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Selewski DT, Barhight MF, Bjornstad EC, Ricci Z, de Sousa Tavares M, Akcan-Arikan A, Goldstein SL, Basu R, Bagshaw SM. Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:955-979. [PMID: 37934274 PMCID: PMC10817849 DOI: 10.1007/s00467-023-06156-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology. METHODS The 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed. CONCLUSIONS The 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Erica C Bjornstad
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zaccaria Ricci
- Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Florence, Italy.
- Department of Health Science, University of Florence, Florence, Italy.
| | - Marcelo de Sousa Tavares
- Pediatric Nephrology Unit, Nephrology Center of Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Ayse Akcan-Arikan
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rajit Basu
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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Harley A, George S, Phillips N, King M, Long D, Keijzers G, Lister P, Raman S, Bellomo R, Gibbons K, Schlapbach LJ. Resuscitation With Early Adrenaline Infusion for Children With Septic Shock: A Randomized Pilot Trial. Pediatr Crit Care Med 2024; 25:106-117. [PMID: 38240535 PMCID: PMC10798589 DOI: 10.1097/pcc.0000000000003351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
OBJECTIVES In children with septic shock, guidelines recommend resuscitation with 40-60 mL/kg of fluid boluses, yet there is a lack of evidence to support this practice. We aimed to determine the feasibility of a randomized trial comparing early adrenaline infusion with standard fluid resuscitation in children with septic shock. DESIGN Open-label parallel randomized controlled, multicenter pilot study. The primary end point was feasibility; the exploratory clinical endpoint was survival free of organ dysfunction by 28 days. SETTING Four pediatric Emergency Departments in Queensland, Australia. PATIENTS Children between 28 days and 18 years old with septic shock. INTERVENTIONS Patients were assigned 1:1 to receive a continuous adrenaline infusion after 20 mL/kg fluid bolus resuscitation (n = 17), or standard care fluid resuscitation defined as delivery of 40 to 60 mL/kg fluid bolus resuscitation prior to inotrope commencement (n = 23). MEASUREMENTS AND MAIN RESULTS Forty of 58 eligible patients (69%) were consented with a median age of 3.7 years (interquartile range [IQR], 0.9-12.1 yr). The median time from randomization to inotropes was 16 minutes (IQR, 12-26 min) in the intervention group, and 49 minutes (IQR, 29-63 min) in the standard care group. The median amount of fluid delivered during the first 24 hours was 0 mL/kg (IQR, 0-10.0 mL/kg) in the intervention group, and 20.0 mL/kg (14.6-28.6 mL/kg) in the standard group (difference, -20.0; 95% CI, -28.0 to -12.0). The number of days alive and free of organ dysfunction did not differ between the intervention and standard care groups, with a median of 27 days (IQR, 26-27 d) versus 26 days (IQR, 25-27 d). There were no adverse events reported associated with the intervention. CONCLUSIONS In children with septic shock, a protocol comparing early administration of adrenaline versus standard care achieved separation between the study arms in relation to inotrope and fluid bolus use.
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Affiliation(s)
- Amanda Harley
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- Children`s Critical Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pediatric and Neonatal Intensive Care Unit, and Children`s Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Shane George
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Natalie Phillips
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Megan King
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Paula Lister
- Children`s Critical Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- Emergency Department Queensland Children`s Hospital, Brisbane, QLD, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- Children`s Critical Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Intensive Care Research, Austin Hospital and Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pediatric and Neonatal Intensive Care Unit, and Children`s Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
- Pediatric and Neonatal Intensive Care Unit, and Children`s Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Atreya MR, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Abulebda K, Lutfi R, Nowak J, Thomas NJ, Baines T, Quasney M, Haileselassie B, Sahay R, Zhang B, Alder MN, Stanski NL, Goldstein SL. Revisiting Post-ICU Admission Fluid Balance Across Pediatric Sepsis Mortality Risk Strata: A Secondary Analysis of a Prospective Observational Cohort Study. Crit Care Explor 2024; 6:e1027. [PMID: 38234587 PMCID: PMC10793970 DOI: 10.1097/cce.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Post-ICU admission cumulative positive fluid balance (PFB) is associated with increased mortality among critically ill patients. We sought to test whether this risk varied across biomarker-based risk strata upon adjusting for illness severity, presence of severe acute kidney injury (acute kidney injury), and use of continuous renal replacement therapy (CRRT) in pediatric septic shock. DESIGN Ongoing multicenter prospective observational cohort. SETTING Thirteen PICUs in the United States (2003-2023). PATIENTS Six hundred and eighty-one children with septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cumulative percent PFB between days 1 and 7 (days 1-7 %PFB) was determined. Primary outcome of interest was complicated course defined as death or persistence of greater than or equal to two organ dysfunctions by day 7. Pediatric Sepsis Biomarker Risk Model (PERSEVERE)-II biomarkers were used to assign mortality probability and categorize patients into high mortality (n = 91), intermediate mortality (n = 134), and low mortality (n = 456) risk strata. Cox proportional hazard regression models with adjustment for PERSEVERE-II mortality probability, presence of sepsis-associated acute kidney injury on day 3, and use of CRRT, demonstrated that time-dependent variable days 1-7%PFB was independently associated with an increased hazard of complicated course. Risk-stratified analyses revealed that each 10% increase in days 1-7 %PFB was associated with increased hazard of complicated course only among patients with high mortality risk strata (adjusted hazard ratio 1.24 (95% CI, 1.08-1.43), p = 0.003). However, this association was not causally mediated by PERSEVERE-II biomarkers. CONCLUSIONS Our data demonstrate the influence of cumulative %PFB on the risk of complicated course in pediatric septic shock. Contrary to our previous report, this risk was largely driven by patients categorized as having a high mortality risk based on PERSEVERE-II biomarkers. Incorporation of such prognostic enrichment tools in randomized trials of restrictive fluid management or early initiation of de-escalation strategies may inform targeted application of such interventions among at-risk patients.
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Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Julie C Fitzgerald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott L Weiss
- Department of Pediatrics, Nemours Children's Hospital, Wilmington, DE
| | | | - Parag N Jain
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Kamal Abulebda
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, IN
| | - Riad Lutfi
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, IN
| | - Jeffrey Nowak
- Department of Pediatrics, Children's Hospital and Clinics of Minnesota, Minneapolis, MN
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, PA
| | - Torrey Baines
- Department of Pediatrics, University of Florida Health Shands Children's Hospital, Gainesville, FL
| | - Michael Quasney
- Department of Pediatrics, CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI
| | | | - Rashmi Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
| | - Matthew N Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Natalja L Stanski
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Nephrology, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH
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Rice B, Hawkins J, Nakato S, Kamara N. Mortality after emergency unit fluid bolus in febrile Ugandan children. PLoS One 2023; 18:e0290790. [PMID: 37651354 PMCID: PMC10470955 DOI: 10.1371/journal.pone.0290790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda. METHODS This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria. RESULTS The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase. CONCLUSIONS This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.
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Affiliation(s)
- Brian Rice
- Department of Emergency Medicine, Stanford University, Palo Alto, California, United States of America
- Global Emergency Care, Shrewsbury, Massachusetts, United States of America
| | - Jessica Hawkins
- Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Serena Nakato
- Global Emergency Care, Shrewsbury, Massachusetts, United States of America
- Karoli Lwanga Hospital, Rukungiri, Uganda
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O'Hearn K, Cayouette F, Cameron S, Martin DA, Tsampalieros A, Menon K. Assent in Pediatric Critical Care Research: A Cross-Sectional Stakeholder Survey of Canadian Research Ethics Boards, Research Coordinators, Pediatric Critical Care Researchers, and Nurses. Pediatr Crit Care Med 2023; 24:e179-e189. [PMID: 36511694 DOI: 10.1097/pcc.0000000000003135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Survey of four stakeholder groups involved in defining and obtaining assent for research in Canadian PICUs to better understand their perspectives and perceived barriers to assent. DESIGN Cross-sectional survey. SETTING Fourteen tertiary-care pediatric hospitals in Canada. PARTICIPANTS Research Ethics Board Chairs, pediatric critical care nurses, research coordinators, and researchers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 193 participants responded. Thirty-seven percent (59/159) thought it was "Never/Almost Never" (59/159, 37%) feasible to obtain assent during the first 48 hours of PICU admission, and 112 of 170 (66%) indicated there are unique barriers to assent at the time of enrollment in PICU studies. Asking children for assent was most frequently rated as Important/Very Important for interviews/focus groups with the child (138/180, 77%), blood sample collection with a needle poke for research (137/178, 77%), and studies involving genetic testing with results communicated to the child/legal guardian (134/180, 74%). In two scenarios where a child and legal guardian disagreed about study participation, most respondents indicated that whether the child should still be enrolled would depend on the patient's age (34-36%), and/or the risk of the study (24-28%). There was a lack of consensus over how the assent process should be operationalized, and when and for how long children should be followed to seek assent for ongoing study participation. Most stakeholders (117/158, 74%) thought that children should have the opportunity to decide if their samples could stay in a biobank once they are old enough to do so. CONCLUSIONS There was an overall lack of consensus on the feasibility of, and challenges associated with, obtaining assent at the time of study enrollment and on how key aspects of the assent process should be operationalized in the PICU. This highlights the need for guidelines to clarify the assent process in pediatric critical care research.
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Affiliation(s)
- Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Florence Cayouette
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Saoirse Cameron
- Children's Hospital - London Health Sciences Centre, London, ON, Canada
| | - Dori-Ann Martin
- Section of Critical Care Medicine, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario, Clinical Research Unit, Ottawa, ON, Canada
| | - Kusum Menon
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Division of Critical Care, Ottawa, ON, Canada
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Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Zaman MAU, Roy O, Chowdhoury SR, Nandi M. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023; 27:139-146. [PMID: 36865513 PMCID: PMC9973056 DOI: 10.5005/jp-journals-10071-24410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023] Open
Abstract
Background To evaluate the role of ultrasound during initial fluid resuscitation along with clinical guidance in reducing the incidence of fluid overload on day 3 in children with septic shock. Materials and methods It was a prospective, parallel limb open-labeled randomized controlled superiority trial done in the PICU of a government-aided tertiary care hospital in Eastern India. Patient enrolment took place between June 2021 and March 2022. Fifty-six children aged between 1 month and 12 years, with proven or suspected septic shock, were randomized to receive either ultrasound-guided or clinically guided fluid boluses (1:1 ratio) and subsequently followed up for various outcomes. The primary outcome was frequency of fluid overload on day 3 of admission. The treatment group received ultrasound-guided fluid boluses along with the clinical guidance and the control group received the same but without ultrasound guidance upto 60 mL/kg of fluid boluses. Results The frequency of fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs 62%, p = 0.012) as was the median (IQR) cumulative fluid balance percentage on day 3 [6.5 (3.3-10.3) vs 11.3 (5.4-17.5), p = 0.02]. The amount of fluid bolus administered was also significantly lower by ultrasound [median 40 (30-50) vs 50 (40-80) mL/kg, p = 0.003]. Resuscitation time was shorter in the ultrasound group (13.4 ± 5.6 vs 20.5 ± 8 h, p = 0.002). Conclusion Ultrasound-guided fluid boluses were found to be significantly better than clinically guided therapy, in preventing fluid overload and its associated complications in children with septic shock. These factors make ultrasound a potentially useful tool for resuscitation of children with septic shock in the PICU. How to cite this article Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Uz Zaman MA, Roy O, et al. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023;27(2):139-146.
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Affiliation(s)
- Ryan Sohail Kaiser
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Mihir Sarkar
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Sumantra Kumar Raut
- Department of Nephrology, North Bengal Medical College, Kolkata, West Bengal India
| | | | | | - Oishik Roy
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Satyabrata Roy Chowdhoury
- Department of Pediatrics, North Bengal Medical College, Kolkata, West Bengal India,Satyabrata Roy Chowdhoury, Department of Pediatrics, North Bengal Medical College, Kolkata, West Bengal, India, Phone: +91 9433765529, e-mail:
| | - Mousumi Nandi
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
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Mullan PC, Pruitt CM, Levasseur KA, Macias CG, Paul R, Depinet H, Nguyen ATH, Melendez E. Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:375-384. [PMID: 35924031 PMCID: PMC9342868 DOI: 10.2147/oaem.s368442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients and Methods Results Conclusion
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Affiliation(s)
- Paul C Mullan
- Department of Pediatrics, Division of Emergency Medicine, Eastern Virginia Medical School, Children’s Hospital of the King’s Daughters, Norfolk, VA, USA
- Correspondence: Paul C Mullan, Email
| | - Christopher M Pruitt
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly A Levasseur
- Pediatric Emergency Medicine, Beaumont Children’s Hospital, Royal Oak, MI, USA
| | - Charles G Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies and Children’s, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raina Paul
- Department of Emergency Medicine, Advocate Children’s Hospital, Park Ridge, IL, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Anh Thy H Nguyen
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Elliot Melendez
- Division of Pediatric Critical Care, Connecticut Children’s Medical Center, University of Connecticut, Hartford, CT, USA
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He C, Hu X, Li T, Wu Q, Fan J, Zhou Y, Jiang L, Hong S, Luo Y. Risk Factors Associated With Prolonged Antibiotic Use in Pediatric Bacterial Meningitis. Front Pharmacol 2022; 13:904322. [PMID: 35800444 PMCID: PMC9253569 DOI: 10.3389/fphar.2022.904322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: To determine the risk factors associated with a prolonged antibiotic course for community-acquired bacterial meningitis (BM) in children.Methods: This retrospective cohort study included children aged 1 month to 18 years with community-acquired BM due to a confirmed causative pathogen from 2011 to 2021. Patients were divided into an antibiotic prolongation group and a nonprolongation group according to whether the antibiotic course exceeded 2 weeks of the recommended course for the causative pathogen. Associations of important clinical characteristics and laboratory and other parameters with antibiotic prolongation were assessed using univariate and multivariable regression logistic analyses.Results: In total, 107 patients were included in this study. Augmented renal clearance (ARC) (OR, 19.802; 95% CI, 7.178–54.628; p < 0.001) was associated with a prolonged antibiotic course; however, septic shock, causative pathogen, preadmission antibiotic use, peripheral white blood cell (WBC) count, initial cerebrospinal fluid (CSF) WBC count, CSF glucose, CSF protein, and surgical intervention were not associated with the prolonged antibiotic course. Patients with ARC had more total fever days (median time: 14 vs. 7.5 days), longer hospitalization (median time: 39 vs. 24 days), higher rates of complications (72.34% vs. 50.00%) and antibiotic adjustments (78.723% vs. 56.667%) than patients with normal renal function.Conclusion: ARC is an independent risk factor for prolonged antibiotic use in children with community-acquired BM. ARC may be associated with longer fever and hospitalization durations, higher rates of complications and antibiotic adjustments.
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Affiliation(s)
- Cuiyao He
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaogang Hu
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Tingsong Li
- Department of Rehabilitation, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Qing Wu
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jisan Fan
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Zhou
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Li Jiang
- Department of Neurology, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yuanyuan Luo
- Department of Neurology, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Yuanyuan Luo,
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Gill PJ, Bayliss A, Sozer A, Buchanan F, Breen-Reid K, De Castris-Garcia K, Green M, Quinlan M, Wong N, Frappier S, Cowan K, Chan C, Arafeh D, Anwar MR, Macarthur C, Parkin PC, Cohen E, Mahant S. Patient, Caregiver, and Clinician Participation in Prioritization of Research Questions in Pediatric Hospital Medicine. JAMA Netw Open 2022; 5:e229085. [PMID: 35471568 PMCID: PMC9044112 DOI: 10.1001/jamanetworkopen.2022.9085] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE The research agenda in pediatric hospital medicine has seldom considered the perspectives of young people, parents and caregivers, and health care professionals. Their perspectives may be useful in identifying questions on topics for research. OBJECTIVE To prioritize unanswered research questions in pediatric hospital medicine from the perspectives of young people, parents/caregivers, and health care professionals. DESIGN, SETTING, AND PARTICIPANTS Between August 4, 2020, and August 19, 2021, two online surveys and a virtual workshop were conducted, using modified Delphi technique and nominal group technique. Young people, parents/caregivers, and health care professionals with experiences in pediatric hospital medicine in Canada were included. INTERVENTIONS The established James Lind Alliance Priority Setting Partnership method was used. In phase 1, a survey collected unanswered questions regarding pediatric hospital medicine via 3 open-ended questions. Survey responses were used to develop summary questions that went through an evidence-checking process. Unanswered questions were brought to a phase 2 interim prioritization survey. The top 10 unanswered research questions in pediatric hospital medicine were established at the final priority setting workshop. MAIN OUTCOMES AND MEASURES Survey responses, top 10 research questions. RESULTS The phase 1 survey was completed by 188 participants (148 of 167 [89%] females; 17 of 167 [10%] males; mean [SD] age, 39.5 [12.4] years) and generated 495 unanswered research questions and comments, of which 58 were deemed out of scope. The remaining 437 responses were grouped into themes (eg, communication, shared decision-making, health service delivery, and health service management) and then refined to 75 unanswered research questions. Of these 75, only 4 questions had sufficient evidence. To make the number of questions in phase 2 manageable, 21 questions submitted by only 1 respondent were eliminated. Fifty unanswered research questions were included in the phase 2 survey, which was completed by 201 participants (165 of 186 [89%] females; 19 of 186 [10%] males; mean [SD] age, 40.0 [11.0] years). A short list of 16 questions-the top 10 questions from patient partners (youths, parents/caregivers) and clinicians-was presented at the final priority setting workshop and the top 10 questions were prioritized. The top 10 questions focused on the care of special inpatient populations (eg, children with medical complexity), communication, shared decision-making, support strategies in the hospital, mental health supports, shortening length of stay, and supporting Indigenous patients, parents/caregivers, and families. CONCLUSIONS AND RELEVANCE This patient-oriented pediatric hospital medicine priority setting partnership identified the most important unanswered research questions focused on the care of children in the hospital. These questions provide a possible roadmap for research on areas deemed important to young people, parents/caregivers, and clinicians.
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Affiliation(s)
- Peter J. Gill
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Pediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Aubrey Sozer
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Francine Buchanan
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Research Family Advisory Committee, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Mairead Green
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Michelle Quinlan
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Noel Wong
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Learning Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shelley Frappier
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | | | - Carol Chan
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Dana Arafeh
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Rashid Anwar
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Colin Macarthur
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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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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Gill PJ, Thavam T, Anwar MR, Zhu J, Parkin PC, Cohen E, To T, Mahant S. Prevalence, Cost, and Variation in Cost of Pediatric Hospitalizations in Ontario, Canada. JAMA Netw Open 2022; 5:e2147447. [PMID: 35138399 PMCID: PMC8829658 DOI: 10.1001/jamanetworkopen.2021.47447] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Identifying conditions that could be prioritized for research based on health care system burden is important for developing a research agenda for the care of hospitalized children. However, existing prioritization studies are decades old or do not include data from both pediatric and general hospitals. OBJECTIVE To assess the prevalence, cost, and variation in cost of pediatric hospitalizations at all general and pediatric hospitals in Ontario, Canada, with the aim of identifying conditions that could be prioritized for future research. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used health administrative data from 165 general and pediatric hospitals in Ontario, Canada. Children younger than 18 years with an inpatient hospital encounter between April 1, 2014, and March 31, 2019, were included. MAIN OUTCOMES AND MEASURES Condition-specific prevalence, cost of pediatric hospitalizations, and condition-specific variation in cost per inpatient encounter across hospitals. Variation in cost was evaluated using (1) intraclass correlation coefficient (ICC) and (2) number of outlier hospitals. Costs were adjusted for inflation to 2018 US dollars. RESULTS Overall, 627 314 inpatient hospital encounters (44.8% among children younger than 30 days and 53.0% among boys) at 165 hospitals (157 general and 8 pediatric) costing $3.3 billion were identified. A total of 408 003 hospitalizations (65.0%) and $1.4 billion (43.8%) in total costs occurred at general hospitals. Among the 50 most prevalent and 50 most costly conditions (of 68 total conditions), the top 10 highest-cost conditions accounted for 55.5% of all costs and 48.6% of all encounters. The conditions with highest prevalence and cost included low birth weight (86.2 per 1000 encounters; $676.3 million), preterm newborn (38.0 per 1000 encounters; $137.4 million), major depressive disorder (20.7 per 1000 encounters; $78.3 million), pneumonia (27.3 per 1000 encounters; $71.6 million), other perinatal conditions (68.0 per 1000 encounters; $65.8 million), bronchiolitis (25.4 per 1000 encounters; $54.6 million), and neonatal hyperbilirubinemia (47.9 per 1000 encounters; $46.7 million). The highest variation in cost per encounter among the most costly medical conditions was observed for 2 mental health conditions (other mental health disorders [ICC, 0.28] and anxiety disorders [ICC, 0.19]) and 3 newborn conditions (intrauterine hypoxia and birth asphyxia [ICC, 0.27], other perinatal conditions [ICC, 0.17], and surfactant deficiency disorder [ICC, 0.17]). CONCLUSIONS AND RELEVANCE This population-based cross-sectional study of hospitalized children identified several newborn and mental health conditions as having the highest prevalence, cost, and variation in cost across hospitals. Findings of this study can be used to develop a research agenda for the care of hospitalized children that includes general hospitals and to ultimately build a more substantial evidence base and improve patient outcomes.
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Affiliation(s)
- Peter J. Gill
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Thaksha Thavam
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | | | - Jingqin Zhu
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Teresa To
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
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12
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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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13
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Awadhare P, Patel R, McCallin T, Mainali K, Jackson K, Starke H, Bhalala U. Non-invasive Cardiac Output Monitoring and Assessment of Fluid Responsiveness in Children With Shock in the Emergency Department. Front Pediatr 2022; 10:857106. [PMID: 35463892 PMCID: PMC9021702 DOI: 10.3389/fped.2022.857106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/04/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The assessment of fluid responsiveness is important in the management of shock but conventional methods of assessing fluid responsiveness are often inaccurate. Our study aims to evaluate changes in objective hemodynamic parameters as measured using electrical cardiometry (ICON® monitor) following the fluid bolus in children presenting with shock and to evaluate whether any specific hemodynamic parameter can best predict fluid responsiveness among children with shock. MATERIALS AND METHODS We conducted a prospective observational study in children presenting with shock to our emergency department between June 2020 and March 2021. We collected the parameters such as heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and hemodynamic data such as cardiac output CO), cardiac index (CI), index of contractility (ICON), stroke volume (SV), stroke index (SI), corrected flow time (FTC), systolic time ratio (STR), variation of index of contractility (VIC), stroke volume variation (SVV), systemic vascular resistance (SVR), and thoracic fluid content (TFC) using the ICON monitor before and after fluid bolus (FB). We assessed percent change (Δ) and used paired-sample Student's t-test to compare pre- and post-hemodynamic data and Mann-Whitney U-test to compare fluid responders and non-responders. P-Values < 0.05 were considered statistically significant. RESULTS We recorded 42 fluid interventions in 40 patients during our study period. The median IQR age was 10.56 (4.8, 14.8) years with male/female ratio (1.2:1). There was a significant decrease in ΔRR [-1.61 (-14.8, 0); p = 0.012], ΔDBP [-5.5 (-14.4, 8); p = 0.027], ΔMAP [-2.2 (-11, 2); p = 0.018], ΔSVR [-5.8 (-20, 5.2); p = 0.025], and ΔSTR [-8.39 (-21, 3); p = 0.001] and significant increase in ΔTFC [6.2 (3.5, 11.4); p = 0.01] following FB. We defined fluid responders by an increase in SV by ≥10% after a single FB of 20 ml/kg crystalloid. Receiver operating curve analysis revealed that among all the parameters, 15% change in ICON had an excellent AUC (0.85) for the fluid responsiveness. CONCLUSION Our study showed significant changes in objective hemodynamic parameters, such as SVR, STR, and TFC following FB in children presenting with shock. A 15% change in ICON had an excellent predictive performance for the fluid responsiveness among our cohort of pediatric shock.
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Affiliation(s)
- Pranali Awadhare
- The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Radha Patel
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Tracy McCallin
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Kiran Mainali
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Kelly Jackson
- The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Hannah Starke
- The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Utpal Bhalala
- Driscoll Children's Hospital, Corpus Christi, TX, United States.,Department of Pediatrics, Texas A&M University, College Station, TX, United States.,Department of Anesthesiology and Critical Care Medicine, University of Texas Medical Branch, Galveston, TX, United States
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14
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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15
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Abstract
OBJECTIVES To describe the characteristics of fluid accumulation in critically ill children and evaluate the association between the degree, timing, duration, and rate of fluid accumulation and patient outcomes. DESIGN Retrospective cohort study. SETTING PICUs in Alberta, Canada. PATIENTS All children admitted to PICU in Alberta, Canada, between January 1, 2015, and December 31, 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,017 patients were included. Fluid overload % increased from median (interquartile range) 1.58% (0.23-3.56%; n = 1,017) on day 1 to 16.42% (7.53-27.34%; n = 111) on day 10 among those remaining in PICU. The proportion of patients (95% CI) with peak fluid overload % greater than 10% and greater than 20% was 32.7% (29.8-35.7%) and 9.1% (7.4-11.1%), respectively. Thirty-two children died (3.1%) in PICU. Peak fluid overload % was associated with greater PICU mortality (odds ratio, 1.05; 95% CI, 1.02-1.09; p = 0.001). Greater peak fluid overload % was associated with Major Adverse Kidney Events within 30 days (odds ratio, 1.05; 95% CI, 1.02-1.08; p = 0.001), length of mechanical ventilation (B coefficient, 0.66; 95% CI, 0.54-0.77; p < 0.001), and length of PICU stay (B coefficient, 0.52; 95% CI, 0.46-0.58; p < 0.001). The rate of fluid accumulation was associated with PICU mortality (odds ratio, 1.15; 95% CI, 1.01-1.31; p = 0.04), Major Adverse Kidney Events within 30 days (odds ratio, 1.16; 95% CI, 1.03-1.30; p = 0.02), length of mechanical ventilation (B coefficient, 0.80; 95% CI, 0.24-1.36; p = 0.005), and length of PICU stay (B coefficient, 0.38; 95% CI, 0.11-0.66; p = 0.007). CONCLUSIONS Fluid accumulation occurs commonly during PICU course and is associated with considerable mortality and morbidity. These findings highlight the need for the development and evaluation of interventional strategies to mitigate the potential harm associated with fluid accumulation.
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16
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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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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Harley A, George S, King M, Phillips N, Keijzers G, Long D, Gibbons K, Bellomo R, Schlapbach LJ. Early Resuscitation in Paediatric Sepsis Using Inotropes - A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED): Study Protocol and Analysis Plan. Front Pediatr 2021; 9:663028. [PMID: 34136441 PMCID: PMC8200662 DOI: 10.3389/fped.2021.663028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/21/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction: Septic shock in children still carries substantial mortality and morbidity. While resuscitation with 40-60 mL/kg intravenous fluid boluses remains a cornerstone of initial resuscitation, an increasing body of evidence indicates potential for harm related to high volume fluid administration. We hypothesize that a protocol on early use of inotropes in children with septic shock is feasible and will lead to less fluid bolus use compared to standard fluid resuscitation. Here, we describe the protocol of the Early Resuscitation in Paediatric Sepsis Using Inotropes - A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED). Methods and analysis: The RESPOND ED study is an open label randomised controlled, two arm, multicentre pilot study conducted at four specialised paediatric Emergency Departments. Forty children aged between 28 days and 18 years treated for presumed septic shock will be randomized in a 1:1 ratio to early inotropes vs. standard fluid resuscitation. Early inotrope treatment is defined as the commencement of a continuous intravenous adrenaline infusion after 20 mL/kg fluid bolus resuscitation. Standard fluid resuscitation is defined as delivery of 40 to 60 mL/kg fluid bolus resuscitation prior to commencement of inotropes. In addition to feasibility outcomes, survival free of organ dysfunction censored at 28 days will be assessed as the main clinical outcome. The study cohort will be followed up at 28 days, and at 6 months post enrolment to assess quality of life and functional status. Biobanking nested in the study cohort will be performed to enable ancillary biomarker studies. Ethics and dissemination: The trial has ethical clearance (Children's Health Queensland, Brisbane, HREC/18/QCHQ/49168) and is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12619000828123). Enrolment commenced on July 21st, 2019. The primary manuscript will be submitted for publication in a peer-reviewed journal. Trial Registration: Australian and New Zealand Clinical Trials Registry, ACTRN12619000828123.
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Affiliation(s)
- Amanda Harley
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Shane George
- 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, Southport, QLD, Australia
| | - Megan King
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia.,Emergency Department Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Natalie Phillips
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Emergency Department Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia.,School of Medicine, Griffith University, Southport, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Southport, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Nursing, Centre of Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, VIC, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Pediatric and Neonatal Intensive Care Unit, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Abstract
Many questions surround fluid bolus therapy and subsequent fluid management in neonatal critical care as they do in pediatric and adult critical care. This review explores the known key clinical aspects of fluid bolus therapy and fluid balance in the first 7 days of life and provides suggestions for further work in this area. It draws on the pediatric and adult critical care literature to provide thought-provoking data around the potential harms of excessive intravenous fluids, which may prove relevant to neonatology. Current data suggest that fluid bolus therapy and early-life positive fluid balance in neonates may be associated with harm.
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Affiliation(s)
- Erin Grace
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia; Adelaide Medical School and the Robinson Research Institute, University of Adelaide, Adelaide, South Australia
| | - Amy K Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia; Adelaide Medical School and the Robinson Research Institute, University of Adelaide, Adelaide, South Australia.
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20
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Abstract
OBJECTIVES To describe legal guardians' understanding of key concepts in a research consent form presented within 24 hours of their child's admission to the PICU and to explore legal guardians' opinions of the format (language, length) of the consent form and the overall consent process. DESIGN Single-center, exploratory pilot study. SETTING PICU at a tertiary-care hospital in Canada. SUBJECTS Forty-one English- and French-speaking legal guardians of children less than 18 years old, who had been admitted to the PICU within the past 24 hours and were expected to stay at least 48 hours, between October 2018 and February 2019. INTERVENTIONS The consent form from a previous PICU trial was given and explained to legal guardians within 24 hours of their child's admission to the PICU. MEASUREMENTS AND MAIN RESULTS Legal guardians' understanding of key concepts in the consent form was evaluated using a questionnaire the day after the form was explained, and opinions were collected verbally and using an additional survey. The median number of questions answered incorrectly was three of seven (interquartile range = 2-4). Participants best understood the topic of the study (5% incorrect), but 80% of participants were unable to recall a single risk. The median rating of the language in the form was five of five (very easy to understand; interquartile range = 4-5), and 88% of participants said it was a reasonable length. CONCLUSIONS Despite positive opinions of the consent form, most legal guardians did not understand all key components of the consent information provided to them orally and in writing within 24 hours of their child's PICU admission. Future studies are required to determine barriers to understanding and explore alternative approaches to obtaining consent in this setting.
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Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med 2019; 26:1346-1356. [PMID: 31183919 DOI: 10.1111/acem.13815] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/17/2019] [Accepted: 05/26/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment. However, the optimal type of crystalloid fluid is unknown. We aimed to determine the feasibility of conducting a pragmatic randomized trial to compare balanced (lactated Ringer's [LR]) with 0.9% normal saline (NS) fluid resuscitation in children with suspected septic shock. METHODS Open-label pragmatic randomized controlled trial at a single academic children's hospital from January to August 2018. Eligible patients were >6 months to <18 years old who were treated in the emergency department for suspected septic shock, operationalized as blood culture, parenteral antibiotics, and fluid resuscitation for abnormal perfusion. Screening, enrollment, and randomization were carried out by the clinical team as part of routine care. Patients were randomized to receive either LR or NS for up to 48 hours following randomization. Other than fluid type, all treatment decisions were at the clinical team's discretion. Feasibility outcomes included proportion of eligible patients enrolled, acceptability of enrollment via the U.S. federal exception from informed consent (EFIC) regulations, and adherence to randomized study fluid administration. RESULTS Of 59 eligible patients, 50 (85%) were enrolled and randomized. Twenty-four were randomized to LR and 26 to NS. Only one (2%) of 44 patients enrolled using EFIC withdrew before study completion. Total median (interquartile range [IQR]) crystalloid fluid volume received during the intervention window was 107 (60 to 155) mL/kg and 98 (63 to 128) mL/kg in the LR and NS arms, respectively (p = 0.50). Patients randomized to LR received a median (IQR) of only 20% (13 to 32) of all study fluid as NS compared to 99% (64% to 100%) of study fluid as NS in the NS arm (absolute difference = 79%, 95% CI = 48% to 85%). CONCLUSIONS A pragmatic study design proved feasible to study comparative effectiveness of LR versus NS fluid resuscitation for pediatric septic shock.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
- Pediatric Sepsis Program Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Marlena Kittick
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Peter McBride
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Ashley L. Woodford
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Nicole Vestal
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - T. Charles Casper
- Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
| | - Melissa Metheney
- Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
| | - Katherine Smith
- Department of Anesthesiology and Critical Care Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Natalie J. Atkin
- Department of Anesthesiology and Critical Care Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jill M. Baren
- Department of Pediatrics Division of Emergency Medicine Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
- Department of Emergency Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - J. Michael Dean
- Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
| | - Nathan Kuppermann
- Department of Emergency Medicine University of California Davis Health Sacramento CA
| | - Scott L. Weiss
- Pediatric Sepsis Program Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
- Department of Anesthesiology and Critical Care Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia PA
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Piehl M, Smith-Ramsey C, Teeter WA. Improving fluid resuscitation in pediatric shock with LifeFlow ®: a retrospective case series and review of the literature. Open Access Emerg Med 2019; 11:87-93. [PMID: 31118839 PMCID: PMC6503651 DOI: 10.2147/oaem.s188110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/28/2019] [Indexed: 11/23/2022] Open
Abstract
Rapid delivery of an intravenous fluid bolus is commonly used in pediatric emergency care for the treatment of shock and hypotension. Early fluid delivery targeted at shock reversal results in improved patient outcomes, yet current methods of fluid resuscitation often limit the ability of providers to achieve fluid delivery goals. We report on the early clinical experience of a new technique for rapid fluid resuscitation. The LifeFlow® infuser is a manually operated device that combines a syringe, automatic check valve, and high-flow tubing set with an ergonomic handle to enable faster and more efficient delivery of fluid by a single health care provider. LifeFlow is currently FDA-cleared for the delivery of crystalloid and colloids. Four cases are presented in which the LifeFlow device was used for emergent fluid resuscitation: a 6-month-old with septic shock, a 2-year-old with intussusception and shock, an 11-year-old with pneumonia and septic shock, and a 15-year-old with trauma and hemorrhagic shock.
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Affiliation(s)
- Mark Piehl
- Department of Pediatrics, Division of Pediatric Critical Care, WakeMed Health and Hospitals, Raleigh, NC, USA.,410 Medical, Inc, Durham, NC, USA.,Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Cherrelle Smith-Ramsey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Teeter
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Inwald D, Canter RR, Woolfall K, O'Hara CB, Mouncey PR, Zenasni Z, Hudson N, Saunders S, Carter A, Jones N, Lyttle MD, Nadel S, Peters MJ, Harrison DA, Rowan KM. Restricted fluid bolus versus current practice in children with septic shock: the FiSh feasibility study and pilot RCT. Health Technol Assess 2019; 22:1-106. [PMID: 30238870 DOI: 10.3310/hta22510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There has been no randomised controlled trial (RCT) of fluid bolus therapy in paediatric sepsis in the developed world despite evidence that excess fluid may be associated with harm. OBJECTIVES To determine the feasibility of the Fluids in Shock (FiSh) trial - a RCT comparing restricted fluid bolus (10 ml/kg) with current practice (20 ml/kg) in children with septic shock in the UK. DESIGN (1) Qualitative feasibility study exploring parents' views about the pilot RCT. (2) Pilot RCT over a 9-month period, including integrated parental and staff perspectives study. SETTING (1) Recruitment took place across four NHS hospitals in England and on social media. (2) Recruitment took place across 13 NHS hospitals in England. PARTICIPANTS (1) Parents of children admitted to a UK hospital with presumed septic shock in the previous 3 years. (2) Children presenting to an emergency department with clinical suspicion of infection and shock after 20 ml/kg of fluid. Exclusion criteria were receipt of > 20 ml/kg of fluid, conditions requiring fluid restriction and the patient not for full active treatment (i.e. palliative care plan in place). Site staff and parents of children in the pilot were recruited to the perspectives study. INTERVENTIONS (1) None. (2) Children were randomly allocated (1 : 1) to 10- or 20-ml/kg fluid boluses every 15 minutes for 4 hours if in shock. MAIN OUTCOME MEASURES (1) Acceptability of FiSh trial, proposed consent model and potential outcome measures. (2) Outcomes were based on progression criteria, including recruitment and retention rates, protocol adherence and separation between the groups, and collection and distribution of potential outcome measures. RESULTS (1) Twenty-one parents were interviewed. All would have consented for the pilot study. (2) Seventy-five children were randomised, 40 to the 10-ml/kg fluid bolus group and 35 to the 20-ml/kg fluid bolus group. Two children were withdrawn. Although the anticipated recruitment rate was achieved, there was variability across the sites. Fifty-nine per cent of children in the 10-ml/kg fluid bolus group and 74% in the 20-ml/kg fluid bolus group required only a single trial bolus before shock resolved. The volume of fluid (in ml/kg) was 35% lower in the first hour and 44% lower over the 4-hour period in the 10-ml/kg fluid bolus group. Fluid boluses were delivered per protocol (volume and timing) for 79% of participants in the 10-ml/kg fluid bolus group and for 55% in the 20-ml/kg fluid bolus group, mainly as a result of delivery not being completed within 15 minutes. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) transfers, and days alive and PICU free did not differ significantly between the groups. Two adverse events were reported in each group. A questionnaire was completed by 45 parents, 20 families and seven staff were interviewed and 20 staff participated in focus groups. Although a minority of site staff lacked equipoise in favour of more restricted boluses, all supported the trial. CONCLUSIONS Even though a successful feasibility and pilot RCT were conducted, participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. FUTURE WORK Further observational work is required to determine the epidemiology of severe childhood infection in the UK in the postvaccine era. TRIAL REGISTRATION Current Controlled Trials ISRCTN15244462. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 51. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Caitlin B O'Hara
- Department of Psychological Sciences, North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Zohra Zenasni
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Steven Saunders
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | | | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
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Paul R. Recognition, Diagnostics, and Management of Pediatric Severe Sepsis and Septic Shock in the Emergency Department. Pediatr Clin North Am 2018; 65:1107-1118. [PMID: 30446051 DOI: 10.1016/j.pcl.2018.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Several new studies have emerged in recent years that have attempted to aid emergency department providers in recognizing and treating pediatric patients with severe sepsis and septic shock. National guidelines and supporting literature are unanimous in recommendations that early recognition and timely therapeutics are necessary for improved survival and decreased morbidity. The literature is less concrete in defining how emerging advances in the field can aid in time-sensitive care of these patients. This article summarizes the recent literature as it pertains to the initial presentation of severe sepsis and septic shock in the pediatric patient within the emergency department.
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Affiliation(s)
- Raina Paul
- Pediatric Emergency Department, Division of Emergency Medicine, Advocate Children's Hospital, 1700 Luther Lane, Park Ridge, IL 60068, USA.
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Ability to Assent in Pediatric Critical Care Research: A Prospective Environmental Scan of Two Canadian PICUs. Pediatr Crit Care Med 2018; 19:e438-e441. [PMID: 29905634 DOI: 10.1097/pcc.0000000000001637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To determine the number of patients considered not appropriate to approach for assent within the first 24 hours of PICU admission. DESIGN Exploratory prospective 1-month environmental scan. SETTING Two tertiary Canadian PICUs. PATIENTS Ninety patients age newborn to 17 years old admitted to the PICU during September 2016 (Site 1) or May 2017 (Site 2). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS At PICU admission, 81% of patients were deemed not appropriate to approach for assent most commonly due to age, influence of psychotropic medications, and/or mechanical ventilation. At PICU discharge, 74% of patients were considered not appropriate to approach, most commonly due to age and/or developmental delay. There was moderate to good agreement between the research team and care team assessments of appropriateness for assent. Only 8% of patients considered not approachable at admission become appropriate to approach for assent by PICU discharge. CONCLUSIONS Very few patients were considered approachable for assent during the first 24 hours of PICU admission. Those who were considered appropriate to approach were less ill, spent less time in PICU, and were unlikely to be considered for enrollment in pediatric critical care research.
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What Goes Up, Must Go Down? Pediatr Crit Care Med 2018; 19:579-581. [PMID: 29863640 DOI: 10.1097/pcc.0000000000001543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alobaidi R, Morgan C, Basu RK, Stenson E, Featherstone R, Majumdar SR, Bagshaw SM. Association Between Fluid Balance and Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2018; 172:257-268. [PMID: 29356810 PMCID: PMC5885847 DOI: 10.1001/jamapediatrics.2017.4540] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE After initial resuscitation, critically ill children may accumulate fluid and develop fluid overload. Accruing evidence suggests that fluid overload contributes to greater complexity of care and worse outcomes. OBJECTIVE To describe the methods to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children. DATA SOURCES Systematic search of MEDLINE, EMBASE, Cochrane Library, trial registries, and selected gray literature from inception to March 2017. STUDY SELECTION Studies of children admitted to pediatric intensive care units that described fluid balance or fluid overload and reported outcomes of interest were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS All stages were conducted independently by 2 reviewers. Data extracted included study characteristics, population, fluid metrics, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. Narrative description of fluid assessment methods and fluid overload definitions was done. When feasible, pooled analyses were performed using random-effects models. MAIN OUTCOMES AND MEASURES Mortality was the primary outcome. Secondary outcomes included treatment intensity, organ failure, and resource use. RESULTS A total of 44 studies (7507 children) were included in this systematic review and meta-analysis. Of those, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case-control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The proportion of children with fluid overload varied by case mix and fluid overload definition (median, 33%; range, 10%-83%). Fluid overload, however defined, was associated with increased in-hospital mortality (17 studies [n = 2853]; odds ratio [OR], 4.34 [95% CI, 3.01-6.26]; I2 = 61%). Survivors had lower percentage fluid overload than nonsurvivors (22 studies [n = 2848]; mean difference, -5.62 [95% CI, -7.28 to -3.97]; I2 = 76%). After adjustment for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage fluid overload (11 studies [n = 3200]; adjusted OR, 1.06 [95% CI, 1.03-1.10]; I2 = 66%). Fluid overload was associated with increased risk for prolonged mechanical ventilation (>48 hours) (3 studies [n = 631]; OR, 2.14 [95% CI, 1.25-3.66]; I2 = 0%) and acute kidney injury (7 studies [n = 1833]; OR, 2.36 [95% CI, 1.27-4.38]; I2 = 78%). CONCLUSIONS AND RELEVANCE Fluid overload is common and is associated with substantial morbidity and mortality in critically ill children. Additional research should now ideally focus on interventions aimed to mitigate the potential for harm associated with fluid overload.
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Affiliation(s)
- Rashid Alobaidi
- Division of Pediatric Critical Care, Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
| | - Catherine Morgan
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rajit K. Basu
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Erin Stenson
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robin Featherstone
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, Alberta Research Center for Health Evidence (ARCHE), Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sumit R. Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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Abstract
OBJECTIVE The objective of the study was to describe the origins, growth, and progress of a national research network in pediatric emergency medicine. METHODS The success of Pediatric Emergency Research Canada (PERC) is described in terms of advancing the pediatric emergency medicine agenda, grant funding, peer-reviewed publications, mentoring new investigators, and global collaborations. RESULTS Since 1995, clinicians and investigators within PERC have grown the network to 15 active tertiary pediatric emergency medicine sites across Canada. Investigators have advanced the research agenda in numerous areas, including gastroenteritis, bronchiolitis, croup, head injury, asthma, and injury management. Since the first PERC Annual Scientific meeting in 2004, the attendance has increased by approximately 400% to 152 attendees, 65 presentations, and 13 project/investigator meetings. More than $33 million in grant funding has been awarded to the network, and has published 76 peer-reviewed articles. In 2011, PERC's success was recognized with a Top Achievement Award in Health Research from Canadian Institutes of Health Research and the Canadian Medical Association Journal. CONCLUSIONS Moving forward, PERC will continue to focus on the creation of new knowledge, the mentorship of new investigators and fellows in developing research projects, and promoting a pediatric emergency medicine-focused research agenda guided by the pooling of expertise from individuals across the nation. Through collaborations with networks across the globe, PERC will continue to strive for the conduct of high-quality, impactful research that improves outcomes in children with acute illness and injury.
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30
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Gelbart B. Fluid Bolus Therapy in Pediatric Sepsis: Current Knowledge and Future Direction. Front Pediatr 2018; 6:308. [PMID: 30410875 PMCID: PMC6209667 DOI: 10.3389/fped.2018.00308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,The University of Melbourne, Melbourne, VIC, Australia
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31
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Kissoon N. Understanding fluid administration approaches in children with co-morbidities and septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:204. [PMID: 28774323 PMCID: PMC5543432 DOI: 10.1186/s13054-017-1741-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Niranjan Kissoon
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, B245, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada. .,Child & Family Research Institute (CFRI), Vancouver, British Columbia, Canada. .,Division of Critical Care, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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