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Becker AE, Dixon KL, Kirschen MP, Conlon TW, Glau CL. Advances in Point-of-Care Ultrasound in Pediatric Acute Care Medicine. Indian J Pediatr 2024:10.1007/s12098-024-05180-4. [PMID: 38842749 DOI: 10.1007/s12098-024-05180-4] [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] [Received: 03/29/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
Pediatric point-of-care ultrasonography (POCUS) has grown in utilization and is now an integral part of pediatric acute care. Applications within the pediatric critical care, neonatology and pediatric emergency were once limited to evaluation of undifferentiated shock states, abdominal free fluid assessments in trauma resuscitation and procedural guidance. The body of pediatric POCUS literature is ever expanding and recently published international consensus guidelines are available to guide implementation into clinical practice. The authors present a review of emerging applications and controversies within thoracic, hemodynamic, neurologic, and ocular POCUS in pediatric acute care medicine.
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Affiliation(s)
| | | | - Matthew P Kirschen
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Thomas W Conlon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Christie L Glau
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Anesthesiology and Critical Care Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Banothu KK, Sankar J, Pathak M, Kandasamy D, Gupta P, Kabra SK, Lodha R. Utility of Inferior Vena Cava Distensibility and Respiratory Variation in Peak Aortic Blood Flow Velocity to Predict Fluid Responsiveness in Children with Shock. Indian J Pediatr 2023; 90:1077-1082. [PMID: 37277686 DOI: 10.1007/s12098-023-04585-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/17/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the sensitivity and specificity of inferior vena cava (IVC) distensibility index (∆IVC) and respiratory variation in peak aortic blood flow velocity (∆Vpeak) to predict fluid responsiveness in ventilated children with shock and to find out the best cut-off values for predicting fluid responsiveness. METHODS In this prospective observational study, conducted in a pediatric ICU from January 2019 through May 2020, consecutive children aged 2 mo to 17 y with shock requiring fluid bolus were included. ∆IVC and ∆Vpeak were measured before and immediately after 10 ml/kg fluid bolus administration. ∆IVC and ∆Vpeak were compared between responders and non-responders, defined by a change in stroke volume index (SVI) of ≥10%. RESULTS Thirty-seven ventilated children [26 (70.4%) boys] with median age of 60 (36, 108) mo were included. The median (IQR) ∆IVC was 21.7% (14.3, 30.9) and the median (IQR) ΔVpeak was 11.3% (7.2, 15.2). Twenty-three (62%) children were fluid responsive. The median (IQR) ∆IVC was higher in responders compared to non-responders [26% (16.9, 36.5) vs. 17.2% (8.4, 21.9); p = 0.018] and mean (SD) ΔVpeak was higher in responders [13.9% (6.1) vs. 8.4% (3.9), p = 0.004]. The prediction of fluid responsiveness with ΔIVC [ROC curve area 0.73 (0.56-0.9), p = 0.01] and ΔVpeak [ROC curve area 0.78 (0.63-0.94), p = 0.002] was similar. The best cut-off of ∆IVC to predict fluid responsiveness was 23% (sensitivity, 60.8%; specificity, 85.7%) and ΔVpeak was 11.3% (sensitivity, 74%; specificity, 86%). CONCLUSIONS In this study, authors found that ∆IVC and ΔVpeak were good predictors of fluid responsiveness in ventilated children with shock.
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Affiliation(s)
- Kiran Kumar Banothu
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India.
| | - Mona Pathak
- Department of Research & Development, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | | | - Priyanka Gupta
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil Kumar Kabra
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
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Sethasathien S, Jariyasakoolroj T, Silvilairat S, Srisurapanont M. Aortic Peak Flow Velocity As a Predictor of Fluid Responsiveness in Mechanically Ventilated Children: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2023; 24:e352-e361. [PMID: 36856439 DOI: 10.1097/pcc.0000000000003219] [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: 03/02/2023]
Abstract
OBJECTIVES This meta-analysis aimed to determine the accuracy of the respiratory variations in aortic peak flow velocity (delta Vpeak) in predicting fluid responsiveness and the moderators of that accuracy. DATA SOURCES We performed searches for studies that used delta Vpeak as a predictor of fluid responsiveness in mechanically ventilated children in PubMed, Embase, Scopus, and CINAHL from inception to June 20, 2022. STUDY SELECTION AND DATA EXTRACTION Fifteen studies ( n = 452) were included in this meta-analysis. The diagnostic test data of the included studies were synthesized as pooled sensitivity, specificity, and diagnostic odds ratio (DOR) and the area under the curve (AUC) of the summary receiver operating characteristic of delta Vpeak. DATA SYNTHESIS The delta Vpeak cutoff values applied in these studies had a median of 12.3% (interquartile range, 11.50-13.25%). The pooled sensitivity and specificity of delta Vpeak were 0.80 (95% CI, 0.71-0.87) and 0.82 (95% CI, 0.75-0.87), respectively. The DOR of delta Vpeak was 23.41 (95% CI, 11.61-47.20). The AUC of delta Vpeak was 0.87. Subgroup analyses revealed that the accuracy of delta Vpeak was not moderated by ventilator settings, measures of delta Vpeak, gold standard index, the cutoff gold standard value of responders, type and volume of fluid, duration of fluid challenge, use of vasoactive drugs, general anesthesia, and cardiopulmonary bypass. CONCLUSIONS By using the cutoff of approximately 12.3%, the delta Vpeak appears to have good accuracy in predicting fluid responsiveness in mechanically ventilated children. The moderators of delta Vpeak predictability are not found.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand
| | - Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand
| | - Manit Srisurapanont
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Weber MD, Lim JKB, Ginsburg S, Conlon T, Nishisaki A. Translating Guidelines into Practical Practice: Point-of-Care Ultrasound for Pediatric Critical Care Clinicians. Crit Care Clin 2023; 39:385-406. [PMID: 36898781 DOI: 10.1016/j.ccc.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Point-of-care ultrasound (POCUS) is now transitioning from an emerging technology to a standard of care for critically ill children. POCUS can provide immediate answers to clinical questions impacting management and outcomes within this fragile population. Recently published international guidelines specific to POCUS use in neonatal and pediatric critical care populations now complement previous Society of Critical Care Medicine guidelines. The authors review consensus statements within guidelines, identify important limitations to statements, and provide considerations for the successful implementation of POCUS in the pediatric critical care setting.
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Affiliation(s)
- Mark D Weber
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Joel K B Lim
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Sarah Ginsburg
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas Conlon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Akira Nishisaki
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
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Lu JC, Riley A, Conlon T, Levine JC, Kwan C, Miller-Hance WC, Soni-Patel N, Slesnick T. Recommendations for Cardiac Point-of-Care Ultrasound in Children: A Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2023; 36:265-277. [PMID: 36697294 DOI: 10.1016/j.echo.2022.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiac point-of-care ultrasound has the potential to improve patient care, but its application to children requires consideration of anatomic and physiologic differences from adult populations, and corresponding technical aspects of performance. This document is the product of an American Society of Echocardiography task force composed of representatives from pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric anesthesiology, and others, assembled to provide expert guidance. This diverse group aimed to identify common considerations across disciplines to guide evolution of indications, and to identify common requirements and infrastructure necessary for optimal performance, training, and quality assurance in the practice of cardiac point-of-care ultrasound in children. The recommendations presented are intended to facilitate collaboration among subspecialties and with pediatric echocardiography laboratories by identifying key considerations regarding (1) indications, (2) imaging recommendations, (3) training and competency assessment, and (4) quality assurance.
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Affiliation(s)
- Jimmy C Lu
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan
| | - Alan Riley
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Thomas Conlon
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jami C Levine
- Harvard School of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Charisse Kwan
- University of Western Ontario, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | | | | | - Timothy Slesnick
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Desgranges FP, Bouvet L, Pereira de Souza Neto E, Evain JN, Terrisse H, Joosten A, Desebbe O. Non-invasive measurement of digital plethysmographic variability index to predict fluid responsiveness in mechanically ventilated children: A systematic review and meta-analysis of diagnostic test accuracy studies. Anaesth Crit Care Pain Med 2023; 42:101194. [PMID: 36640908 DOI: 10.1016/j.accpm.2023.101194] [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: 08/29/2022] [Revised: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND To date, the use of the plethysmographic variability index (PVI) has not been recommended to guide fluid management in the paediatric surgical population. This systematic review and meta-analysis aimed to summarise available evidence about the diagnostic accuracy of digital PVI to predict fluid responsiveness in mechanically ventilated children. METHODS We searched the Pubmed, Embase and Web of Science databases, from inception to January 2022, to identify all relevant studies that investigated the ability of the PVI recorded at the finger to predict fluid responsiveness in mechanically ventilated children. Using a random-effects model, we calculated pooled values of diagnostic odds ratio, sensitivity, and specificity of PVI to predict the response to fluid challenge. RESULTS Eight studies met the inclusion criteria with a total of 283 patients and 360 fluid challenges. All the studies were carried out in a surgical setting. The area under the summary receiver operating characteristic curve of PVI to predict fluid responsiveness was 0.82. The pooled sensitivity, specificity, and diagnostic odds ratio of PVI for the overall population were 72.4% [95% CI: 65.3-78.7], 65.9% [58.5-72.8], and 9.26 [5.31-16.16], respectively. CONCLUSION Our results suggest that digital PVI is a reliable predictor for fluid responsiveness in mechanically ventilated children in the perioperative setting. The diagnostic performance of digital PVI reported in our work for discrimination between responders and non-responders to the fluid challenge was however not as high as previously reported in the adult population.
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Affiliation(s)
- François-Pierrick Desgranges
- Department of Anaesthesiology, L'Hôpital Nord-Ouest, Villefranche-sur-Saône Hospital, Villefranche-sur-Saône, France.
| | - Lionel Bouvet
- Department of Anaesthesiology and Intensive Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Bron, France; Research Unit APCSe VetAgro Sup UPSP 2016.A101, Claude Bernard Lyon 1 University, Marcy-l'Etoile, France
| | | | - Jean-Noël Evain
- Department of Anaesthesiology and Intensive Care, Grenoble Alpes University Hospital, Grenoble, France; Alps Research Assessment and Simulation Centre, Grenoble Alpes University Hospital, Grenoble, France; TIMC-IMAG Laboratory, UMR, CNRS 5525, Grenoble Alpes University, Grenoble, France
| | - Hugo Terrisse
- Department of Biostatistics, Grenoble Alpes University Hospital, Grenoble, France; TIMC-IMAG Laboratory, UMR, CNRS 5525, Grenoble Alpes University, Grenoble, France
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Olivier Desebbe
- Department of Anaesthesiology and Intensive Care, Ramsay Santé, Sauvegarde Clinic, Lyon, France
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Lee JH, Jang HS, Kang P, Song IS, Ji SH, Jang YE, Kim EH, Kim HS, Kim JT. Prediction of fluid responsiveness following liver compression in pediatric patients with single ventricle physiology. Paediatr Anaesth 2022; 32:637-646. [PMID: 35156257 DOI: 10.1111/pan.14417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The role of liver compression in predicting fluid responsiveness in children with a single ventricle has never been evaluated. The purpose of this study was to assess whether blood pressure changes during liver compression predict fluid responsiveness in children with single ventricle physiology. METHODS This prospective, interventional study included children aged 3 months to 5 years who underwent surgery for bidirectional cavopulmonary shunt or extracardiac Fontan operation. Before fluid loading, the right upper abdomen was compressed at 30 mmHg for 10 s, and changes in the blood pressure waves were recorded before administering 10 ml kg-1 of crystalloid solution. Systolic arterial pressure, diastolic arterial pressure, central venous pressure, pleth variability index, respiratory variation in aortic blood flow peak velocity, and stroke volume were measured before and after fluid loading. A volume responder was defined as a patient with >15% increase in stroke volume index. RESULTS Thirty patients underwent bidirectional cavopulmonary shunt (15 responders and 15 non-responders), and 32 underwent Fontan surgery (17 responders and 15 non-responders). In children with bidirectional cavopulmonary shunt, Δsystolic arterial pressure > 8 mmHg (sensitivity 76.9% and specificity 93.3%), Δdiastolic arterial pressure > 7 mmHg (sensitivity 69.2% and specificity 93.3%), and Δmean arterial pressure > 7 mmHg (sensitivity 69.2% and specificity 100%) during liver compression predicted fluid responsiveness. The areas under the receiver operating characteristic curves of Δsystolic arterial pressure, Δdiastolic arterial pressure, and Δmean arterial pressure were 0.928, 0.859, and 0.874 (all p < .001). In children who underwent Fontan surgery, only Δsystolic arterial pressure > 16 mmHg was predictive of fluid responsiveness (sensitivity of 41.2% and specificity of 100%), with the areas under the receiver operating characteristic curves curve of 0.786 (p < .001). Pleth variability index and respiratory variation in aortic blood flow peak velocity had no predictive value for fluid responsiveness after both types of surgeries. DISCUSSION In BCPS patients, liver compression increases the inferior vena cava flow which directly leads to an increase in preload. On the other hand, blood flow from the liver drains directly into the pulmonary arteries in Fontan circulation. Because of this characteristics for preload determination, the clinical application of liver compression to monitor hemodynamic changes might be more useful in patients with bidirectional cavopulmonary shunt than those with Fontan circulation. CONCLUSION Increase in blood pressure induced by liver compression is predictive of fluid responsiveness in children with single ventricle physiology.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hwan-Suk Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Pyoyoon Kang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - In Sun Song
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang-Hwan Ji
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Young-Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Eun-Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Yenjabog P, Kanchongkittiphon W, Chutipongtanate S, Lertbunrian R, Ungprasert P. Dynamic parameters for fluid responsiveness in mechanically ventilated children: A systematic review. Front Pediatr 2022; 10:1010600. [PMID: 36353262 PMCID: PMC9638161 DOI: 10.3389/fped.2022.1010600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/28/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Fluid administration is the initial step of treatment of unstable pediatric patients. Evaluation of fluid responsiveness is crucial in mechanically ventilated children to avoid fluid overload, which increases mortality. We aim to review and compare the diagnostic performance of dynamically hemodynamic parameters for predicting fluid responsiveness in mechanically ventilated children. DESIGN A systematic review was performed using four electronic databases, including PubMed, EMBASE, Scopus, and Central, for published articles from 1 January 2010 to 31 December 2020. Studies were included if they described diagnostic performance of dynamic parameters after fluid challenge was performed in mechanically ventilated children. SETTINGS Pediatric intensive and cardiac intensive care unit, and operative room. PATIENTS Children aged 1 month to 18 years old who were under mechanical ventilation and required an intravenous fluid challenge. MEASUREMENTS AND MAIN RESULTS Twenty-seven studies were included in the systematic review, which included 1,005 participants and 1,138 fluid challenges. Respiratory variation in aortic peak velocity was reliable among dynamic parameters for predicting fluid responsiveness in mechanically ventilated children. All studies of respiratory variation in aortic peak velocity showed that the area under the receiver operating characteristic curve ranged from 0.71 to 1.00, and the cutoff value for determining fluid responsiveness ranged from 7% to 20%. Dynamic parameters based on arterial blood pressure (pulse pressure variation and stroke volume variation) were also used in children undergoing congenital heart surgery. The plethysmography variability index was used in children undergoing neurological and general surgery, including the pediatric intensive care patients. CONCLUSIONS The respiratory variation in aortic peak velocity exhibited a promising diagnostic performance across all populations in predicting fluid responsiveness in mechanically ventilated children. High sensitivity is advantageous in non-cardiac surgical patients and the pediatric intensive care unit because early fluid resuscitation improves survival in these patients. Furthermore, high specificity is beneficial in congenital heart surgery because fluid overload is particularly detrimental in this group of patients. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206400.
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Affiliation(s)
- Patcha Yenjabog
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wacharoot Kanchongkittiphon
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Chutipongtanate
- Pediatric Translational Research Unit, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Clinical Epidemiology and Biostatistics, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States
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Respiratory Variation in Aortic Blood Flow Velocity in Hemodynamically Unstable, Ventilated Neonates: A Pilot Study of Fluid Responsiveness. Pediatr Crit Care Med 2021; 22:380-391. [PMID: 33315755 DOI: 10.1097/pcc.0000000000002628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To assess whether respiratory variation in aortic blood flow peak velocity can predict preload responsiveness in mechanically ventilated and hemodynamically unstable neonates. DESIGN Prospective observational diagnostic accuracy study. SETTING Third-level neonatal ICU. PATIENTS Hemodynamically unstable neonates under mechanical ventilation. INTERVENTIONS Fluid challenge with 10 mL/kg of normal saline over 20 minutes. MEASUREMENTS AND MAIN RESULTS Respiratory variation in aortic blood flow peak velocity and superior vena cava flow were measured at baseline (T0), immediately upon completion of the fluid infusion (T1), and at 1 hour after fluid administration (T2). Our main outcome was preload responsiveness which was defined as an increase in superior vena cava flow of at least 10% from T0 to T1. Forty-six infants with a median (interquartile range) gestational age of 30.5 weeks (28-36 wk) were included. Twenty-nine infants (63%) were fluid responders, and 17 (37%) were nonresponders Fluid responders had a higher baseline (T0) respiratory variation in aortic blood flow peak velocity than nonresponders (9% [8.2-10.8] vs 5.5% [3.7-6.6]; p < 0.001). Baseline respiratory variation in aortic blood flow peak velocity was correlated with the increase in superior vena cava flow from T0 to T1 (rho = 0.841; p < 0.001). The area under the receiver operating characteristic curve of respiratory variation in aortic blood flow peak velocity to predict preload responsiveness was 0.912 (95% CI, 0.82-1). A respiratory variation in aortic blood flow peak velocity cut-off point of 7.8% provided a 90% sensitivity (95% CI, 71-97), 88% specificity (95% CI, 62-98), 7.6 positive likelihood ratio (95% CI, 2-28), and 0.11 negative likelihood ratio (95% CI, 0.03-0.34) to predict preload responsiveness. CONCLUSIONS Respiratory variation in aortic blood flow velocity may be useful to predict the immediate response to a fluid challenge in hemodynamically unstable neonates under mechanical ventilation. If our results are confirmed, this measurement could be used to guide safe and individualized fluid resuscitation in critically ill neonates.
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Prediction of Fluid Responsiveness by Stroke Volume Variation in Children Undergoing Fontan Operation. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2595960. [PMID: 33224977 PMCID: PMC7669329 DOI: 10.1155/2020/2595960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/19/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022]
Abstract
Background Fontan operation is a palliative medical procedure performed on children with single-ventricle defects. As postoperative success of the procedure largely depends on the preload volume, it is necessary to maintain an appropriate pressure gradient between the systemic vein and the left atrium to ensure the effective volume of systemic circulation. However, there is a lack of effective indexes to evaluate fluid responsiveness in Fontan patients. Stroke volume variation (SVV) is a dynamic hemodynamic parameter based on cardiopulmonary interaction in mechanical ventilation. This study is aimed at validating the sensitivity and specificity of SVV and central venous pressure (CVP) in assessing the fluid responsiveness of Fontan patients. Method Sixty-four children with single ventricle who underwent modified Fontan operation between May 2018 and January 2020 were included in this study. Patients were administered 10 ml·kg−1 albumin for fluid challenge within 10 min after cardiopulmonary bypass. Before and after fluid challenge, the invasive arterial pressure module was connected to MostCare™ equipment to collect the cardiac index (CI) and SVV dynamically in a time window of 30 s at a frequency of 1000 Hz. According to the range of CI change, patients with ΔCI ≥ 15% were classified into the responder (R) group and those with ΔCI < 15% into the nonresponder (NR) group. Using SVV and CVP as indicators, the receiver operating characteristic (ROC) curve of the patients was established, and the area under curve (AUC), diagnostic threshold, sensitivity, and specificity were calculated. Results The SVV values were 16.28% (25th and 75th percentiles 14.17%-19.24%) and 13.68% (25th and 75th percentiles 12.90%-15.89%) before and after fluid challenge treatment in responders, respectively, and the values were 18.60 ± 1.83 mmHg before and 20.20 ± 2.39 mmHg for CVP after treatment. The AUC of SVV was 0.74 (95% confidence interval (CI) 0.54-0.94, P < 0.05), and the cutoff value was 16%, offering a sensitivity of 50% and a specificity of 91.7%. Meanwhile, the AUC of CVP was 0.70 (95% CI 0.50-0.92, P > 0.05), and the cutoff value was 19.5 mmHg, offering a sensitivity of 58% and a specificity of 76%. Conclusion SVV exhibited a good predictive value for fluid responsiveness in pediatric Fontan patients. Appropriate fluid therapy according to SVV could improve the cardiac function of such patients. Trial registration. This study was registered in Chinese Clinical Trail Registry on Jan 26, 2018. Registration number is ChiCTR1800014654. Registry URL is http://www.chictr.org.cn/showproj.aspx?proj=25019. This observational prospective study was approved by the Local Ethics Committee of Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University (SCMCIRB-K2017035).
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Singh Y, Villaescusa JU, da Cruz EM, Tibby SM, Bottari G, Saxena R, Guillén M, Herce JL, Di Nardo M, Cecchetti C, Brierley J, de Boode W, Lemson J. Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:620. [PMID: 33092621 PMCID: PMC7579971 DOI: 10.1186/s13054-020-03326-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. METHODS Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature-a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. RESULTS Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached "strong agreement," 20 "weak agreement," and 2 had "no agreement." Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. CONCLUSIONS These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Javier Urbano Villaescusa
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Eduardo M da Cruz
- Department of Pediatrics, Children's Hospital Colorado, Section of Cardiac Intensive Care, The Heart Institute, Pittsburgh, USA
| | - Shane M Tibby
- Department of Pediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Gabriella Bottari
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Rohit Saxena
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Marga Guillén
- Department of Pediatric Intensive Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jesus Lopez Herce
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Matteo Di Nardo
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Joe Brierley
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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