogotá, Colombia
| | - Vanessa Soares Lanziotti
- Pediatric Intensive Care Unit & Research and Education Division, Pediatric Institute of Federal University of Rio de Janeiro (IPPMG-UFRJ), Rio de Janeiro, Brazil
| | - Sergio Agudelo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Bogotá, Colombia
| |
Collapse
|
6
|
Fernández-Sarmiento J, Hernández-Sarmiento R, Salazar MP, Barrera S, Castilla V, Duque C. The association between hypoalbuminemia and microcirculation, endothelium, and glycocalyx disorders in children with sepsis. Microcirculation 2023; 30:e12829. [PMID: 37639384 DOI: 10.1111/micc.12829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/05/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the association between serum albumin levels and microcirculation changes, glycocalyx degradation, and the clinical outcomes of interest. METHODS Observational, prospective study in children with sepsis. The primary outcome was the association between hypoalbuminemia and microcirculation disorders, endothelial activation and glycocalyx degradation using a perfused boundary region (PBR) (abnormal >2.0 μm on sublingual video microscopy) or plasma biomarkers (syndecan-1, angiopoietin-2). RESULTS A total of 125 patients with sepsis were included. The median age was 2.0 years (IQR 0.5-12.5). Children with hypoalbuminemia had more abnormal microcirculation with a higher PBR (2.16 μm [IQR 2.03-2.47] vs. 1.92 [1.76-2.28]; p = .01) and more 4-6 μm capillaries recruited (60% vs. 40%; p = .04). The low albumin group that had the worst PBR had the most 4-6 μm capillaries recruited (rho 0.29; p < .01), 48% higher Ang-2 (p = .04), worse annexin A5 (p = 0.03) and no syndecan-1 abnormalities (p = .21). Children with hypoalbuminemia and a greater percentage of blood volume in their capillaries needed mechanical ventilation more often (56.3% vs. 43.7%; aOR 2.01 95% CI 1.38-3.10: p < .01). CONCLUSIONS In children with sepsis, an association was found between hypoalbuminemia and microcirculation changes, vascular permeability, and greater endothelial glycocalyx degradation.
Collapse
Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Ricardo Hernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - María Paula Salazar
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sofia Barrera
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Valeria Castilla
- Department of Pediatrics Fundación Cardioinfantil-Instituo de Cardiología, Universidad del Rosario, Bogotá, Colombia
| | - Catalina Duque
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| |
Collapse
|
7
|
Ranjit S, Kissoon N, Argent A, Inwald D, Ventura AMC, Jaborinsky R, Sankar J, de Souza DC, Natraj R, De Oliveira CF, Samransamruajkit R, Jayashree M, Schlapbach LJ. Haemodynamic support for paediatric septic shock: a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:588-598. [PMID: 37354910 DOI: 10.1016/s2352-4642(23)00103-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/26/2023]
Abstract
Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.
Collapse
Affiliation(s)
- Suchitra Ranjit
- Paediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, India.
| | | | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - David Inwald
- Addenbrooke's Hospital, University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andréa Maria Cordeiro Ventura
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil
| | - Roberto Jaborinsky
- Northeastern National University, Corrientes, Argentina; Latin American Society of Pediatric Intensive Care (LARed Network), Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, AIIMS, New Delhi, India
| | - Daniela Carla de Souza
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil; Latin American Sepsis Institute, São Paulo, Brazil
| | - Rajeswari Natraj
- Department of Paediatric Intensive Care, Apollo Children's Hospitals, Chennai, India
| | | | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Muralidharan Jayashree
- Pediatric Emergency and Intensive Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
8
|
Fernández-Sarmiento J, Casas-Certain C, Ferro-Jackaman S, Solano-Vargas FH, Domínguez-Rojas JÁ, Pilar-Orive FJ. A brief history of crystalloids: the origin of the controversy. Front Pediatr 2023; 11:1202805. [PMID: 37465421 PMCID: PMC10351043 DOI: 10.3389/fped.2023.1202805] [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: 04/09/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023] Open
Abstract
Fluid resuscitation with crystalloids has been used in humans for more than 100 years. In patients with trauma, sepsis or shock of any etiology, they can help modify the clinical course of the illness. However, these solutions are medications which are not side-effect free. Recently, they have been questioned in terms of quantity (fluid overload) and their composition. The most frequently used crystalloids, both in high and low-income countries, are 0.9% normal saline (NS) and Ringer's lactate. The first descriptions of the use of sodium and water solutions in humans date from the cholera epidemic which spread throughout Europe in 1831. The composition of the fluids used by medical pioneers at that time differs greatly from the 0.9% NS used routinely today. The term "physiological solution" referred to fluids which did not cause red blood cell hemolysis in amphibians in in vitro studies years later. 0.9% NS has an acid pH, a more than 40% higher chloride concentration than plasma and a strong ion difference of zero, leading many researchers to consider it an unbalanced solution. In many observational studies and clinical trials, this 0.9% NS composition has been associated with multiple microcirculation and immune response complications, acute kidney injury, and worse clinical outcomes. Ringer's lactate has less sodium than plasma, as well as other electrolytes which can cause problems in patients with traumatic brain injury. This review provides a brief summary of the most important historical aspects of the origin of the most frequently used intravenous crystalloids today.
Collapse
Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Carolina Casas-Certain
- Department of Pediatrics, Universidad del Rosario, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sarah Ferro-Jackaman
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Fabian H. Solano-Vargas
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | | | - Francisco Javier Pilar-Orive
- Department of Pediatrics and Critical Care, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| |
Collapse
|
9
|
Agulnik A. Management of septic shock in children with cancer-Common challenges and research priorities. J Pediatr (Rio J) 2023; 99:101-104. [PMID: 36706794 PMCID: PMC10031354 DOI: 10.1016/j.jped.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN.
| |
Collapse
|
10
|
Agudelo-Pérez S, Fernández-Sarmiento J, Rivera León D, Peláez RG. Metagenomics by next-generation sequencing (mNGS) in the etiological characterization of neonatal and pediatric sepsis: A systematic review. Front Pediatr 2023; 11:1011723. [PMID: 37063664 PMCID: PMC10098018 DOI: 10.3389/fped.2023.1011723] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/23/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction Pediatric and neonatal sepsis is one of the main causes of mortality and morbidity in these age groups. Accurate and early etiological identification is essential for guiding antibiotic treatment, improving survival, and reducing complications and sequelae. Currently, the identification is based on culture-dependent methods, which has many limitations for its use in clinical practice, and obtaining its results is delayed. Next-generation sequencing enables rapid, accurate, and unbiased identification of multiple microorganisms in biological samples at the same time. The objective of this study was to characterize the etiology of neonatal and pediatric sepsis by metagenomic techniques. Methods A systematic review of the literature was carried out using the PRISMA-2020 guide. Observational, descriptive, and case report studies on pediatric patients were included, with a diagnostic evaluation by clinical criteria of sepsis based on the systemic inflammatory response, in sterile and non-sterile biofluid samples. The risk of bias assessment of the observational studies was carried out with the STROBE-metagenomics instrument and the CARE checklist for case reports. Results and Discussion Five studies with a total of 462 patients were included. Due to the data obtained from the studies, it was not possible to perform a quantitative synthesis (meta-analysis). Based on the data from the included studies, the result identified that mNGS improves the etiological identification in neonatal and pediatric sepsis, especially in the context of negative cultures and in the identification of unusual microorganisms (bacteria that are difficult to grow in culture, viruses, fungi, and parasites). The number of investigations is currently limited, and the studies are at high risk of bias. Further research using this technology would have the potential to improve the rational use of antibiotics.
Collapse
Affiliation(s)
- Sergio Agudelo-Pérez
- Department of Pediatrics, Faculty of Medicine, Universidad de La Sabana, Chia, Colombia
- Correspondence: Sergio Agudelo-Pérez
| | - Jaime Fernández-Sarmiento
- Department of Pediatrics, Faculty of Medicine, Universidad de La Sabana, Chia, Colombia
- Departament of Pediatrics and Critical Care, Fundación Cardioinfantil, Bogotá, Colombia
| | - Diana Rivera León
- Department of Pediatrics, Faculty of Medicine, Universidad de La Sabana, Chia, Colombia
| | - Ronald Guillermo Peláez
- Life Sciences and Health Research Group, Graduates School, CES University, Medellin, Colombia
| |
Collapse
|
11
|
Iramain R, Ortiz J, Jara A, Bogado N, Morinigo R, Cardozo L, Kissoon N. Fluid Resuscitation and Inotropic Support in Patients With Septic Shock Treated in Pediatric Emergency Department: An Open-Label Trial. Cureus 2022; 14:e30029. [PMID: 36225249 PMCID: PMC9541896 DOI: 10.7759/cureus.30029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Fluid resuscitation and inotropic support are essential interventions to improve cardiovascular function in patients with septic shock. However, the optimal volume of fluids and the timing of inotropic support to achieve the resolution of shock are controversial. They may depend on the availability of critical care support services. Aims To compare early versus the delayed start of epinephrine administration after fluids bolus in children with septic shock. Methods We conducted an open-label randomized trial in which patients under 18 years of age diagnosed with septic shock and arterial hypotension were treated in two Pediatric Emergency Departments in Paraguay (Hospital de Clinicas of Universidad Nacional de Asunción and Instituto Privado del Niño) between 2015 and 2020. Septic shock was defined according to the American College of Critical Care Medicine (ACCM) guidelines. All patients received antibiotics and 40 ml/kg of fluids (two boluses of 20ml/kg if there were no signs of fluid overload) during the first hour. They were then divided into two groups: Group 1 received epinephrine infusion and maintenance fluids. Group 2 received an additional 20 ml/kg of fluids and then was started on epinephrine infusion. Results Of 229 patients screened, 63 patients were included in the study. The mean age was 2.8±3.5 years. A total of 52% were female. Group 1 comprised 33 patients, and group 2 comprised a total of 30. Significant differences were found between group 1 and group 2 in the following: mortality (10% vs. 33%, p: 0.026, RR: 3.1, CI: 95%: 1-10), need for mechanical ventilation (10% vs. 41%, p: 0.006, RR: 4, CI: 95%: 1.3-12), and altered vascular hypoperfusion after one hour of interventions (7% vs. 59%, p<0,001, RR: 8.2, CI: 95%: 2-32). Conclusions Early administration of epinephrine infusion after initial fluid therapy was associated with better clinical outcomes than delayed administration.
Collapse
Affiliation(s)
| | - Jorge Ortiz
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Alfredo Jara
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Norma Bogado
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Rocío Morinigo
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Laura Cardozo
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Niranjan Kissoon
- Pediatrics and Emergency Medicine Department, University of British Columbia, Vancouver, CAN
| |
Collapse
|
12
|
Huang H, Chen J, Dang H, Liu C, Fu YQ. Comparing outcomes between culture-positive and culture-negative septic shock in a PICU: A retrospective cohort study. Front Pediatr 2022; 10:1001565. [PMID: 36313890 PMCID: PMC9608626 DOI: 10.3389/fped.2022.1001565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We assessed the outcomes and characteristics of culture-negative septic shock (CNSS) and culture-positive septic shock (CPSS) in pediatric intensive care unit (PICU). METHODS We performed a retrospective study on the data of children admitted to the PICU due to septic shock between January 2018 and December 2021. The primary outcome was in-hospital mortality. The secondary outcomes were the length of stay (LOS) of hospital, the need for mechanical ventilation (MV) and continue renal replacement therapy (CRRT). RESULTS Overall, 238 patients were enrolled. 114 patients (47.9%) had positive cultures (60 blood samples, 41 sputum samples, 17 pus samples, and 19 others), 18 of whom were cultured positive at two sites, 1 at three sites, and 3 had two different types of bacteria at same site. The in-hospital mortality was 47.1%. There were no significant differences in the in-hospital mortality (47.6% vs. 46.5%, P = 0.866), PRISM-III score (10 vs. 12, P = 0.409), PIM-3 score (0.08 vs. 0.07, P = 0.845), pSOFA score (10 vs. 10, P = 0.677) or the need for MV (64.5% vs. 68.4%, P = 0.524) and CRRT (29.8% vs. 34.2%, P = 0.470) between the CNSS group and the CPSS group. The Procalcitonin (8.89 ng/ml vs. 28.39 ng/ml, P = 0.001) and C-reactive protein (28 mg/L vs. 58 mg/L, P = 0.001) levels were significantly lower in the CNSS group than in the CPSS group, while WBC count (9.03 × 109/L vs. 5.02 × 109/L, P = 0.002) and serum sodium (137 mmol/L vs. 132 mmol/L, P = 0.001) was significantly higher in CNSS. The LOS of hospital was significantly longer (16 days vs. 11 days, P = 0.011) in the CPSS group than in the CNSS group, while the LOS of PICU (5 days vs. 4 days, P = 0.094) stay was not significantly different. CONCLUSION Compared with children with CNSS, children with CPSS had higher PCT and CRP levels, but lower WBC count. Children with CPSS had longer LOS of hospital. However, positive or negative culture results were not associated with in-hospital mortality, the LOS of PICU, the need for MV or CRRT in children with septic shock.
Collapse
Affiliation(s)
- Haixin Huang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jian Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hongxing Dang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yue-Qiang Fu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| |
Collapse
|
13
|
Lamprea S, Fernández-Sarmiento J, Barrera S, Mora A, Fernández-Sarta JP, Acevedo L. Capillary refill time in sepsis: A useful and easily accessible tool for evaluating perfusion in children. Front Pediatr 2022; 10:1035567. [PMID: 36467476 PMCID: PMC9714817 DOI: 10.3389/fped.2022.1035567] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022] Open
Abstract
The international sepsis guidelines emphasize the importance of early identification along with the combined administration of fluids, antibiotics and vasopressors as essential steps in the treatment of septic shock in childhood. However, despite these recommendations, septic shock mortality continues to be very high, especially in countries with limited resources. Cardiovascular involvement is common and, in most cases, determines the outcomes. Early recognition of hemodynamic dysfunction, both in the macro and microcirculation, can help improve outcomes. Capillary refill time (CRT) is a useful, available and easily accessible tool at all levels of care. It is a clinical sign of capillary vasoconstriction due to an excessive sympathetic response which seeks to improve blood redistribution from the micro- to the macrocirculation. An important reason for functionally evaluating the microcirculation is that, in septic shock, the correction of macrocirculation variables is assumed to result in improved tissue perfusion. This has been termed "hemodynamic coherence." However, this coherence often does not occur in advanced stages of the disease. Capillary refill time is useful in guiding fluid resuscitation and identifying more seriously affected sepsis patients. Several factors can affect its measurement, which should preferably be standardized and performed on the upper extremities. In this review, we seek to clarify a few common questions regarding CRT and guide its correct use in patients with sepsis.
Collapse
Affiliation(s)
- Shirley Lamprea
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sofía Barrera
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Alicia Mora
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Juan Pablo Fernández-Sarta
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| |
Collapse
|