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Boland W, Datta D, Namazzi R, Bond C, Conroy AL, Mellencamp KA, Opoka RO, John CC, Rivera ML. Peripheral Perfusion Index in Ugandan Children With Plasmodium falciparum Severe Malaria: Secondary Analysis of Outcomes in a 2014-2017 Cohort Study. Pediatr Crit Care Med 2024:00130478-990000000-00385. [PMID: 39324855 DOI: 10.1097/pcc.0000000000003624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
OBJECTIVES Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality. DESIGN Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017. SETTING Two referral hospitals in Central and Eastern Uganda. PATIENTS Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%. CONCLUSIONS In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.
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Affiliation(s)
- Wesley Boland
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Kagan A Mellencamp
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Michael Lintner Rivera
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Callum J, Skubas NJ, Bathla A, Keshavarz H, Clark EG, Rochwerg B, Fergusson D, Arbous S, Bauer SR, China L, Fung M, Jug R, Neill M, Paine C, Pavenski K, Shah PS, Robinson S, Shan H, Szczepiorkowski ZM, Thevenot T, Wu B, Stanworth S, Shehata N. Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. Chest 2024; 166:321-338. [PMID: 38447639 PMCID: PMC11317816 DOI: 10.1016/j.chest.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis. STUDY DESIGN AND METHODS Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation. RESULTS The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused. INTERPRETATION Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.
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Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada.
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | | | | | - Edward G Clark
- Division of Nephrology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sesmu Arbous
- Department of Critical Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Louise China
- Department of Hepatology and Institute for Liver and Digestive Health, The Royal Free NHS Trust and University College London, London, England
| | - Mark Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT
| | - Rachel Jug
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cary Paine
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Prakesh S Shah
- Institute of Health Policy, Management, and Evaluation, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Susan Robinson
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Hua Shan
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA
| | | | - Thierry Thevenot
- Service d'Hépatologie, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France
| | - Bovey Wu
- Department of Internal Medicine, Graduate Medical Education, Loma Linda University, Loma Linda, CA
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford, England; Radcliffe Department of Medicine, University of Oxford, Oxford, England; John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Nadine Shehata
- Department of Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada; Transfusion Medicine Laboratory, Mount Sinai Hospital, Toronto, ON, Canada
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La Via L, Sangiorgio G, Stefani S, Marino A, Nunnari G, Cocuzza S, La Mantia I, Cacopardo B, Stracquadanio S, Spampinato S, Lavalle S, Maniaci A. The Global Burden of Sepsis and Septic Shock. EPIDEMIOLOGIA 2024; 5:456-478. [PMID: 39189251 PMCID: PMC11348270 DOI: 10.3390/epidemiologia5030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/07/2024] [Accepted: 07/18/2024] [Indexed: 08/28/2024] Open
Abstract
A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.
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Affiliation(s)
- Luigi La Via
- Department of Anaesthesia and Intensive Care, University Hospital Policlinico “G. Rodolico-San Marco”, 24046 Catania, Italy
| | - Giuseppe Sangiorgio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy; (G.S.); (S.S.); (S.S.)
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy; (G.S.); (S.S.); (S.S.)
| | - Andrea Marino
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Giuseppe Nunnari
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Salvatore Cocuzza
- Department of Medical, Surgical Sciences and Advanced Technologies “GF Ingrassia” ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (I.L.M.)
| | - Ignazio La Mantia
- Department of Medical, Surgical Sciences and Advanced Technologies “GF Ingrassia” ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (I.L.M.)
| | - Bruno Cacopardo
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Stefano Stracquadanio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy; (G.S.); (S.S.); (S.S.)
| | - Serena Spampinato
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Salvatore Lavalle
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (S.L.); (A.M.)
| | - Antonino Maniaci
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (S.L.); (A.M.)
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Fitzgerald E, Ciccone EJ, Mvalo T, Chiume M, Mgusha Y, Mkaliainga TB, Tilly AE, Chen J, Bell G, Crouse H, Robison JA, Eckerle M. Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement. BMJ Paediatr Open 2024; 8:e002404. [PMID: 38719563 PMCID: PMC11086186 DOI: 10.1136/bmjpo-2023-002404] [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: 01/16/2024] [Accepted: 03/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the reduction in global under-5 mortality over the last decade, childhood deaths remain high. To combat this, there has been a shift in focus from disease-specific interventions to use of healthcare data for resource allocation, evaluation of performance and impact, and accountability. This is a descriptive analysis of data derived from a prospective cohort study describing paediatric admissions to a tertiary referral hospital in Malawi for the purpose of process evaluation and quality improvement. METHODS Using a REDCap database, we collected data for patients admitted acutely to Kamuzu Central Hospital, a tertiary referral centre in the central region. Data were collected from 17 123 paediatric inpatients from 2017 to 2020. RESULTS Approximately 6% of patients presented with either two or more danger signs or severely abnormal vital signs. Infants less than 6 months, who had the highest mortality rate, were also the most critically ill on arrival to the hospital. Sepsis was diagnosed in about 20% of children across all age groups. Protocols for the management of high-volume, lower-acuity conditions such as uncomplicated malaria and pneumonia were generally well adhered to, but there was a low rate of completion for labs, radiology studies and subspecialty consultations required to provide care for high acuity or complex conditions. The overall mortality rate was 4%, and 60% of deaths occurred within the first 48 hours of admission. CONCLUSION Our data highlight the need to improve the quality of care provided at this tertiary-level centre by focusing on the initial stabilisation of high-acuity patients and augmenting resources to provide comprehensive care. This may include capacity building through the training of specialists, implementation of clinical processes, provision of specialised equipment and increasing access to and reliability of ancillary services. Data collection, analysis and routine use in policy and decision-making must be a pillar on which improvement is built.
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Affiliation(s)
- Elizabeth Fitzgerald
- Department of Pediatrics, Division of Emergency Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Emily Jane Ciccone
- Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Tisungane Mvalo
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Yamikani Mgusha
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Alyssa Evelyn Tilly
- Divisions of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Jane Chen
- Institute for Global Health and Infectious Disease, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Griffin Bell
- Epidemiology, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Heather Crouse
- Department of Pediatrics, Division of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jeff A Robison
- Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michelle Eckerle
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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5
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Patel S, Puri N, Hussain S, Rachoin JS, Green A. A Review of Fluid Bolus in Critically Ill Patients After Initial Volume Expansion: Bayesian Probability Analysis and Case Studies. Cureus 2024; 16:e59517. [PMID: 38826945 PMCID: PMC11144048 DOI: 10.7759/cureus.59517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Fluid resuscitation is a crucial intervention for the management of critically ill patients. However, after initial volume expansion, the advantages of fluid bolus administration remain controversial. Our aim was to investigate the probabilistic reasoning against fluid bolus administration in critically ill patients after initial volume expansion. We then applied this reasoning to two hypothetical case studies that evaluated the benefits and risks associated with a fluid bolus for each patient. Methods We analyzed data from 12 previously published studies, totaling 334 patients, on fluid responsiveness in critically ill patients. Owing to differences in these studies, we used a Monte Carlo simulation based on their parameters to improve our Bayesian prior, generate strong estimates, and address uncertainty. Using the established Bayesian prior for volume responsiveness, we scrutinized two hypothetical case studies employing Bayesian mathematical notation to assess the pre-test probability, posterior probability, and likelihood ratios in patients with septic shock. Results The Monte Carlo simulation yielded a mean response rate of 0.54 (SD = 0.026), suggesting that only approximately 54% of patients were responsive to fluid bolus administration. These results had an effective sample size of 17,204 and an R-hat value of 1, demonstrating the reliability of our results. In our Bayesian case studies, we demonstrate the low probabilities of volume and VO2 responsiveness over time using common bedside testing. Conclusion Our analysis shows that the pretest and posttest probabilities for volume responsiveness following initial fluid resuscitation are low. Additional bedside testing should be pursued before administering additional volume. This approach emphasizes the importance of evidence-based decision-making in the management of critically ill patients to optimize patient outcomes and minimize potential risks.
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Affiliation(s)
- Sharad Patel
- Critical Care, Cooper University Hospital, Camden, USA
| | - Nitin Puri
- Critical Care, Cooper University Hospital, Camden, USA
| | | | | | - Adam Green
- Critical Care, Cooper University Hospital, Camden, USA
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Dunican C, Andradi-Brown C, Ebmeier S, Georgiadou A, Cunnington AJ. The malarial blood transcriptome: translational applications. Biochem Soc Trans 2024; 52:651-660. [PMID: 38421063 PMCID: PMC11088907 DOI: 10.1042/bst20230497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
The blood transcriptome of malaria patients has been used extensively to elucidate the pathophysiological mechanisms and host immune responses to disease, identify candidate diagnostic and prognostic biomarkers, and reveal new therapeutic targets for drug discovery. This review gives a high-level overview of the three main translational applications of these studies (diagnostics, prognostics, and therapeutics) by summarising recent literature and outlining the main limitations and future directions of each application. It highlights the need for consistent and accurate definitions of disease states and subject groups and discusses how prognostic studies must distinguish clearly between analyses that attempt to predict future disease states and those which attempt to discriminate between current disease states (classification). Lastly it examines how many promising therapeutics fail due to the choice of imperfect animal models for pre-clinical testing and lack of appropriate validation studies in humans, and how future transcriptional studies may be utilised to overcome some of these limitations.
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Affiliation(s)
- Claire Dunican
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, U.K
- Centre for Paediatrics and Child Health, Imperial College London, London, U.K
| | - Clare Andradi-Brown
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, U.K
- Centre for Paediatrics and Child Health, Imperial College London, London, U.K
| | - Stefan Ebmeier
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, U.K
- Centre for Paediatrics and Child Health, Imperial College London, London, U.K
| | - Athina Georgiadou
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, U.K
- Centre for Paediatrics and Child Health, Imperial College London, London, U.K
| | - Aubrey J. Cunnington
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, U.K
- Centre for Paediatrics and Child Health, Imperial College London, London, U.K
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Gendreau S, Frapard T, Carteaux G, Kwizera A, Adhikari NKJ, Mer M, Hernandez G, Mekontso Dessap A. Geo-economic Influence on the Effect of Fluid Volume for Sepsis Resuscitation: A Meta-Analysis. Am J Respir Crit Care Med 2024; 209:517-528. [PMID: 38259196 DOI: 10.1164/rccm.202309-1617oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/22/2024] [Indexed: 01/24/2024] Open
Abstract
Rationale: Sepsis management relies on fluid resuscitation avoiding fluid overload and its related organ congestion. Objectives: To explore the influence of country income group on risk-benefit balance of fluid management strategies in sepsis. Methods: We searched e-databases for all randomized controlled trials on fluid resuscitation in patients with sepsis or septic shock up to January 2023, excluding studies on hypertonic fluids, colloids, and depletion-based interventions. The effect of fluid strategies (higher versus lower volumes) on mortality was analyzed per income group (i.e., low- and middle-income countries [LMICs] or high-income countries [HICs]). Measurements and Main Results: Twenty-nine studies (11,798 patients) were included in the meta-analysis. There was a numerically higher mortality in studies of LMICs as compared with those of HICs: median, 37% (interquartile range [IQR]: 26-41) versus 29% (IQR: 17-38; P = 0.06). Income group significantly interacted with the effect of fluid volume on mortality: Higher fluid volume was associated with higher mortality in LMICs but not in HICs: odds ratio (OR), 1.47; 95% confidence interval (95% CI): 1.14-1.90 versus 1.00 (95% CI: 0.87-1.16), P = 0.01 for subgroup differences. Higher fluid volume was associated with increased need for mechanical ventilation in LMICs (OR, 1.24 [95% CI: 1.08-1.43]) but not in HICs (OR, 1.02 [95% CI: 0.80-1.29]). Self-reported access to mechanical ventilation also significantly influenced the effect of fluid volume on mortality, which increased with higher volumes only in settings with limited access to mechanical ventilation (OR: 1.45 [95% CI: 1.09-1.93] vs. 1.09 [95% CI: 0.93-1.28], P = 0.02 for subgroup differences). Conclusions: In sepsis trials, the effect of fluid resuscitation approach differed by setting, with higher volume of fluid resuscitation associated with increased mortality in LMICs and in settings with restricted access to mechanical ventilation. The precise reason for these differences is unclear and may be attributable in part to resource constraints, participant variation between trials, or other unmeasured factors.
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Affiliation(s)
- Ségolène Gendreau
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
| | - Thomas Frapard
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
| | - Guillaume Carteaux
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
- INSERM U955, Faculté de Santé de Créteil, Université Paris Est Créteil, Créteil, France
| | - Arthur Kwizera
- Department of Anaesthesia and Critical Care, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Neill K J Adhikari
- Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Glenn Hernandez
- Facultad de Medicina, Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Armand Mekontso Dessap
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Medecine Intensive Réanimation, Créteil, France
- Institut Mondor de Recherche Biomédicale, Groupe de recherche clinique CARMAS, Faculté de Santé de Créteil, Université Paris est Créteil, Créteil, France
- INSERM U955, Faculté de Santé de Créteil, Université Paris Est Créteil, Créteil, France
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Sukudom S, Smart L, Macdonald S. Association between intravenous fluid administration and endothelial glycocalyx shedding in humans: a systematic review. Intensive Care Med Exp 2024; 12:16. [PMID: 38403742 PMCID: PMC10894789 DOI: 10.1186/s40635-024-00602-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION Several studies have demonstrated associations between greater rate/volume of intravenous (IV) fluid administration and poorer clinical outcomes. One postulated mechanism for harm from exogenous fluids is shedding of the endothelial glycocalyx (EG). METHODS A systematic review using relevant search terms was performed using Medline, EMBASE and Cochrane databases from inception to October 2023. Included studies involved humans where the exposure was rate or volume of IV fluid administration and the outcome was EG shedding. The protocol was prospectively registered on PROSPERO: CRD42021275133. RESULTS The search yielded 450 articles, with 20 articles encompassing 1960 participants included in the review. Eight studies were randomized controlled clinical trials. Half of studies examined patients with sepsis and critical illness; the remainder examined perioperative patients or healthy subjects. Almost all reported blood measurements of soluble EG components; one study used in vivo video-microscopy to estimate EG thickness. Four of 10 sepsis studies, and 9 of 11 non-sepsis studies, found a positive relationship between IV fluid rate/volume and measures of EG shedding. CONCLUSIONS A trend toward an association between IV fluid rate/volume and EG shedding was found in studies of stable patients, but was not consistently observed among studies of septic and critically ill patients.
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Affiliation(s)
- Sara Sukudom
- Emergency Department, Royal Perth Hospital, PO Box 2213, Perth, WA, 6000, Australia
| | - Lisa Smart
- Emergency and Critical Care, Small Animal Specialist Hospital, Tuggerah, NSW, Australia
- College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
| | - Stephen Macdonald
- Emergency Department, Royal Perth Hospital, PO Box 2213, Perth, WA, 6000, Australia.
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.
- Medical School, University of Western Australia, Perth, WA, Australia.
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Venczel K, Lesh N, Jouriles N, Seaberg D, Gothard D, Harrell C, Reuter Q. Beyond SEP-1 Compliance: Assessing the Impact of Antibiotic Overtreatment and Fluid Overload in Suspected Septic Patients. J Emerg Med 2024; 66:74-82. [PMID: 38278684 DOI: 10.1016/j.jemermed.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) developed the Severe Sepsis and Septic Shock Performance Measure bundle (SEP-1) metric to improve sepsis care, but evidence supporting this bundle is limited and harms secondary to compliance have not been investigated. OBJECTIVE This study investigates the effect of an emergency department (ED) sepsis quality-improvement (QI) effort to improve CMS SEP-1 compliance, looking specifically at antibiotic overtreatment and harm from fluid resuscitation. METHODS This was a retrospective observational study conducted between March and July 2021 with patients for whom a sepsis order set was initiated. The primary outcomes included the number of patients treated with antibiotics who were ultimately deemed nonseptic and the number of patients who developed pulmonary edema, with or without need for positive pressure ventilation (PPV), within 48 h of receiving a 30 mL/kg fluid bolus. Data were collected via nonblinded chart reviews, with a free marginal κ-calculation indicating excellent interrater reliability. RESULTS The study cohort included 273 patients, 170 (62.3%) who were ultimately determined to be septic and 103 (37.7%) who were nonseptic. Of the 103 nonseptic patients, 82 (79.6%) received antibiotics in the ED. Of the 121 patients (44.3%) who received a 30 mL/kg bolus, 5 patients (4.1%) developed pulmonary edema and 0 of 121 patients required PPV within 48 h. CONCLUSIONS The QI effort led to moderate rates of antibiotic overtreatment and very few patients developed pulmonary edema due to a 30 mL/kg fluid bolus.
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Affiliation(s)
- Kevin Venczel
- Department of Emergency, Summa Health System, Akron, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | | | - Nicholas Jouriles
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | - David Seaberg
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | - David Gothard
- Department of Emergency, Summa Health System, Akron, Ohio
| | - Caleb Harrell
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | - Quentin Reuter
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
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10
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Brehm R, South A, George EC. Use of point-of-care haemoglobin tests to diagnose childhood anaemia in low- and middle-income countries: A systematic review. Trop Med Int Health 2024; 29:73-87. [PMID: 38044262 PMCID: PMC7615606 DOI: 10.1111/tmi.13957] [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] [Indexed: 12/05/2023]
Abstract
OBJECTIVES Anaemia is a major cause of mortality and transfusion in children in low- and middle-income countries (LMICs); however, current diagnostics are slow, costly and frequently unavailable. Point-of-care haemoglobin tests (POC(Hb)Ts) could improve patient outcomes and use of resources by providing rapid and affordable results. We systematically reviewed the literature to investigate what, where and how POC(Hb)Ts are being used by health facilities in LMICs to diagnose childhood anaemia, and to explore challenges to their use. METHODS We searched a total of nine databases and trial registries up to 10 June 2022 using the concepts: anaemia, POC(Hb)T, LMIC and clinical setting. Adults ≥21 years and literature published >15 years ago were excluded. A single reviewer conducted screening, data extraction and quality assessment (of diagnostic studies) using QUADAS-2. Outcomes including POC(Hb)T used, location, setting, challenges and diagnostic accuracy were synthesised. RESULTS Of 626 records screened, 41 studies were included. Evidence is available on the use of 15 POC(Hb)Ts in hospitals (n = 28, 68%), health centres (n = 9, 22%) and clinics/units (n = 10, 24%) across 16 LMICs. HemoCue (HemoCue AB, Ängelholm, Sweden) was the most used test (n = 31, 76%). Key challenges reported were overestimation of haemoglobin concentration, clinically unacceptable limits of agreement, errors/difficulty in sampling, environmental factors, cost, inter-observer variability and supply of consumables. Five POC(Hb)Ts (33%) could not detect haemoglobin levels below 4.5 g/dL. Diagnostic accuracy varied, with sensitivity and specificity to detect anaemia ranging from 24.2% to 92.2% and 70% to 96.7%, respectively. CONCLUSIONS POC(Hb)Ts have been successfully utilised in health facilities in LMICs to diagnose childhood anaemia. However, limited evidence is available, and challenges exist that must be addressed before wider implementation. Further research is required to confirm accuracy, clinical benefits and cost-effectiveness.
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Affiliation(s)
- Rebecca Brehm
- Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Annabelle South
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
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11
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Kiguli S, Maitland K, George E. Avoid re-interpreting fluid bolus recommendations for low-income settings. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:e18. [PMID: 37858509 DOI: 10.1016/s2352-4642(23)00257-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Sarah Kiguli
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Kampala, Uganda
| | - Kathryn Maitland
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya; Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK.
| | - Elizabeth George
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
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12
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Woodcock T. Does albumin really hold unrealised physiological promise as a resuscitation fluid? J Intensive Care Soc 2023; 24:62. [PMID: 37928081 PMCID: PMC10621524 DOI: 10.1177/17511437221116473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- Tom Woodcock
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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13
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Xiang H, Zhao Y, Ma S, Li Q, Kashani KB, Peng Z, Li J, Hu B. Dose-related effects of norepinephrine on early-stage endotoxemic shock in a swine model. JOURNAL OF INTENSIVE MEDICINE 2023; 3:335-344. [PMID: 38028636 PMCID: PMC10658043 DOI: 10.1016/j.jointm.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/20/2023] [Accepted: 06/20/2023] [Indexed: 12/01/2023]
Abstract
Background The benefits of early use of norepinephrine in endotoxemic shock remain unknown. We aimed to elucidate the effects of different doses of norepinephrine in early-stage endotoxemic shock using a clinically relevant large animal model. Methods Vasodilatory shock was induced by endotoxin bolus in 30 Bama suckling pigs. Treatment included fluid resuscitation and administration of different doses of norepinephrine, to induce return to baseline mean arterial pressure (MAP). Fluid management, hemodynamic, microcirculation, inflammation, and organ function variables were monitored. All animals were supported for 6 h after endotoxemic shock. Results Infused fluid volume decreased with increasing norepinephrine dose. Return to baseline MAP was achieved more frequently with doses of 0.8 µg/kg/min and 1.6 µg/kg/min (P <0.01). At the end of the shock resuscitation period, cardiac index was higher in pigs treated with 0.8 µg/kg/min norepinephrine (P <0.01), while systemic vascular resistance was higher in those receiving 0.4 µg/kg/min (P <0.01). Extravascular lung water level and degree of organ edema were higher in animals administered no or 0.2 µg/kg/min norepinephrine (P <0.01), while the percentage of perfused small vessel density (PSVD) was higher in those receiving 0.8 µg/kg/min (P <0.05) and serum lactate was higher in the groups administered no and 1.6 µg/kg/min norepinephrine (P <0.01). Conclusions The impact of norepinephrine on the macro- and micro-circulation in early-stage endotoxemic shock is dose-dependent, with very low and very high doses resulting in detrimental effects. Only an appropriate norepinephrine dose was associated with improved tissue perfusion and organ function.
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Affiliation(s)
- Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Yuqian Zhao
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Siqing Ma
- Department of Critical Care Medicine, Qinghai Provincial People's Hospital, Xining 810007, Qinghai, China
| | - Qi Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
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14
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Pudjiadi AH, Putri ND, Wijaya S, Alatas FS. Pediatric sepsis profile in a tertiary-care hospital in Indonesia: a 4-year retrospective study. J Trop Pediatr 2023; 69:fmad029. [PMID: 37697654 DOI: 10.1093/tropej/fmad029] [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] [Indexed: 09/13/2023]
Abstract
AIM This study aimed to explore the factors contributing to mortality and its management among pediatric sepsis patients at a single center in Indonesia. METHOD We conducted a retrospective study of children admitted due to sepsis from January 2015 to December 2019 in an Indonesian tertiary hospital. RESULTS The mortality rate of pediatric sepsis in our study was 76.1% among 176 records with outcome identified. Mortality was significantly associated with septic shock at triage, number of organ failure, intensive care unit admission, inotropic use, septic shock and severe sepsis during hospitalization. Timing of antibiotic use did not affect mortality. Death within the first 24 h occurred in 41.8% of subjects, mostly due to septic shock. CONCLUSION This study illuminates the current state of pediatric sepsis management in our Indonesian hospital, revealing it as inadequate. Findings highlight the need for improved pre-hospital systems and sepsis recognition tools, and wider use of mechanical ventilators and advanced monitoring due to limited pediatric intensive care unit beds. Future research should focus on hospital-specific sepsis protocols to reduce pediatric sepsis mortality rates.
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Affiliation(s)
- Antonius Hocky Pudjiadi
- Department of Child Health, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Nina Dwi Putri
- Department of Child Health, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Stephanie Wijaya
- Department of Child Health, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Fatima Safira Alatas
- Department of Child Health, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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15
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Ospina-Tascón GA, Aldana JL, García Marín AF, Calderón-Tapia LE, Marulanda A, Escobar EP, García-Gallardo G, Orozco N, Velasco MI, Ríos E, De Backer D, Hernández G, Bakker J. Immediate Norepinephrine in Endotoxic Shock: Effects on Regional and Microcirculatory Flow. Crit Care Med 2023; 51:e157-e168. [PMID: 37255347 DOI: 10.1097/ccm.0000000000005885] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To investigate the effects of immediate start of norepinephrine versus initial fluid loading followed by norepinephrine on macro hemodynamics, regional splanchnic and intestinal microcirculatory flows in endotoxic shock. DESIGN Animal experimental study. SETTING University translational research laboratory. SUBJECTS Fifteen Landrace pigs. INTERVENTIONS Shock was induced by escalating dose of lipopolysaccharide. Animals were allocated to immediate start of norepinephrine (i-NE) ( n = 6) versus mandatory 1-hour fluid loading (30 mL/kg) followed by norepinephrine (i-FL) ( n = 6). Once mean arterial pressure greater than or equal to 75 mm Hg was, respectively, achieved, successive mini-fluid boluses of 4 mL/kg of Ringer Lactate were given whenever: a) arterial lactate greater than 2.0 mmol/L or decrease less than 10% per 30 min and b) fluid responsiveness was judged to be positive. Three additional animals were used as controls (Sham) ( n = 3). Time × group interactions were evaluated by repeated-measures analysis of variance. MEASUREMENTS AND MAIN RESULTS Hypotension was significantly shorter in i-NE group (7.5 min [5.5-22.0 min] vs 49.3 min [29.5-60.0 min]; p < 0.001). Regional mesenteric and microcirculatory flows at jejunal mucosa and serosa were significantly higher in i-NE group at 4 and 6 hours after initiation of therapy ( p = 0.011, p = 0.032, and p = 0.017, respectively). Misdistribution of intestinal microcirculatory blood flow at the onset of shock was significantly reversed in i-NE group ( p < 0.001), which agreed with dynamic changes in mesenteric-lactate levels ( p = 0.01) and venous-to-arterial carbon dioxide differences ( p = 0.001). Animals allocated to i-NE showed significantly higher global end-diastolic volumes ( p = 0.015) and required significantly less resuscitation fluids ( p < 0.001) and lower doses of norepinephrine ( p = 0.001) at the end of the experiment. Pulmonary vascular permeability and extravascular lung water indexes were significantly lower in i-NE group ( p = 0.021 and p = 0.004, respectively). CONCLUSIONS In endotoxemic shock, immediate start of norepinephrine significantly improved regional splanchnic and intestinal microcirculatory flows when compared with mandatory fixed-dose fluid loading preceding norepinephrine. Immediate norepinephrine strategy was related with less resuscitation fluids and lower vasopressor doses at the end of the experiment.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - José L Aldana
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Alberto F García Marín
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Luis E Calderón-Tapia
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Angela Marulanda
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Elena P Escobar
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Gustavo García-Gallardo
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Nicolás Orozco
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - María I Velasco
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Edwin Ríos
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Daniel De Backer
- Intensive Care Department, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jan Bakker
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
- Intensive Care Department, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, NY
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY
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16
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Syed MKH, Pendleton K, Park J, Weinert C. Physicians' Clinical Behavior During Fluid Evaluation Encounters. Crit Care Explor 2023; 5:e0933. [PMID: 37387710 PMCID: PMC10306425 DOI: 10.1097/cce.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
We sought to identify factors affecting physicians' cognition and clinical behavior when evaluating patients that may need fluid therapy. BACKGROUND Proponents of dynamic fluid responsiveness testing advocate measuring cardiac output or stroke volume after a maneuver to prove that further fluids will increase cardiac output. However, surveys suggest that fluid therapy in clinical practice is often given without prior responsiveness testing. DESIGN Thematic analysis of face-to-face structured interviews. SETTING ICUs and medical-surgical wards in acute care hospitals. SUBJECTS Intensivists and hospitalist physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We conducted 43 interviews with experienced physicians in 19 hospitals. Hospitalized patients with hypotension, tachycardia, oliguria, or elevated serum lactate are commonly seen by physicians who weigh the risks and benefits of more fluid therapy. Encounters are often with unfamiliar patients and evaluation and decisions are completed quickly without involving other physicians. Dynamic testing for fluid responsiveness is used much less often than static methods and fluid boluses are often ordered with no testing at all. This approach is rationalized by factors that discourage dynamic testing: unavailability of equipment, time to obtain test results, or lack of expertise in obtaining valid data. Two mental calculations are particularly influential: physicians' estimate of the base rate of fluid responsiveness (determined by physical examination, chart review, and previous responses to fluid boluses) and physicians' perception of patient harm if 500 or 1,000 mL fluid boluses are ordered. When the perception of harm is low, physicians use heuristics that rationalize skipping dynamic testing. LIMITATIONS Geographic limitation to hospitals in Minnesota, United States. CONCLUSIONS If dynamic responsiveness testing is to be used more often in routine clinical practice, physicians must be more convinced of the benefits of dynamic testing, that they can obtain valid results quickly and believe that even small fluid boluses harm their patients.
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Affiliation(s)
| | - Kathryn Pendleton
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School. Minneapolis, MN
| | - John Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Craig Weinert
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School. Minneapolis, MN
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17
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Macdonald S, Bosio E, Keijzers G, Burrows S, Hibbs M, O'Donoghue H, Taylor D, Mukherjee A, Kinnear F, Smart L, Ascencio-Lane JC, Litton E, Fraser J, Shapiro NI, Arendts G, Fatovich D. Effect of intravenous fluid volume on biomarkers of endothelial glycocalyx shedding and inflammation during initial resuscitation of sepsis. Intensive Care Med Exp 2023; 11:21. [PMID: 37062769 PMCID: PMC10106534 DOI: 10.1186/s40635-023-00508-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/10/2023] [Indexed: 04/18/2023] Open
Abstract
PURPOSE To investigate the effect of IV fluid resuscitation on endothelial glycocalyx (EG) shedding and activation of the vascular endothelium and inflammation. MATERIALS AND METHODS A planned biomarker sub-study of the REFRESH trial in which emergency department (ED) patients) with suspected sepsis and hypotension were randomised to a restricted fluid/early vasopressor regimen or IV fluid resuscitation with later vasopressors if required (usual care). Blood samples were collected at randomisation (T0) and at 3 h (T3), 6 h (T6)- and 24 h (T24) for measurement of a range of biomarkers if EG shedding, endothelial cell activation and inflammation. RESULTS Blood samples were obtained in 95 of 99 enrolled patients (46 usual care, 49 restricted fluid). Differences in the change in biomarker over time between the groups were observed for Hyaluronan (2.2-fold from T3 to T24, p = 0.03), SYN-4 (1.5-fold from T3 to T24, P = 0.01) and IL-6 (2.5-fold from T0 to T3, p = 0.03). No difference over time was observed between groups for the other biomarkers. CONCLUSIONS A consistent signal across a range of biomarkers of EG shedding or of endothelial activation or inflammation was not demonstrated. This could be explained by pre-existing EG shedding or overlap between the fluid volumes administered in the two groups in this clinical trial. Trial registration Australia New Zealand Clinical Trials Registry ACTRN126160000006448 Registered 12 January 2016.
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Affiliation(s)
- Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.
- Medical School, University of Western Australia, Perth, WA, Australia.
- Emergency Department, Royal Perth Hospital, Perth, WA, Australia.
| | - Erika Bosio
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Sally Burrows
- Medical School, University of Western Australia, Perth, WA, Australia
- Research Foundation, Royal Perth Hospital, Perth, WA, Australia
| | - Moira Hibbs
- Research Centre, Royal Perth Hospital, Perth, WA, Australia
| | | | - David Taylor
- Emergency Department, Austin Health, Melbourne, Australia
| | - Ashes Mukherjee
- Emergency Department, Armadale Health Service, Perth, WA, Australia
| | - Frances Kinnear
- Department of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Lisa Smart
- School of Science, Health Engineering and Education, Murdoch University, Perth, WA, Australia
| | | | - Edward Litton
- Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
- Emergency Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
- Emergency Department, Royal Perth Hospital, Perth, WA, Australia
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18
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Sarmin M, Shaly NJ, Sultana T, Tariqujjaman M, Shikha SS, Mariam N, Jeorge DH, Tabassum M, Nahar B, Afroze F, Shahrin L, Hossain MI, Alam B, Faruque ASG, Islam MM, Osmany DEMMF, Ahmed CM, Manji K, Kissoon N, Chisti MJ, Ahmed T. Efficacy of dopamine, epinephrine and blood transfusion for treatment of fluid refractory shock in children with severe acute malnutrition or severe underweight and cholera or other dehydrating diarrhoeas: protocol for a randomised controlled clinical trial. BMJ Open 2023; 13:e068660. [PMID: 37045565 PMCID: PMC10106066 DOI: 10.1136/bmjopen-2022-068660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION Diarrhoea is one of the leading causes of under-5 childhood mortality and accounts for 8% of 5.4 million global under-5 deaths. In severely malnourished children, diarrhoea progresses to shock, where the risk of mortality is even higher. At icddr,b Dhaka Hospital, the fatality rate is as high as 69% in children with severe malnutrition and fluid refractory septic shock. To date, no study has evaluated systematically the effects of inotrope or vasopressor or blood transfusion in children with dehydrating diarrhoea (eg, in cholera) and severe acute malnutrition (SAM) or severe underweight who are in shock and unresponsive to WHO-recommended fluid therapy. To reduce the mortality of severely malnourished children presenting with diarrhoea and fluid refractory shock, we aim to compare the efficacy of blood transfusion, dopamine and epinephrine in fluid refractory shock in children who do not respond to WHO-recommended fluid resuscitation. METHODS AND ANALYSIS In this randomised, three-arm, controlled, non-masked clinical trial in children 1-59 months old with SAM or severe underweight and fluid refractory shock, we will compare the efficacy of dopamine or epinephrine administration versus blood transfusion in children who failed to respond to WHO-recommended fluid resuscitation. The primary outcome variable is the case fatality rate. The effect of the intervention will be assessed by performing an intention-to-treat analysis. Recruitment and data collection began in July 2021 and are now ongoing. Results are expected by May 2023. ETHICS AND DISSEMINATION This study has been approved by the icddr,b Institutional Review Board. We adhere to the 'Declaration of Helsinki' (2000), guidelines for Good Clinical Practice. Before enrolment, we collect signed informed consent from the parents or caregivers of the children. We will publish the results in a peer-reviewed journal and will arrange a dissemination seminar. TRIAL REGISTRATION NUMBER NCT04750070.
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Affiliation(s)
- Monira Sarmin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nusrat Jahan Shaly
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tania Sultana
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Tariqujjaman
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shamima Sharmin Shikha
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nafisa Mariam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Didarul Haque Jeorge
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mosharrat Tabassum
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Baitun Nahar
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Afroze
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lubaba Shahrin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Baharul Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Syed Golam Faruque
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Karim Manji
- Department of Pediatrics, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research,Bangladesh (icddr,b), Dhaka, Bangladesh
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Dumbuya JS, Li S, Liang L, Zeng Q. Paediatric sepsis-associated encephalopathy (SAE): a comprehensive review. Mol Med 2023; 29:27. [PMID: 36823611 PMCID: PMC9951490 DOI: 10.1186/s10020-023-00621-w] [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: 10/31/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
Sepsis-associated encephalopathy (SAE) is one of the most common types of organ dysfunction without overt central nervous system (CNS) infection. It is associated with higher mortality, low quality of life, and long-term neurological sequelae, its mortality in patients diagnosed with sepsis, progressing to SAE, is 9% to 76%. The pathophysiology of SAE is still unknown, but its mechanisms are well elaborated, including oxidative stress, increased cytokines and proinflammatory factors levels, disturbances in the cerebral circulation, changes in blood-brain barrier permeability, injury to the brain's vascular endothelium, altered levels of neurotransmitters, changes in amino acid levels, dysfunction of cerebral microvascular cells, mitochondria dysfunction, activation of microglia and astrocytes, and neuronal death. The diagnosis of SAE involves excluding direct CNS infection or other types of encephalopathies, which might hinder its early detection and appropriate implementation of management protocols, especially in paediatric patients where only a few cases have been reported in the literature. The most commonly applied diagnostic tools include electroencephalography, neurological imaging, and biomarker detection. SAE treatment mainly focuses on managing underlying conditions and using antibiotics and supportive therapy. In contrast, sedative medication is used judiciously to treat those showing features such as agitation. The most widely used medication is dexmedetomidine which is neuroprotective by inhibiting neuronal apoptosis and reducing a sepsis-associated inflammatory response, resulting in improved short-term mortality and shorter time on a ventilator. Other agents, such as dexamethasone, melatonin, and magnesium, are also being explored in vivo and ex vivo with encouraging results. Managing modifiable factors associated with SAE is crucial in improving generalised neurological outcomes. From those mentioned above, there are still only a few experimentation models of paediatric SAE and its treatment strategies. Extrapolation of adult SAE models is challenging because of the evolving brain and technical complexity of the model being investigated. Here, we reviewed the current understanding of paediatric SAE, its pathophysiological mechanisms, diagnostic methods, therapeutic interventions, and potential emerging neuroprotective agents.
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Affiliation(s)
- John Sieh Dumbuya
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Siqi Li
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Lili Liang
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Qiyi Zeng
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China.
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Effect of Fluid Resuscitation Strategies for Obese Patients with Sepsis and Septic Shock: A Systematic Review. INTENSIVE CARE RESEARCH 2023; 3:61-68. [PMID: 36320644 PMCID: PMC9610334 DOI: 10.1007/s44231-022-00019-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/17/2022] [Indexed: 11/02/2022]
Abstract
Purpose As the Surviving Sepsis Campaign (2021) recommended, patients with sepsis should be given a liquid infusion of 30 ml/kg (ideal body weight). However, the strategy may result in insufficient resuscitation for obese patients with sepsis. Therefore, we conducted a systematic evaluation of the effectiveness of the initial resuscitation strategy in obese sepsis patients. Materials and methods A computer search of PubMed, Embase, Cochrane library, and other databases collected cohort studies from the beginning of the survey to December 2021 to include articles evaluating initial resuscitation strategies for sepsis-obese patients. Results Of the six studies included, five used ideal body weight infusion strategies, and three used actual body weight infusion strategies. Differences in fluid volume were observed between the two strategies, but no significant difference was observed in the mortality of obese sepsis patients. In addition, there may be an infusion strategy other than the above two infusion methods, and the safety and efficacy of the new infusion strategy are unclear. The obesity paradox has been observed in most infusion strategies. Conclusion The association between obesity and infusion strategy has rarely been investigated in patients with sepsis and septic shock, and the existing results are conflicting. The risk of bias in all included studies was moderate or high. Before providing broad recommendations on the optimal first resuscitation approach to lower the chance of mortality, further clinical trials, and prospective research need to be done.
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Whelan AJ, Ricci M, Harthan AA, Deshpande G. Calcium Responsive Pediatric Septic Shock Refractory to Isotonic Crystalloids and Inotropic Agents. J Pediatr Pharmacol Ther 2022; 27:765-769. [PMID: 36989008 PMCID: PMC9674360 DOI: 10.5863/1551-6776-27.8.765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022]
Abstract
Pediatric septic shock is a life-threatening condition with significant rates of morbidity and mortality. Standard management includes fluid resuscitation, timely antimicrobial administration, and epinephrine or norepinephrine if unresolved with initial management. Additional therapies are not well defined and include vasopressin, hydrocortisone, phenylephrine, levosimendan, dopamine, and others. Many of these agents modify cellular effects of calcium in the smooth muscle. The use of a calcium infusion may improve vasoactivity in the smooth muscle without the use of signaling pathways. Children are more susceptible to the effects of calcium, which may predispose them to enhanced vasoconstriction with the administration of intravenous calcium. We present a case in which a patient on chronic calcium channel blocker therapy presented with septic shock. She continued to remain hypotensive after fluid resuscitation, antibiotics, epinephrine, and norepinephrine. Her blood pressure improved with the initiation of a continuous calcium chloride infusion. Norepinephrine and epinephrine doses were decreased after the initiation of the calcium infusion.
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Affiliation(s)
- Aviva J. Whelan
- Department of Clinical Pediatrics (AJW), OSF Healthcare Children's Hospital of Illinois, Peoria, IL
| | - Morgan Ricci
- Department of Emergency Medicine (MR), OSF Healthcare Children's Hospital of Illinois, Peoria, IL
| | - Aaron A. Harthan
- Department of Clinical Pharmacy (AAH), OSF Healthcare Children's Hospital of Illinois, Peoria, IL
| | - Girish Deshpande
- Division of Pediatric Critical Care Medicine (GD), Department of Pediatrics, University of Illinois College of Medicine at Peoria, OSF Healthcare Children's Hospital of Illinois, Peoria, IL
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Macdonald S. Fluid Resuscitation in Patients Presenting with Sepsis: Current Insights. Open Access Emerg Med 2022; 14:633-638. [PMID: 36471825 PMCID: PMC9719278 DOI: 10.2147/oaem.s363520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/23/2022] [Indexed: 04/05/2024] Open
Abstract
Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid. The rationale is to restore circulating fluid volume and optimise stroke volume. It is acknowledged that there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design. In the past decade, evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation. Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation, however, translating these findings to other settings is not possible. This uncertainty has led to variation in practice with some advocating a more conservative fluid strategy coupled with the earlier introduction of vasopressors for haemodynamic support. This question is the subject of several ongoing clinical trials. This article summarises the current state of the evidence for IV fluid resuscitation in septic shock and provides guidance for practitioners in the face of our evolving understanding of this important area.
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Affiliation(s)
- Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
- Emergency Department, Royal Perth Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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23
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Chia PY, Teo A, Yeo TW. Association of Neutrophil Mediators With Dengue Disease Severity and Cardiac Impairment in Adults. J Infect Dis 2022; 226:1974-1984. [PMID: 36208158 DOI: 10.1093/infdis/jiac383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/19/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cardiac impairment contributes to hypotension in severe dengue (SD). However, studies examining pathogenic factors affecting dengue-associated cardiac impairment are lacking. We examined the role of neutrophil mediators on cardiac impairment in clinical dengue. METHODS We prospectively enrolled adult patients with dengue and controls. Cardiac parameters were measured using a bioimpedance device. Neutrophils mediators were measured, including myeloperoxidase (MPO) and citrullinated histone H3. RESULTS We recruited 107 dengue patients and 30 controls. Patients with dengue were classified according to World Health Organization 2009 guidelines (44 with dengue fever [DF], 51 with DF with warning signs, and 12 with SD). During critical phase, stroke index (P < .001), cardiac index (P = .03), and Granov-Goor index (P < .001) were significantly lower in patients with dengue than in controls. During critical phase, MPO was significantly higher in patients with dengue than in controls (P < .001) and also significantly higher in patients with SD than in those with DF. In addition, MPO was inversely associated with the stroke, cardiac, and Granov-Goor indexes, during the critical phase, and longitudinally as well. CONCLUSIONS Cardiac function was decreased, and MPO increased, during with critical phase in patients SD compared with those with DF and controls. MPO may mediate dengue-associated cardiac impairment.
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Affiliation(s)
- Po Ying Chia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,National Centre for Infectious Diseases, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Andrew Teo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Department of Medicine, The Doherty Institute, University of Melbourne, Victoria, Australia
| | - Tsin Wen Yeo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,National Centre for Infectious Diseases, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
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Macdonald S, Peake SL, Corfield AR, Delaney A. Fluids or vasopressors for the initial resuscitation of septic shock. Front Med (Lausanne) 2022; 9:1069782. [PMID: 36507525 PMCID: PMC9729725 DOI: 10.3389/fmed.2022.1069782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.
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Affiliation(s)
- Stephen Macdonald
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Sandra L. Peake
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Alasdair R. Corfield
- Consultant Emergency Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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Zhang B, Guo S, Fu Z, Wu N, Liu Z. Association between fluid balance and mortality for heart failure and sepsis: a propensity score-matching analysis. BMC Anesthesiol 2022; 22:324. [PMID: 36273128 PMCID: PMC9587660 DOI: 10.1186/s12871-022-01865-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 10/07/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Fluid resuscitation is necessary to correct the sepsis-induced hypoperfusion, which is contradictory to the treatment of heart failure. This study explored the association between fluid balance (FB) of the first 24 h after ICU admission and mortality in critically ill patients with heart failure and sepsis. METHODS Data were extracted from the Medical Information Mart for Intensive Care database. The locally weighted scatterplot smoothing (Lowess) method was used to demonstrate the relationship between FB and in-hospital mortality. Groups were divided into high FB (≥ 55.85 ml/kg) and low FB (< 55.85 ml/kg) according to the cut-off value of FB using Receiver operating characteristic analysis and Youden index method. The primary outcome was in-hospital mortality. Subgroup analyses, multivariable logistic regression analyses, and Kaplan-Meier curves were used to detect the association and survival difference between groups. Inverse probability treatment weighting (IPTW) and propensity score matching (PSM) were performed to minimize the bias of confounding factors and facilitate the comparability between groups. RESULTS A total of 936 patients were included. The Lowess curve showed an approximate positive linear relationship for FB and in-hospital mortality. In the multivariable logistic regression adjusted model, high FB showed strong associations with in-hospital mortality (OR 2.53, 95% CI 1.60-3.99, p < 0.001) as compared to the low FB group. In IPTW and PSM models, high FB consistently showed higher in-hospital mortality (IPTW model: OR 1.94, 95% CI 1.52-2.49, p < 0.001; PSM model: OR 2.93, 95% CI 1.75-4.90, p < 0.001) and 30-day mortality (IPTW model: OR 1.65, 95% CI 1.29-2.10, p < 0.001; PSM model: OR 2.50, 95% CI 1.51-4.15, p < 0.001), compared with the low FB group. CONCLUSION For critically ill patients with heart failure and sepsis, high FB within the first 24 h after ICU admission could serve as an independent risk factor for in-hospital mortality and 30-day mortality. The avoidance of fluid overload exerts important effects on reducing mortality in such patients.
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Affiliation(s)
- Bufan Zhang
- Department of Cardiovascular Surgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
- Department of Cardiovascular Surgery & Intensive Care Unit, TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, Tianjin, People's Republic of China
| | - Shaohua Guo
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Zean Fu
- Department of Cardiovascular Surgery & Intensive Care Unit, TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, Tianjin, People's Republic of China
| | - Naishi Wu
- Department of Cardiovascular Surgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China.
| | - Zhigang Liu
- Department of Cardiovascular Surgery & Intensive Care Unit, TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, Tianjin, People's Republic of China.
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Gardner Yelton SE, Ramos LC, Reuland CJ, Evangelista PPG, Shilkofski NA. Implementation and evaluation of a shock curriculum using simulation in Manila, Philippines: a prospective cohort study. BMC MEDICAL EDUCATION 2022; 22:606. [PMID: 35932072 PMCID: PMC9354294 DOI: 10.1186/s12909-022-03669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Shock causes significant morbidity and mortality in children living in resource-limited settings. Simulation has been successfully used as an educational tool for medical professionals internationally. We sought to improve comfort and knowledge regarding shock recognition and fluid management by implementing a pediatric shock curriculum using simulation as an assessment for trainees in Manila, Philippines. METHODS We assessed a shock curriculum focused on patients with malnutrition in a prospective cohort study, using a written test and a videotaped simulation-based objective standardized clinical examination. Implementation occurred in March 2020 with 24 Filipino pediatric residents at a single institution in Manila. Outcomes included time to initiation of fluid resuscitation, improvement in confidence, knowledge on a written assessment, and performance in simulation. Results were compared pre- and post-intervention using Wilcoxon signed-rank test. RESULTS The time to initiation of fluids did not change between the baseline simulation (median [interquartile range] = 71.5 seconds [52-116.5]) and the final simulation (68 seconds [52.5-89]; P = 0.42). Confidence in identifying shock and malnutrition, managing hypovolemic shock, managing septic shock, and placing intraosseous access all increased (P < 0.01) post-intervention. Written test scores showed no improvement, but performance in simulation, measured using a checklist, improved from a total score of 10 [8.5-11] to 15 [13-16] (P < 0.01). CONCLUSION In our study of a simulation-based shock education program, we showed improvement in confidence and knowledge as measured by a resuscitation checklist. It is feasible to establish a successful simulation-based education program in a low-resource setting.
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Affiliation(s)
- Sarah E Gardner Yelton
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1, Baltimore, MD, 21287, USA.
| | - Lorelie Cañete Ramos
- Department of Pediatric Critical Care, Philippine Children's Medical Center, Quezon City, Philippines
| | | | - Paula Pilar G Evangelista
- Department of Pediatric Critical Care, Philippine Children's Medical Center, Quezon City, Philippines
| | - Nicole A Shilkofski
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1, Baltimore, MD, 21287, USA
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
OBJECTIVES Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC. METHODS We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected. RESULTS We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC. CONCLUSIONS Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.
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Abstract
OBJECTIVES To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels. DESIGN Prospective observational study. SETTING Pediatric ward of a tertiary government referral hospital in Malawi. PATIENTS Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018. INTERVENTIONS Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes. MEASUREMENTS AND MAIN RESULTS Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4-40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate. CONCLUSIONS Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.
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Obonyo NG, Olupot-Olupot P, Mpoya A, Nteziyaremye J, Chebet M, Uyoga S, Muhindo R, Fanning JP, Shiino K, Chan J, Fraser JF, Maitland K. A Clinical and Physiological Prospective Observational Study on the Management of Pediatric Shock in the Post-Fluid Expansion as Supportive Therapy Trial Era. Pediatr Crit Care Med 2022; 23:502-513. [PMID: 35446796 PMCID: PMC7613033 DOI: 10.1097/pcc.0000000000002968] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Fluid bolus resuscitation in African children is harmful. Little research has evaluated physiologic effects of maintenance-only fluid strategy. DESIGN We describe the efficacy of fluid-conservative resuscitation of septic shock using case-fatality, hemodynamic, and myocardial function endpoints. SETTING Pediatric wards of Mbale Regional Referral Hospital, Uganda, and Kilifi County Hospital, Kenya, conducted between October 2013 and July 2015. Data were analysed from August 2016 to July 2019. PATIENTS Children (≥ 60 d to ≤ 12 yr) with severe febrile illness and clinical signs of impaired perfusion. INTERVENTIONS IV maintenance fluid (4 mL/kg/hr) unless children had World Health Organization (WHO) defined shock (≥ 3 signs) where they received two fluid boluses (20 mL/kg) and transfusion if shock persisted. Clinical, electrocardiographic, echocardiographic, and laboratory data were collected at presentation, during resuscitation and on day 28. Outcome measures were 48-hour mortality, normalization of hemodynamics, and cardiac biomarkers. MEASUREMENT AND MAIN RESULTS Thirty children (70% males) were recruited, six had WHO shock, all of whom died (6/6) versus three of 24 deaths in the non-WHO shock. Median fluid volume received by survivors and nonsurvivors were similar (13 [interquartile range (IQR), 9-32] vs 30 mL/kg [28-61 mL/kg], z = 1.62, p = 0.23). By 24 hours, we observed increases in median (IQR) stroke volume index (39 mL/m 2 [32-42 mL/m 2 ] to 47 mL/m 2 [41-49 mL/m 2 ]) and a measure of systolic function: fractional shortening from 30 (27-33) to 34 (31-38) from baseline including children managed with no-bolus. Children with WHO shock had a higher mean level of cardiac troponin ( t = 3.58; 95% CI, 1.24-1.43; p = 0.02) and alpha-atrial natriuretic peptide ( t = 16.5; 95% CI, 2.80-67.5; p < 0.01) at admission compared with non-WHO shock. Elevated troponin (> 0.1 μg/mL) and hyperlactatemia (> 4 mmol/L) were putative makers predicting outcome. CONCLUSIONS Maintenance-only fluid therapy normalized clinical and myocardial perturbations in shock without compromising cardiac or hemodynamic function whereas fluid-bolus management of WHO shock resulted in high fatality. Troponin and lactate biomarkers of cardiac dysfunction could be promising outcome predictors in pediatric septic shock in resource-limited settings.
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Affiliation(s)
- Nchafatso G Obonyo
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
- Initiative to Develop African Research Leaders, Kilifi, Kenya
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
| | - Peter Olupot-Olupot
- Initiative to Develop African Research Leaders, Kilifi, Kenya
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
- Busitema University, Faculty of Health sciences, Mbale, Uganda
| | - Ayub Mpoya
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Martin Chebet
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
- Busitema University, Faculty of Health sciences, Mbale, Uganda
| | - Sophie Uyoga
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
- Initiative to Develop African Research Leaders, Kilifi, Kenya
| | - Rita Muhindo
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
| | - Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- Faculty of Medicine, University of Queensland, Brisbane, VIC, Australia
| | - Kenji Shiino
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Jonathan Chan
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- Faculty of Medicine, University of Queensland, Brisbane, VIC, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Kathryn Maitland
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, United Kingdom
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Ultrasound Technology: Providing "More" for Research and Clinical Care in Low-Resource Settings. Pediatr Crit Care Med 2022; 23:560-562. [PMID: 35797571 DOI: 10.1097/pcc.0000000000002984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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No association between intravenous fluid volume and endothelial glycocalyx shedding in patients undergoing resuscitation for sepsis in the emergency department. Sci Rep 2022; 12:8733. [PMID: 35610344 PMCID: PMC9130214 DOI: 10.1038/s41598-022-12752-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/28/2022] [Indexed: 11/29/2022] Open
Abstract
Endothelial glycocalyx (EG) shedding is associated with septic shock and described following intravenous (IV) fluid administration. To investigate the possible impact of IV fluids on the pathobiology of septic shock we investigated associations between biomarkers of EG shedding and endothelial cell activation, and relationships with IV fluid volume. Serum samples were obtained on admission (T0) and at 24 h (T24) in patients undergoing haemodynamic resuscitation for suspected septic shock in the emergency department. Biomarkers of EG shedding—Syndecan-1 (Syn-1), Syndecan-4 (Syn-4), Hyaluronan, endothelial activation—Endothelin-1 (ET-1), Angiopoeitin-2 (Ang-2), Vascular Endothelial Growth Factor Receptor-1(VEGF-1) and leucocyte activation/inflammation—Resistin, Neutrophil Gelatinase Associated Lipocalin (NGAL) and a marker of cardiac stretch—Pro-Atrial Natriuretic Peptide (Pro-ANP) were compared to the total IV fluid volume administered using Tobit regression. Data on 86 patients (52 male) with a mean age of 60 (SD 18) years were included. The mean fluid volume administered to T24 was 4038 ml (SD 2507 ml). No significant association between fluid volume and Pro-ANP or any of the biomarkers were observed. Syn-1 and Syn-4 were significantly correlated with each other (Spearman Rho 0.43, p < 0.001) but not with Hyaluronan. Syn-1 and Syn-4 both correlated with VEGFR-1 (Rho 0.56 and 0.57 respectively, p < 0.001) whereas Hyaluronan correlated with ET-1 (Rho 0.43, p < 0.001) and Ang-2 (Rho 0.43, p < 0.001). There was no correlation between Pro-ANP and any of the EG biomarkers. Distinct patterns of association between biomarkers of EG shedding and endothelial cell activation were observed among patients undergoing resuscitation for sepsis. No relationship between IV fluid volume and Pro-ANP or any of the other biomarkers was observed.
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Chen L, Mutabandama Y, McCall N, Umuhoza C. Focused Cardiac Ultrasound Findings in Children Presenting With Shock to a Tertiary Care Hospital in Rwanda. Pediatr Emerg Care 2022; 38:e1198-e1200. [PMID: 34570083 DOI: 10.1097/pec.0000000000002546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Shock remains a leading proximate cause of death in children. Children in sub-Saharan African (SSA) countries present with shock from a wide range of pathologies. Routine physiologic parameters may not reflect underlying physiology. No previous work has systematically described ultrasound findings in children with shock in an SSA country. We set out to perform focused cardiac ultrasound (FOCUS) on children with shock in Rwanda and describe the findings in this pilot study. METHODS In a prospective descriptive study, we trained pediatric residents to perform FOCUS on children presenting with shock to an urban tertiary care pediatric emergency department in Kigali, Rwanda. Images were transmitted via cellphone network and reviewed by experts. Primary outcome was expert's description of the FOCUS findings. Secondary outcomes included mortality at 48-hour, change in assessment and treatment after FOCUS, and agreement of FOCUS findings between residents and experts. RESULTS Between January 2020 and April 2020, 25 subjects were enrolled by 8 residents. Eleven of 25 (44%) were newly diagnosed with acquired or congenital heart disease. The 48-hour mortality rate was higher in this group compared with those without heart disease (8 of 11 vs 1 of 14). The resident reported changing assessment and treatment based on FOCUS findings in 60% of patients (15 of 25). There was good to excellent agreements between residents and FOCUS experts on left ventricle function, pericardial effusion, and intravascular volume. CONCLUSIONS In children presenting with signs and symptoms of shock in SSA, one could perform a screening FOCUS to distinguish between hypovolemic and cardiogenic shock.
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Affiliation(s)
- Lei Chen
- From the Section of Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Yves Mutabandama
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Natalie McCall
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Christian Umuhoza
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
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Al-Eyadhy A, Hasan G, Temsah MH, Alseneidi S, Alalwan M, Alali F, Alhaboob A, Alabdulhafid M, Alsohime F, Almaziad M, Somily AM. Initial Fluid Balance Associated Outcomes in Children With Severe Sepsis and Septic Shock. Pediatr Emerg Care 2022; 38:e1112-e1117. [PMID: 34469401 DOI: 10.1097/pec.0000000000002520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Net fluid balance and its role in sepsis-related mortality is not clear; studies suggest that aggressive fluid resuscitation can help in treatment, whereas others consider it is associated with poor outcomes. This study aimed to clarify the possible association of initial 24 hours' fluid balance with poor outcomes in pediatric patients with sepsis. METHODS Retrospective data analysis included pediatric patients admitted with suspected or proven sepsis or septic shock to pediatric intensive care unit (PICU) of a tertiary care teaching hospital in Saudi Arabia. RESULTS The study included 47 patients; 13 (28%) died, and mortality rate was significant in children with neurologic failure (P < 0.02), mechanical ventilation within 24 hours of admission (P < 0.03), leukopenia (P < 0.02), abnormal international normalized ratio (P < 0.02), initial blood lactate levels higher than 5 mmol/L (P < 0.02), or positive fluid balance at 24 hours of admission to the PICU (P < 0.001). CONCLUSION Among children with sepsis and/or septic shock, there is significant association between mortality and initial high blood lactate levels and positive fluid balance at 24 hours from admission to the PICU.
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Affiliation(s)
- Ayman Al-Eyadhy
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Mohamad-Hani Temsah
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | | | | | - Ali Alhaboob
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Majed Alabdulhafid
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Fahad Alsohime
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed Almaziad
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ali Mohammed Somily
- Department of Pathology and Laboratory Medicine, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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McPherson C. Know the Code: Medications for Resuscitation in Neonates. Neonatal Netw 2022; 41:107-113. [PMID: 35260428 DOI: 10.1891/nn-2021-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Jeffreys KL, Eckerle M, Depinet H. Patterns of Vasoactive Agent Initiation Among Children With Septic Shock in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e205-e208. [PMID: 32941359 DOI: 10.1097/pec.0000000000002219] [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: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to describe patterns of initiation (and factors associated with delayed initiation) of vasoactive agents among pediatric emergency patients with septic shock. METHODS Patients with septic shock from November 2013 to September 2016 who had a vasoactive agent initiated for documented hypotension were classified as "guideline adherent" (hypotensive following the final fluid bolus and had vasoactive agents initiated within 60 minutes) or "delayed initiation" (hypotensive after the final bolus and were initiated on vasoactive agents after >60 minutes). Patient-level factors (demographics, presence of underlying condition including central venous catheter, and markers of disease severity) and outcomes (mortality, length of stay) were compared between groups. RESULTS Of the 37 eligible patients, 17 received vasoactive agents within "guideline adherent" timelines and 10 were "delayed initiation." An additional group was identified as "transient responders"; these patients were normotensive after a final fluid bolus but developed hypotension and were initiated on a vasoactive agent within 2 hours after admission (n = 10). We found no significant difference between the "guideline adherent" and "delayed initiation" groups according to patient-level factors or outcomes; "transient responders" were more likely than other groups to have a central venous catheter and had longer lengths of stay. CONCLUSIONS Although there are perceived barriers to vasoactive agent initiation, we found no significant difference in patient-level factors between the timely and delayed groups. This study also identified a group of patients labeled as transient responders, who initially appeared volume responsive but who required vasoactive support within several hours. This cohort requires further study.
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Affiliation(s)
- Kristen L Jeffreys
- From the Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center; University of Cincinnati School of Medicine
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Ranjit S, Kissoon N. Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings. Transl Pediatr 2021; 10:2646-2665. [PMID: 34765491 PMCID: PMC8578780 DOI: 10.21037/tp-20-310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.
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Affiliation(s)
- Suchitra Ranjit
- Senior Consultant and Head, Pediatric ICU, Apollo Children's Hospital, Chennai, India
| | - Niranjan Kissoon
- Children's and Women's Global Health, UBC & BC Children's Hospital Professor in Critical Care - Global Child Health, Department of Pediatrics and Emergency Medicine, UBC, Child and Family Research Institute, Vice President Global Sepsis Alliance, Vancouver, Canada
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Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, Lovato WJ, Amêndola CP, Assunção MSC, Serpa-Neto A, Paranhos JLR, Andrade J, Godoy MMG, Romano E, Dal Pizzol F, Silva EB, Silva MML, Machado MCV, Malbouisson LMS, Manoel ALO, Thompson MM, Figueiredo LM, Soares RM, Miranda TA, de Lima LM, Santucci EV, Corrêa TD, Azevedo LCP, Kellum JA, Damiani LP, Silva NB, Cavalcanti AB. Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021; 326:830-838. [PMID: 34547081 PMCID: PMC8356145 DOI: 10.1001/jama.2021.11444] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality. OBJECTIVE To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately). INTERVENTIONS Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design. MAIN OUTCOMES AND MEASURES The primary end point was 90-day survival. RESULTS Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98). CONCLUSIONS AND RELEVANCE Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02875873.
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Flávia R Machado
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Rodrigo S Biondi
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Instituto de Cardiologia do Distrito Federal, Brasília, Brazil
| | - Flávio G R Freitas
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital SEPACO, São Paulo, Brazil
| | - Viviane C Veiga
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Rodrigo C Figueiredo
- Hospital Maternidade São José, Centro Universitário do Espírito Santo (UNESC), Colatina, Brazil
| | - Wilson J Lovato
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | | | - Ary Serpa-Neto
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jorge L R Paranhos
- Santa Casa de Misericórdia de São João Del Rei, São João Del Rei, Brazil
| | - José Andrade
- Hospital Geral de Vitória da Conquista, Vitória da Conquista, Brazil
| | - Michele M G Godoy
- Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
| | | | - Felipe Dal Pizzol
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital São José, Criciúma, Brazil
| | | | | | | | | | | | - Marlus M Thompson
- Hospital Evangélico Cachoeiro do Itapemirim, Cachoeiro do Itapemirim, Brazil
| | | | | | | | | | | | - Thiago D Corrêa
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luciano C P Azevedo
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, Brazil
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nilton B Silva
- School of Medicine, Federal University of Health Sciences, Porto Alegre, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
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Ranjit S, Natraj R, Kissoon N, Thiagarajan RR, Ramakrishnan B, Monge García MI. Variability in the Hemodynamic Response to Fluid Bolus in Pediatric Septic Shock. Pediatr Crit Care Med 2021; 22:e448-e458. [PMID: 33750093 DOI: 10.1097/pcc.0000000000002714] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Fluid boluses are commonly administered to improve the cardiac output and tissue oxygen delivery in pediatric septic shock. The objective of this study is to evaluate the effect of an early fluid bolus administered to children with septic shock on the cardiac index and mean arterial pressure, as well as on the hemodynamic response and its relationship with outcome. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS We prospectively collected hemodynamic data from children with septic shock presenting to the emergency department or the PICU who received a fluid bolus (10 mL/kg of Ringers Lactate over 30 min). A clinically significant response in cardiac index-responder and mean arterial pressure-responder was both defined as an increase of greater than or equal to 10% 10 minutes after fluid bolus. MEASUREMENTS AND MAIN RESULTS Forty-two children with septic shock, 1 month to 16 years old, median Pediatric Risk of Mortality-III of 13 (interquartile range, 9-19), of whom 66% were hypotensive and received fluid bolus within the first hour of shock recognition. Cardiac index- and mean arterial pressure-responsiveness rates were 31% and 38%, respectively. We failed to identify any association between cardiac index and mean arterial pressure changes (r = 0.203; p = 0.196). Cardiac function was similar in mean arterial pressure- and cardiac index-responders and nonresponders. Mean arterial pressure-responders increased systolic, diastolic, and perfusion pressures (mean arterial pressure - central venous pressure) after fluid bolus due to higher indexed systemic vascular resistance and arterial elastance index. Mean arterial pressure-nonresponders required greater vasoactive-inotrope support and had higher mortality. CONCLUSIONS The hemodynamic response to fluid bolus in pediatric septic shock was variable and unpredictable. We failed to find a relationship between mean arterial pressure and cardiac index changes. The adverse effects of fluid bolus extended beyond fluid overload and, in some cases, was associated with reduced mean arterial pressure, perfusion pressures and higher vasoactive support. Mean arterial pressure-nonresponders had increased mortality. The response to the initial fluid bolus may be helpful to understand each patient's individualized physiologic response and guide continued hemodynamic management.
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Affiliation(s)
| | | | - Niranjan Kissoon
- The University of British Columbia, The Child and Family Research Institute, and BC Children's Hospital, Vancouver, BC, Canada
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - M Ignacio Monge García
- Servicio de Cuidados Críticos y Urgencias Hospital SAS de Jerez C/Circunvalación s/n, Jerez de la Frontera, Spain
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Association of fluid balance with mortality in sepsis is modified by admission hemoglobin levels: A large database study. PLoS One 2021; 16:e0252629. [PMID: 34125858 PMCID: PMC8202933 DOI: 10.1371/journal.pone.0252629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Sepsis involves a dysregulated inflammatory response to infection that leads to organ dysfunction. Early fluid resuscitation has been advocated by the Surviving Sepsis Campaign guidelines. However, recent studies have shown that a positive fluid balance is associated with increased mortality in septic patients. We investigated if haemoglobin levels on admission to the intensive care unit (ICU) could modify the association of fluid balance with mortality in patients with sepsis. We hypothesized that with increasing fluid balance, patients with moderate anemia (hemoglobin 7-10g/dL) would have poorer outcomes compared to those without moderate anemia (hemoglobin >10g/dL). Materials and methods This retrospective study utilized the Medical Information Mart for Intensive Care-III (MIMIC-III) database. Patients with sepsis, as identified by the International Classification of Diseases, 9th, Clinical Modification codes, were studied. Patients were stratified into those with and without moderate anemia at ICU admission. We investigated the influence of fluid balance measured within 24 hours of ICU admission on 28-day mortality for both patient groups using multivariable logistic regression models. Subgroup and sensitivity analyses were conducted. Results 8,132 patients (median age 68.6 years, interquartile range 55.1–79.8 years; 52.8% female) were included. Increasing fluid balance (in L) was associated with a significantly decreased risk of 28-day mortality in patients without moderate anemia (OR 0.91, 95%CI 0.84–0.97, p = 0.005, at 6-hour). Conversely, increasing fluid balance was associated with a significantly increased risk of 28-day mortality in patients with moderate anemia (OR 1.05, 95% CI 1.01–1.1, p = 0.022, at 24-hour). Interaction analyses showed that mortality was highest when haemoglobin decreased in patients with moderate anemia who had the most positive fluid balance. Multiple subgroups and sensitivity analyses yielded consistent results. Conclusions In septic patients admitted to ICU, admission hemoglobin levels modified the association between fluid balance and mortality and are an important consideration for future fluid therapy trials.
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Brems JH, Casey JD, Wang L, Self WH, Rice TW, Semler MW. Balanced crystalloids versus saline in critically ill adults with low plasma bicarbonate: A secondary analysis of a clinical trial. J Crit Care 2021; 63:250-253. [PMID: 33500146 PMCID: PMC9084443 DOI: 10.1016/j.jcrc.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We aimed to determine if balanced crystalloids compared with saline improve outcomes in critically ill adults admitted with low plasma bicarbonate. MATERIALS AND METHODS We performed a secondary analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). We included patients who presented to the Emergency Department with a first measured plasma bicarbonate less than 20 mmol/L. Among these patients, we compared the effect of balanced crystalloid versus saline on the primary outcome of major adverse kidney events within 30 days (MAKE30), defined as a composite of death, new renal-replacement therapy, or persistent renal dysfunction (final inpatient creatinine ≥200% baseline). Secondary outcomes included 30 day in-hospital mortality, receipt of new RRT, persistent renal dysfunction, incident AKI, and vasopressor-free days. RESULTS Among the 2029 patients with an initial plasma bicarbonate concentration < 20 mmol/L, there was no difference in the incidence of MAKE30 between those assigned to balanced crystalloid versus saline (21.8% vs 21.3%; P = 0.93). Secondary outcomes were similar between the balanced crystalloid and saline groups. CONCLUSIONS Among critically ill adults presenting to the Emergency Department, initial plasma bicarbonate concentration does not appear to be a useful marker to guide the selection of balanced crystalloid versus saline.
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Affiliation(s)
- J Henry Brems
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Variability in the Physiologic Response to Fluid Bolus in Pediatric Patients Following Cardiac Surgery. Crit Care Med 2021; 48:e1062-e1070. [PMID: 32947469 DOI: 10.1097/ccm.0000000000004621] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Fluid boluses aiming to improve the cardiac output and oxygen delivery are commonly administered in children with shock. An increased mean arterial pressure in addition to resolution of tachycardia and improved peripheral perfusion are often monitored as clinical surrogates for improvement in cardiac output. The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance. OBJECTIVE The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS We prospectively analyzed hemodynamic data from children in the cardiac ICU who received fluid bolus (10mL/kg of Ringers-Lactate over 30 min) for management of shock and/or hypoperfusion within 12h of cardiac surgery. Cardiac index responders and mean arterial pressure-responders were defined as CI ≥10% and mean arterial pressure ≥10%, respectively. We evaluated the gradient for venous-return (mean systemic filling pressure-central venous pressure), arterial load properties (systemic vascular resistance index and elastance index) and changes in vasopressor support after fluid bolus. MEASUREMENTS AND MAIN RESULTS Fifty-seven children between 1 month and 16 years (median Risk adjustment after congenital heart surgery Model for Outcome Surveillance in Australia and New Zealand score of 3.8 (interquartile range 3.7-4.6) received fluid bolus. Cardiac index-responsiveness and mean arterial pressure-responsiveness rates were 33% and 56%, respectively. No significant correlation was observed between changes in mean arterial pressure and cardiac index (r = 0.035, p = 0.79). Although the mean systemic filling pressure - central venous pressure and the number of cardiac index-responders after fluid bolus were similar, the arterial load parameters did not change in mean arterial pressure-nonresponders. Forty-three patients (75%) had a change in Vasoactive-Inotrope Score after the fluid bolus, of whom 60% received higher level of vasoactive support. CONCLUSIONS The mean arterial pressure response to fluid bolus in cardiac ICU patients was unpredictable with a poor relationship between cardiac index-responsiveness and mean arterial pressure-responsiveness. Because arterial hypotension is frequently a trigger for administering fluids and changes in blood pressure are commonly used for tracking changes in cardiac output, we suggest a cautious and individualized approach to repeat fluid bolus based solely on lack of mean arterial pressure response to the initial fluid, since the implications include decreased arterial tone even if the cardiac index increases.
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Harley A, Schlapbach LJ, Johnston ANB, Massey D. Challenges in the recognition and management of paediatric sepsis - The journey. Australas Emerg Care 2021; 25:23-29. [PMID: 33865753 DOI: 10.1016/j.auec.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/25/2021] [Accepted: 03/16/2021] [Indexed: 01/06/2023]
Abstract
Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.
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Affiliation(s)
- Amanda Harley
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Switzerland.
| | - Amy N B Johnston
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Debbie Massey
- School of Nursing and Midwifery, Southern Cross University, Coolangatta, QLD, Australia.
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Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med 2021; 78:1-19. [PMID: 33840511 DOI: 10.1016/j.annemergmed.2021.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 12/12/2022]
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Musikatavorn K, Plitawanon P, Lumlertgul S, Narajeenron K, Rojanasarntikul D, Tarapan T, Saoraya J. Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock. West J Emerg Med 2021; 22:369-378. [PMID: 33856325 PMCID: PMC7972359 DOI: 10.5811/westjem.2020.11.48571] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/10/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy. Methods This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups. Results A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm. Conclusion In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used.
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Affiliation(s)
- Khrongwong Musikatavorn
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand.,Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Department of Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Poj Plitawanon
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Suthaporn Lumlertgul
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Khuansiri Narajeenron
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Dhanadol Rojanasarntikul
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Tanawat Tarapan
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Jutamas Saoraya
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand.,Chulalongkorn University, Faculty of Medicine, Division of Academic Affairs, Bangkok, Thailand
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45
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Purcell LN, Prin M, Sincavage J, Kadyaudzu C, Phillips MR, Charles A. Outcomes Following Intensive Care Unit Admission in a Pediatric Cohort in Malawi. J Trop Pediatr 2020; 66:621-629. [PMID: 32417909 DOI: 10.1093/tropej/fmaa025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The burden of critical illness in low- and middle-income countries (LMICs) is high; however, there is a paucity of data describing pediatric critical care outcomes in this setting. METHODS We performed a prospective observational study of the pediatric (≤18 years) intensive care population in Malawi, from August 2016 to May 2018. Data collected include patient demographics and clinical data, admission criteria and outcome. A multivariate Poisson regression was performed to determine risk factors for mortality. RESULTS Over the study period, 499 patients were admitted to the intensive care unit (ICU) and 105 (21.0%) were children. The average age was 10.6 ± 5.4 years. Primary indications for ICU admission were sepsis (n = 30, 30.3%) and traumatic brain injury (TBI, n = 23, 23.2%). Of those who died, sepsis (n = 18, 32.7%), acute respiratory failure (n = 11, 20.0%) and TBI (n = 11, 20.0%) were the primary admission diagnoses. Overall, ICU mortality was 54.3% (n = 57). Multivariate regression for increased ICU mortality revealed: age ≤5 years [risk ratio (RR) 1.96, 95% CI 1.10-2.26, p < 0.001], hemoglobin < 10 g/dl (RR 1.58, 95% CI 1.08-2.01, p = 0.01) and shock requiring epinephrine support (RR 2.76, 95% CI 1.80-4.23, p < 0.001). CONCLUSIONS Pediatric ICU mortality is high. Predictors of mortality were age ≤5 years, anemia at ICU admission and the need for epinephrine support. Training of pediatric intensive care specialists and increased blood product availability may attenuate the high mortality for critically ill children in Malawi.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, NC 27599, USA
| | - Meghan Prin
- Department of Anesthesiology, University of Colorado, Denver, CO 80045, USA
| | - John Sincavage
- Department of Surgery, UNC Project-Malawi, Lilongwe, Malawi
| | | | - Michael R Phillips
- Department of Surgery, University of North Carolina at Chapel Hill, NC 27599, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, NC 27599, USA.,Department of Anesthesia, Kamuzu Central Hospital, Lilongwe, Malawi
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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47
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McBride A, Chanh HQ, Fraser JF, Yacoub S, Obonyo NG. Microvascular dysfunction in septic and dengue shock: Pathophysiology and implications for clinical management. Glob Cardiol Sci Pract 2020; 2020:e202029. [PMID: 33447608 PMCID: PMC7773436 DOI: 10.21542/gcsp.2020.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The microcirculation comprising of arterioles, capillaries and post-capillary venules is the terminal vascular network of the systemic circulation. Microvascular homeostasis, comprising of a balance between vasoconstriction, vasodilation and endothelial permeability in healthy states, regulates tissue perfusion. In severe infections, systemic inflammation occurs irrespective of the infecting microorganism(s), resulting in microcirculatory dysregulation and dysfunction, which impairs tissue perfusion and often precedes end-organ failure. The common hallmarks of microvascular dysfunction in both septic shock and dengue shock, are endothelial cell activation, glycocalyx degradation and plasma leak through a disrupted endothelial barrier. Microvascular tone is also impaired by a reduced bioavailability of nitric oxide. In vitro and in vivo studies have however demonstrated that the nature and extent of microvascular dysfunction as well as responses to volume expansion resuscitation differ in these two clinical syndromes. This review compares and contrasts the pathophysiology of microcirculatory dysfunction in septic versus dengue shock and the attendant effects of fluid administration during resuscitation.
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Affiliation(s)
- Angela McBride
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Brighton and Sussex Medical School, United Kingdom
| | - Ho Q Chanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - John F Fraser
- Critical Care Research Group, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
| | - Nchafatso G Obonyo
- Critical Care Research Group, Brisbane, Australia.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Initiative to Develop African Research Leaders, Kilifi, Kenya
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48
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Abstract
Background Severe malaria remains a leading cause of death worldwide. A greater understanding of its impact on multiple organ systems is essential in reducing the burden of disease. In this review we will summarize previously reported cardiovascular parameters of both adults and children with severe malaria. Method For this systematic review we searched MEDLINE and PUBMED for all papers published on cardiac function in severe malaria from January 1, 1990 until September 1, 2019. Severe malaria was defined as per World Health Organization. Publications were included if there was data from echocardiography, Pulse Contour Cardiac Output (PiCCO), or Pulmonary Arterial catheters (PAC) reported. Studies were excluded if related to medication induced cardiac dysfunction, malaria in pregnancy, or included subjects with known pre-existing heart disease. Results Twenty-four studies met inclusion criteria, the majority of which were studies of adult patients or a mixed cohort. Six solely involved pediatric patients. Significant heterogeneity existed in the cardiac parameters measured and results reported. One pediatric and one adult study suggested a reduced preload state during severe malaria. Cardiac systolic function was reported primarily within, or above, normative numeric ranges established in uninfected pediatric patients without anemia. Extensive variability existed in adult studies with reports of an elevated cardiac index in two studies, normal cardiac function in two studies, and descriptions of decreased function in two studies. Two reports suggest afterload in pediatric severe malaria is reduced. Reports of changes in the systemic vascular resistance of adults with severe malaria are inconsistent, with two trials demonstrating an increase and two suggesting a decrease. Studies demonstrated a mild rise in pulmonary pressure in both pediatric and adult patients that normalized by discharge. Conclusion Based on limited data, the cardiovascular effects of severe malaria appear to be heterogeneous and vary depending on age. Further detailed studies are required to explore and understand the overall hemodynamic effects of this high burden disease.
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49
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Abstract
The syndrome of critical illness is a complex physiological stressor that can be triggered by diverse pathologies. It is widely believed that organ dysfunction and death result from bioenergetic failure caused by inadequate cellular oxygen supply. Teleologically, life has evolved to survive in the face of stressors by undergoing a suite of adaptive changes. Adaptation not only comprises alterations in systemic physiology but also involves molecular reprogramming within cells. The concept of cellular adaptation in critically ill patients is a matter of contention in part because medical interventions mask underlying physiology, creating the artificial construct of "chronic critical illness," without which death would be imminent. Thus far, the intensive care armamentarium has not targeted cellular metabolism to preserve a temporary equilibrium but instead attempts to normalize global oxygen and substrate delivery. Here, we review adaptations to hypoxia that have been demonstrated in cellular models and in human conditions associated with hypoxia, including the hypobaric hypoxia of high altitude, the intrauterine low-oxygen environment, and adult myocardial hibernation. Common features include upregulation of glycolytic ATP production, enhancement of respiratory efficiency, downregulation of mitochondrial density, and suppression of energy-consuming processes. We argue that these innate cellular adaptations to hypoxia represent potential avenues for intervention that have thus far remained untapped by intensive care medicine.
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Affiliation(s)
- Helen T McKenna
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.,Royal Free Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | - Andrew J Murray
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Daniel S Martin
- Royal Free Intensive Care Unit, Royal Free Hospital, London, United Kingdom.,Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
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50
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Gordon D, Spiegel R. Fluid Resuscitation: History, Physiology, and Modern Fluid Resuscitation Strategies. Emerg Med Clin North Am 2020; 38:783-793. [PMID: 32981617 DOI: 10.1016/j.emc.2020.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Intravenous (IV) fluids are among the most common interventions performed in the emergency department. They are at times lifesaving, but if used recklessly can be harmful. Given their ubiquity, it is important to understand the history, physiology, and current strategies that govern the use of IV fluids during the resuscitation of the critically ill.
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Affiliation(s)
- David Gordon
- Department of Medicine, University of Maryland Medical Center, 110 South Paca Pratt Street, Baltimore, MD 21201, USA
| | - Rory Spiegel
- Attending Emergency Medicine, Georgetown University Hospital, Washington Hospital Center, Faculty Critical Care, 110 Irving Street, East Building Room 3124, Washington, DC 20010, USA.
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