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Sethasathien S, Jariyasakoolroj T, Silvilairat S, Srisurapanont M. Aortic Peak Flow Velocity As a Predictor of Fluid Responsiveness in Mechanically Ventilated Children: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2023; 24:e352-e361. [PMID: 36856439 DOI: 10.1097/pcc.0000000000003219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVES This meta-analysis aimed to determine the accuracy of the respiratory variations in aortic peak flow velocity (delta Vpeak) in predicting fluid responsiveness and the moderators of that accuracy. DATA SOURCES We performed searches for studies that used delta Vpeak as a predictor of fluid responsiveness in mechanically ventilated children in PubMed, Embase, Scopus, and CINAHL from inception to June 20, 2022. STUDY SELECTION AND DATA EXTRACTION Fifteen studies ( n = 452) were included in this meta-analysis. The diagnostic test data of the included studies were synthesized as pooled sensitivity, specificity, and diagnostic odds ratio (DOR) and the area under the curve (AUC) of the summary receiver operating characteristic of delta Vpeak. DATA SYNTHESIS The delta Vpeak cutoff values applied in these studies had a median of 12.3% (interquartile range, 11.50-13.25%). The pooled sensitivity and specificity of delta Vpeak were 0.80 (95% CI, 0.71-0.87) and 0.82 (95% CI, 0.75-0.87), respectively. The DOR of delta Vpeak was 23.41 (95% CI, 11.61-47.20). The AUC of delta Vpeak was 0.87. Subgroup analyses revealed that the accuracy of delta Vpeak was not moderated by ventilator settings, measures of delta Vpeak, gold standard index, the cutoff gold standard value of responders, type and volume of fluid, duration of fluid challenge, use of vasoactive drugs, general anesthesia, and cardiopulmonary bypass. CONCLUSIONS By using the cutoff of approximately 12.3%, the delta Vpeak appears to have good accuracy in predicting fluid responsiveness in mechanically ventilated children. The moderators of delta Vpeak predictability are not found.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand
| | - Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand
| | - Manit Srisurapanont
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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2
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Koh W, Schneider KA, Zang H, Batlivala SP, Monteleone MP, Benscoter AL, Chlebowski MM, Iliopoulos ID, Cooper DS. Measurement of Cardiac Output Using an Ultrasonic Cardiac Output Monitor (USCOM) in Patients with Single-Ventricle Physiology. Pediatr Cardiol 2022; 43:1205-1213. [PMID: 35124709 DOI: 10.1007/s00246-022-02840-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
We evaluate the validity of cardiac index (CI) measurements utilizing the Ultrasonic Cardiac Output Monitor (USCOM), a non-invasive Doppler ultrasound device, by comparing measurements to cardiac catheterization-derived CI measurements in patients with single-ventricle physiology. USCOM measurements were repeated three times for each patient at the beginning of a cardiac catheterization procedure for twenty-six patients undergoing elective pre-Glenn or pre-Fontan catheterization. CI was measured by USCOM and was calculated from cardiac catheterization data using Fick's method. Bland-Altman analysis for CI showed bias of 0.95 L/min/m2 with the 95% limits of agreement of - 1.85 and 3.75. Pearson's correlation coefficient was 0.89 (p < 0.001) indicating a strong positive relationship between USCOM and cardiac catheterization CI measurements. When excluding two patients with significant dilation of the neo-aortic valve (z-score > + 5), the bias improved to 0.66 L/min/m2 with the 95% limits of agreement of - 1.38 and 2.70. Percent error of limits of agreement was 34%. There was excellent intra-operator reproducibility of USCOM CI measurements with an intra-class coefficient of 0.96. We demonstrate the use of USCOM to measure CI in patients with single-ventricle physiology for the first time, showing acceptable agreement of the CI measurements between USCOM and cardiac catheterization with a high intra-operator reproducibility.
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Affiliation(s)
- Wonshill Koh
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Kristin A Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Huaiyu Zang
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sarosh P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew P Monteleone
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexis L Benscoter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Meghan M Chlebowski
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ilias D Iliopoulos
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Greiwe G, Balfanz V, Hapfelmeier A, Zajonz TS, Müller M, Saugel B, Schulte-Uentrop L. Pulse Wave Analysis Using the Pressure Recording Analytical Method to Measure Cardiac Output in Pediatric Cardiac Surgery Patients: A Method Comparison Study Using Transesophageal Doppler Echocardiography as Reference Method. Anesth Analg 2022; 135:71-78. [PMID: 35452017 DOI: 10.1213/ane.0000000000006010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac output (CO) is a key determinant of oxygen delivery, but choosing the optimal method to obtain CO in pediatric patients remains challenging. The pressure recording analytical method (PRAM), implemented in the MostCareUp system (Vygon), is an invasive uncalibrated pulse wave analysis (PWA) method to measure CO. The objective of this study is to compare CO measured by PRAM (PRAM-CO; test method) with CO simultaneously measured by transesophageal Doppler echocardiography (TEE-CO; reference method) in pediatric patients. METHODS In this prospective observational method comparison study, PRAM-CO and TEE-CO were assessed in pediatric elective cardiac surgery patients at 2 time points: after anesthesia induction and after surgery. The study was performed in a German university medical center from March 2019 to March 2020. We included pediatric patients scheduled for elective cardiac surgery with arterial catheter and TEE monitoring. PRAM-CO and TEE-CO were compared using Bland-Altman analysis accounting for repeated measurements per subject, and the percentage error (PE). RESULTS We included 52 PRAM-CO and TEE-CO measurement pairs of 30 patients in the final analysis. Mean ± SD TEE-CO was 2.15 ± 1.31 L/min (range 0.55-6.07 L/min), and mean PRAM-CO was 2.21 ± 1.38 L/min (range 0.55-5.90 L/min). The mean of the differences between TEE-CO and PRAM-CO was -0.06 ±0.38 L/min with 95% limits of agreement (LOA) of 0.69 (95% confidence interval [CI], 0.53-0.82 L/min) to -0.80 L/min (95% CI, -1.00 to -0.57 L/min). The resulting PE was 34% (95% CI, 27%-41%). CONCLUSIONS With a PE of <45%, PRAM-CO shows clinically acceptable agreement with TEE-CO in hemodynamically stable pediatric patients before and after cardiac surgery.
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Affiliation(s)
- Gillis Greiwe
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vanessa Balfanz
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Hapfelmeier
- Institute of General Practice and Health Services Research
- Institute for AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thomas S Zajonz
- Institute for AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Müller
- Institute for AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernd Saugel
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonie Schulte-Uentrop
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Comparison of non-invasive physiological assessment tools between simple and perforated appendicitis in children. Pediatr Surg Int 2021; 37:851-857. [PMID: 33783635 DOI: 10.1007/s00383-021-04876-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The role of non-invasive measures of physiologic reserve, specifically the Compensatory reserve index (CRI) and the Shock index pediatric age-adjusted (SIPA), is unknown in the management of children with acute appendicitis. CRI is a first-in-class algorithm that uses pulse oximetry waveforms to continuously monitor central volume status loss. SIPA is a well-validated, but a discontinuous measure of shock that has been calibrated for children. METHODS Children with suspected acute appendicitis (2-17 years old) were prospectively enrolled at a single center from 2014 to 2015 and monitored with a CipherOx CRI™ M1 pulse oximeter. CRI values range from 1 (normovolemia) to 0 (life-threatening hypovolemia). SIPA is calculated by dividing heart rate by systolic blood pressure and categorized as normal or abnormal, based on age-specific cutoffs. Univariate and multivariable regression models were developed with simple versus perforated appendicitis as the outcome. RESULTS Almost half the patients (45/94, 48%) had perforated appendicitis. On univariate analysis, the median admission CRI value was significantly higher (0.60 versus 0.33, p < 0.001) and the ED SIPA values were significantly lower (0.90 versus 1.10, p = 0.002) in children with simple versus perforated appendicitis. In a multivariable model, only CRI significantly detected differences in the physiologic state between patients with simple and perforated appendicitis. CONCLUSIONS CRI is a non-invasive measure of physiologic reserve that may be used to accurately guide early management of children with acute simple versus perforated appendicitis.
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Gupta D, Dhingra S. Electrocardiometry Fluid Responsiveness in Pediatric Septic Shock. Indian J Crit Care Med 2021; 25:123-125. [PMID: 33707887 PMCID: PMC7922445 DOI: 10.5005/jp-journals-10071-23745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Hemodynamic monitoring and categorization of patients based on fluid responsiveness is the key to decisions prompting the use of fluids and vasoactive agents in septic shock. Distinguishing patients who are going to benefit from fluids from those who will not is of paramount importance as large amounts of fluids used conventionally based on surviving sepsis guidelines may be detrimental. Noninvasive monitoring techniques for the assessment of various cardiovascular parameters are increasingly accepted as the current medical practice. Electrical cardiometry (EC) is one such method for the determination of stroke volume, cardiac output (CO), and other hemodynamic parameters and is based on changes in electrical conductivity within the thorax. It has been validated against gold standard methods such as thermodilution [Malik V, Subramanian A, Chauhan S, et al. World J 2014;4(7):101-108] and is being used more often as a point-of-care noninvasive technique for hemodynamic monitoring. EC is Food and Drug Administration approved and validated for use in neonates, children, and adults. A meta-analysis in 2016, including 20 studies and 624 patients comparing the accuracy of CO measurement by using EC with other noninvasive technologies, demonstrated that EC was the device that offered the most correct measurements. The article in the current issue of IJCCM by Rao et al. (2020) has extended the use of EC to categorize pediatric patients with septic shock into vasodilated and vasoconstricted states based on systemic vascular resistance and correlate the categorization clinically. The authors also studied the changes in hemodynamic parameters after an isotonic fluid bolus of 20 mL/kg was administered. This is a pilot prospective observational study of 30 patients, which has given an insight into physiological rearrangements following fluid administration in patients with septic shock. How to cite this article: Gupta D, Dhingra. Electrocardiometry Fluid Responsiveness in Pediatric Septic Shock. Indian J Crit Care Med 2021;25(2):123-125.
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Affiliation(s)
- Dhiren Gupta
- Division of Pediatric Emergency and Critical Care, Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Sandeep Dhingra
- Department of Pediatrics, Command Hospital, Panchkula, Haryana, India
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Extracorporeal Arteriovenous Ultrasound Measurement of Cardiac Output in Small Children. Anesthesiology 2020; 130:712-718. [PMID: 30907763 DOI: 10.1097/aln.0000000000002582] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Technology for cardiac output (CO) and blood volume measurements has been developed based on blood dilution with a small bolus of physiologic body temperature saline, which, after transcardiopulmonary mixing, is detected with ultrasound sensors attached to an extracorporeal arteriovenous loop using existing central venous and peripheral arterial catheters. This study aims to compare the precision and agreement of this technology to measure cardiac output with a reference method, a perivascular flow probe placed around the aorta, in young children. The null hypothesis is that the methods are equivalent in precision, and there is no bias in the cardiac output measurements. METHODS Forty-three children scheduled for cardiac surgery were included in this prospective single-center comparison study. After corrective cardiac surgery, five consecutive repeated cardiac output measurements were performed simultaneously by both methods. RESULTS A total of 215 cardiac output measurements were compared in 43 children. The mean age of the children was 354 days (range, 30 to 1,303 days), and the mean weight was 7.1 kg (range, 2.7 to 13.6 kg). The precision assessed as two times the coefficient of error was 3.6% for the ultrasound method and 5.0% for the flow probe. Bias (mean COultrasound 1.28 l/min - mean COflow probe 1.20 l/min) was 0.08 l/min, limits of agreement was ±0.32 l/min, and the percentage error was 26.6%. CONCLUSIONS The technology to measure cardiac output with ultrasound detection of blood dilution after a bolus injection of saline yields comparable precision as cardiac output measurements by a periaortic flow probe. The difference in accuracy in the measured cardiac output between the methods can be explained by the coronary blood flow, which is excluded in the cardiac output measurements by the periaortic flow probe.
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Sigurdsson TS, Lindberg L. Estimation of intracardiac shunts in young children with a novel indicator dilution technology. Sci Rep 2020; 10:1337. [PMID: 31992787 PMCID: PMC6987168 DOI: 10.1038/s41598-020-58347-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 01/14/2020] [Indexed: 11/20/2022] Open
Abstract
Clinical evaluation of intracardiac shunts in children is not straightforward. Echocardiography can only diagnose the presence of a shunt but does not estimate the shunt ratio. This can be a critical factor that influences treatment options. In this single-center, prospective, observational, method-comparison study, we validate the ability of a novel monitoring device COstatus to estimate the intracardiac shunt ratio (Qp/Qs) of pulmonary (Qp) to systemic (Qs) blood flow in young children before and after corrective cardiac surgery. The indicator dilution technology COstatus monitor was compared to two other more invasive reference techniques, perivascular ultrasonic flow probes (placed around the pulmonary truncus and ascending aorta) and the oximetric shunt equation (using arterial and venous blood gases). Our study revealed that the COstatus monitor detected intracardiac shunts with high sensitivity and specificity but there was some underestimation of the shunt ratios compared to the reference techniques.
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Affiliation(s)
- Theodor Skuli Sigurdsson
- Department of Pediatric Anesthesia and Intensive Care, Children´s Hospital, University Hospital of Lund, Lund, Sweden. .,Department of Anesthesia and Intensive Care, Landspítalinn, University Hospital of Iceland, Reykjavík, Iceland.
| | - Lars Lindberg
- Department of Pediatric Anesthesia and Intensive Care, Children´s Hospital, University Hospital of Lund, Lund, Sweden
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8
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Sigurdsson TS, Lindberg L. Indirect Calorimetry Overestimates Oxygen Consumption in Young Children: Caution is Advised Using Direct Fick Method as a Reference Method in Cardiac Output Comparison Studies. Pediatr Cardiol 2020; 41:149-154. [PMID: 31741015 PMCID: PMC6987070 DOI: 10.1007/s00246-019-02238-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 10/30/2019] [Indexed: 11/26/2022]
Abstract
Direct Fick method is considered a standard reference method for estimation of cardiac output. It relies on indirect calorimetry to measure oxygen consumption. This is important as only a minor measurement error in oxygen consumption can result in false estimation of cardiac output. A number of studies have shown that indirect calorimetry overestimates oxygen consumption in adults. The aim of this prospective single center observational method comparison study was to compare the determination of oxygen consumption by indirect calorimetry and reverse Fick method in pediatric patients. Forty-two children mean age 352 days (range 30 to 1303 days) and mean weight 7.1 kg (range 2.7-13.6 kg) undergoing corrective cardiac surgery were included in the study. The mean (standard deviation) oxygen consumption by reverse Fick method was 43.5 (16.2) ml/min and by indirect calorimetry 49.9 (18.8) ml/min (p < 0.001). Indirect calorimetry overestimated the reverse Fick oxygen consumption by 14.7%. Bias between methods was 6.5 (11.3) ml/min, limits of agreement (LOA) - 15.7 and 28.7 ml/min and percentage error of 47.7%. A significant bias and large percentage error indicates that the methods are not interchangeable. Indirect calorimetry and the direct Fick method should be used with caution as a reference method in cardiac output comparison studies in young children.
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Affiliation(s)
- Theodor S Sigurdsson
- Department of Pediatric Anesthesia and Intensive Care, Children's Hospital, Skåne University Hospital, Lund, Sweden.
- Department of Anesthesia and Intensive Care, Landspítalinn University Hospital, Reykjavík, Iceland.
| | - Lars Lindberg
- Department of Pediatric Anesthesia and Intensive Care, Children's Hospital, Skåne University Hospital, Lund, Sweden
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Guyon PW, Karamlou T, Ratnayaka K, El-Said HG, Moore JW, Rao RP. An Elusive Prize: Transcutaneous Near InfraRed Spectroscopy (NIRS) Monitoring of the Liver. Front Pediatr 2020; 8:563483. [PMID: 33330267 PMCID: PMC7711108 DOI: 10.3389/fped.2020.563483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/26/2020] [Indexed: 01/20/2023] Open
Abstract
Introduction: We postulate a relationship between a transcutaneous hepatic NIRS measurement and a directly obtained hepatic vein saturation. If true, hepatic NIRS monitoring (in conjunction with the current dual-site cerebral-renal NIRS paradigm) might increase the sensitivity for detecting shock since regional oxygen delivery changes in the splanchnic circulation before the kidney or brain. We explored a reliable technique for hepatic NIRS monitoring as a prelude to rigorously testing this hypothesis. This proof-of-concept study aimed to validate hepatic NIRS monitoring by comparing hepatic NIRS measurements to direct hepatic vein samples obtained during cardiac catheterization. Method: IRB-approved prospective pilot study of hepatic NIRS monitoring involving 10 patients without liver disease who were already undergoing elective cardiac catheterization. We placed a NIRS monitor on the skin overlying liver during catheterization. Direct measurement of hepatic vein oxygen saturation during the case compared with simultaneous hepatic NIRS measurement. Results: There was no correlation between the Hepatic NIRS values and the directly measured hepatic vein saturation (R = -0.035; P = 0.9238). However, the Hepatic NIRS values correlated with the cardiac output (R = 0.808; P = 0.0047), the systolic arterial blood pressure (R = 0.739; P = 0.0146), and the diastolic arterial blood pressure (R = 0.7548; P = 0.0116). Conclusions: Using the technique described, hepatic NIRS does not correlate well with the hepatic vein saturation. Further optimization of the technique might provide a better measurement. Hepatic NIRS does correlate with cardiac output and thus may still provide a valuable additional piece of hemodynamic information when combined with other non-invasive monitoring.
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Affiliation(s)
- Peter W Guyon
- Division of Pediatric Cardiology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Tara Karamlou
- Division of Pediatric Cardiothoracic Surgery, Cleveland Clinic Children's and the Heart Vascular and Thoracic Institute, Cleveland, OH, United States
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Howaida G El-Said
- Division of Pediatric Cardiology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - John W Moore
- Division of Pediatric Cardiology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Rohit P Rao
- Division of Pediatric Cardiology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
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Fathi EM, Narchi H, Chedid F. Noninvasive hemodynamic monitoring of septic shock in children. World J Methodol 2018; 8:1-8. [PMID: 29988909 PMCID: PMC6033738 DOI: 10.5662/wjm.v8.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/10/2018] [Accepted: 05/11/2018] [Indexed: 02/06/2023] Open
Abstract
Septic shock in children is associated with high mortality and morbidity. Its management is time-sensitive and must be aggressive and target oriented. The use of clinical assessment alone to differentiate between cold and warm shock and to select the appropriate inotropic and vasoactive medications is fraught with errors. Semi-quantitative and quantitative assessment of the preload, contractility and afterload using non-invasive tools has been suggested, in conjunction with clinical and laboratory assessment, to direct shock management and select between vasopressors, vasodilators and inotropes or a combination of these drugs. This review aims to describe non-invasive tools to assess the hemodynamic status in septic shock including echocardiography, trans-thoracic/trans-esophageal Doppler and electrical cardiometry. As septic shock is a dynamic condition that changes markedly overtime, frequent or continuous measurement of the cardiac output (CO), systemic vascular resistance (SVR) and other hemodynamic parameters using the above-mentioned tools is essential to personalize the treatment and adapt it over time. The different combinations of blood pressure, CO and SVR serve as a pathophysiological framework to manage fluid therapy and titrate inotropic and vasoactive drugs. Near infrared spectroscopy is introduced as a non-invasive method to measure end organ perfusion and assess the response to treatment.
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Affiliation(s)
- Emad Mohamed Fathi
- Department of Critical Care, Al Jalila Children’s Specialty Hospital, Dubai 7662, United Arab Emirates
| | - Hassib Narchi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 17666, United Arab Emirates
| | - Fares Chedid
- Neonatal Intensive Care Unit, Oasis Hospital, Al Ain 1016, United Arab Emirates
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Díaz F, Nuñez MJ, Pino P, Erranz B, Cruces P. Implementation of preemptive fluid strategy as a bundle to prevent fluid overload in children with acute respiratory distress syndrome and sepsis. BMC Pediatr 2018; 18:207. [PMID: 29945586 PMCID: PMC6020419 DOI: 10.1186/s12887-018-1188-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/21/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Fluid overload (FO) is associated with unfavorable outcomes in critically ill children. Clinicians are encouraged to avoid FO; however, strategies to avoid FO are not well-described in pediatrics. Our aim was to implement a bundle strategy to prevent FO in children with sepsis and pARDS and to compare the outcomes with a historical cohort. METHODS A quality improvement initiative, known as preemptive fluid strategy (PFS) was implemented to prevent early FO, in a 12-bed general PICU. Infants on mechanical ventilation (MV) fulfilling pARDS and sepsis criteria were prospectively recruited. For comparison, data from a historical cohort from 2015, with the same inclusion and exclusion criteria, was retrospectively reviewed. The PFS bundle consisted of 1. maintenance of intravenous fluids (MIVF) at 50% of requirements; 2. drug volume reduction; 3. dynamic monitoring of preload markers to determine the need for fluid bolus administration; 4. early use of diuretics; and 5. early initiation of enteral feeds. The historical cohort treatment, the standard fluid strategy (SFS), were based on physician preferences. Peak fluid overload (PFO) was the primary outcome. PFO was defined as the highest FO during the first 72 h. FO was calculated as (cumulative fluid input - cumulative output)/kg*100. Fluid input/output were registered every 12 h for 72 h. RESULTS Thirty-seven patients were included in the PFS group (54% male, 6 mo (IQR 2,11)) and 39 with SFS (64%male, 3 mo (IQR1,7)). PFO was lower in PFS (6.31% [IQR4.4-10]) compared to SFS (12% [IQR8.4-15.8]). FO was lower in PFS compared to CFS as early as 12 h after admission [2.4(1.4,3.7) v/s 4.3(1.5,5.5), p < 0.01] and maintained during the study. These differences were due to less fluid input (MIVF and fluid boluses). There were no differences in the renal function test. PRBC requirements were lower during the first 24 h in the PFS (5%) compared to SFS (28%, p < 0.05). MV duration was 81 h (58,98) in PFS and 118 h (85154) in SFS(p < 0.05). PICU LOS in PFS was 5 (4, 7) and in SFS was 8 (6, 10) days. CONCLUSION Implementation of a bundle to prevent FO in children on MV with pARDS and sepsis resulted in less PFO. We observed a decrease in MV duration and PICU LOS. Future studies are needed to address if PFS might have a positive impact on health outcomes.
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Affiliation(s)
- Franco Díaz
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile.,Pediatric Intensive Care Unit, Clínica Alemana de Santiago, Santiago, Chile.,Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - María José Nuñez
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile
| | - Pablo Pino
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile
| | - Benjamín Erranz
- Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Pablo Cruces
- Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Santiago, Chile. .,Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Avda. Republica 217, Santiago, Chile.
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Transpulmonary Thermodilution Versus Transthoracic Echocardiography for Cardiac Output Measurements in Severely Burned Children. Shock 2018; 46:249-53. [PMID: 27058051 DOI: 10.1097/shk.0000000000000627] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Severe burns trigger a hyperdynamic state, necessitating accurate measurement of cardiac output (CO) for cardiovascular observation and guiding fluid resuscitation. However, it is unknown whether, in burned children, the increasingly popular transthoracic echocardiography (TTE) method of CO measurement is as accurate as the widely used transpulmonary thermodilution (TPTD) method. PATIENTS AND METHODS We retrospectively compared near-simultaneously performed CO measurements in severely burned children using TPTD with the Pulse index Continuous Cardiac Output (PiCCO) system or TTE. Outcomes were compared using t tests, multiple linear regression, and a Bland-Altman plot. RESULTS Fifty-four children (9 ± 5 years) with 68 ± 18% total body surface area burns were studied. An analysis of 105 data pairs revealed that PiCCO yielded higher CO measurements than TTE (190 ± 39% vs. 150 ± 50% predicted values; P < 0.01). PiCCO- and TTE-derived CO measurements correlated moderately well (R = 0.54, P < 0.01). A Bland-Altman plot showed a mean bias of 1.53 L/min with a 95% prediction interval of 4.31 L/min. CONCLUSIONS TTE-derived estimates of CO may underestimate severity of the hyperdynamic state in severely burned children. We propose using the PiCCO system for objective cardiovascular monitoring and to guide goal-directed fluid resuscitation in this population.
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Vrancken SL, van Heijst AF, de Boode WP. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring. Front Pediatr 2018; 6:87. [PMID: 29675404 PMCID: PMC5895966 DOI: 10.3389/fped.2018.00087] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022] Open
Abstract
Maintenance of neonatal circulatory homeostasis is a real challenge, due to the complex physiology during postnatal transition and the inherent immaturity of the cardiovascular system and other relevant organs. It is known that abnormal cardiovascular function during the neonatal period is associated with increased risk of severe morbidity and mortality. Understanding the functional and structural characteristics of the neonatal circulation is, therefore, essential, as therapeutic hemodynamic interventions should be based on the assumed underlying (patho)physiology. The clinical assessment of systemic blood flow (SBF) by indirect parameters, such as blood pressure, capillary refill time, heart rate, urine output, and central-peripheral temperature difference is inaccurate. As blood pressure is no surrogate for SBF, information on cardiac output and systemic vascular resistance should be obtained in combination with an evaluation of end organ perfusion. Accurate and reliable hemodynamic monitoring systems are required to detect inadequate tissue perfusion and oxygenation at an early stage before this result in irreversible damage. Also, the hemodynamic response to the initiated treatment should be re-evaluated regularly as changes in cardiovascular function can occur quickly. New insights in the understanding of neonatal cardiovascular physiology are reviewed and several methods for current and future neonatal hemodynamic monitoring are discussed.
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Affiliation(s)
- Sabine L Vrancken
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Arno F van Heijst
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem P de Boode
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Bilgili B, Haliloglu M, Tugtepe H, Umuroglu T. The Assessment of Intravascular Volume with Inferior Vena Cava and Internal Jugular Vein Distensibility Indexes in Children Undergoing Urologic Surgery. J INVEST SURG 2017; 31:523-528. [PMID: 28952826 DOI: 10.1080/08941939.2017.1364806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this work is to assess the predictive value, for fluid responsiveness (FR), of the inferior vena cava distensibility index (IVC-DI) and internal jugular vein distensibility index (IJV-DI) in pediatric surgical patients. MATERIAL AND METHODS Prior to being placed under general anesthesia, 24 surgical patients were enrolled. Baseline parameters were recorded with the patient in the semirecumbent position (Stage 1). Next, the passive leg raising (PLR) maneuver was carried out and a second measurement was recorded (Stage 2). Patients with an increase in the cardiac index (CI) of >10%, induced by PLR, were considered to be responders (R), otherwise they were classified as nonresponders (NR). At both stages, CI and DI of the IVC and IJV were measured. RESULTS Responders had higher IVC-DI and IVJ-DI than NR in stage 1 (both p <.001). In stage 2, IVC-DI and IJV-DI were not different in R and NR groups (p =.164, p =.201). Utilizing cut-off values of > 22.7% for IVC-DI and > 25% for IJV-DI, these parameters had positive correlation coefficients, both in R and NR of, respectively, 0.626 and 0.929. CONCLUSIONS The IVC-DI predicts FR in anesthetized pediatric patients and correlates well with the IJV-DI; both may be used as prediction markers of FR in children.
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Affiliation(s)
- Beliz Bilgili
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
| | - Murat Haliloglu
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
| | - Halil Tugtepe
- b Marmara University, School of Medicine , Department of Pediatric Surgery , Pendik, Istanbul , Turkey
| | - Tumay Umuroglu
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
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Non-invasive cardiac output monitor validation study in pediatric cardiac surgery patients. J Clin Anesth 2017; 38:129-132. [DOI: 10.1016/j.jclinane.2017.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/31/2017] [Accepted: 02/04/2017] [Indexed: 11/30/2022]
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Kuiper JW, Tibboel D, Ince C. The vulnerable microcirculation in the critically ill pediatric patient. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:352. [PMID: 27794361 PMCID: PMC5086412 DOI: 10.1186/s13054-016-1496-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In neonates, cardiovascular system development does not stop after the transition from intra-uterine to extra-uterine life and is not limited to the macrocirculation. The microcirculation (MC), which is essential for oxygen, nutrient, and drug delivery to tissues and cells, also develops. Developmental changes in the microcirculatory structure continue to occur during the initial weeks of life in healthy neonates. The physiologic hallmarks of neonates and developing children make them particularly vulnerable during critical illness; however, the cardiovascular monitoring possibilities are limited compared with critically ill adult patients. Therefore, the development of non-invasive methods for monitoring the MC is necessary in pediatric critical care for early identification of impending deterioration and to enable the initiation and titration of therapy to ensure cell survival. To date, the MC may be non-invasively monitored at the bedside using hand-held videomicroscopy, which provides useful information regarding the microcirculation. There is an increasing number of studies on the MC in neonates and pediatric patients; however, additional steps are necessary to transition MC monitoring from bench to bedside. The recently introduced concept of hemodynamic coherence describes the relationship between changes in the MC and macrocirculation. The loss of hemodynamic coherence may result in a depressed MC despite an improvement in the macrocirculation, which represents a condition associated with adverse outcomes. In the pediatric intensive care unit, the concept of hemodynamic coherence may function as a framework to develop microcirculatory measurements towards implementation in daily clinical practice.
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Affiliation(s)
- J W Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Postbox 2040, 3000 CA, Rotterdam, The Netherlands
| | - C Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Grindheim G, Eidet J, Bentsen G. Transpulmonary thermodilution (PiCCO) measurements in children without cardiopulmonary dysfunction: large interindividual variation and conflicting reference values. Paediatr Anaesth 2016; 26:418-24. [PMID: 26857433 DOI: 10.1111/pan.12859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The PiCCO system, based on transpulmonary thermodilution, is one of the few tools available for continuous hemodynamic monitoring in children. However, published data for some of the derived variables reveal indexed values that seem questionable. AIMS The aim of this study was to collect data from hemodynamically normal children and compare these to existing reference values. Furthermore, we sought to explore if indexing some of the variables differently could improve the clinical application of the obtained values. METHODS This is a prospective observational study in a tertiary university hospital including 31 children without cardiopulmonary disease scheduled for major neurosurgery. Measurements were performed after induction of general anesthesia. RESULTS Median age was 8 months. PiCCO-derived median Cardiac Index (CI) was 3.8 l · min(-1) · m(-2) (range 2.6-6.6), reference range 3.0-5.0, median Global End-Diastolic Volume Index (GEDVI) was 366 ml · m(-2) (range 269-685), reference range 680-800, whereas median Extravascular Lung Water Index (EVLWI) was 12 ml · kg(-1) (range 7-31), reference range 3-7. All measured variables had a high interindividual variation, especially in children weighing less than 15 kg. CONCLUSIONS Values obtained by the PiCCO system in children have a wide range, and should therefore be interpreted with caution. Current reference values published for GEDVI and EVLWI are not applicable in children; the former is too high and the latter too low, and should not guide clinical practice. Indexing by other physiological indices may reduce this problem. Using current variables, we find GEDVI 280-590 ml · m(-2) and ELWI 7-27 ml · kg(-1) to be typical ranges for children.
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Affiliation(s)
- Guro Grindheim
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Jo Eidet
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Gunnar Bentsen
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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Lin YR, Syue YJ, Buddhakosai W, Lu HE, Chang CF, Chang CY, Chen CH, Chen WL, Li CJ. Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest. Medicine (Baltimore) 2016; 95:e3195. [PMID: 27015217 PMCID: PMC4998412 DOI: 10.1097/md.0000000000003195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA.Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003-2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15-30, and late: >30 minutes after collapse) were analyzed.Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome.Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration.
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Affiliation(s)
- Yan-Ren Lin
- From the Department of Emergency Medicine (Y-RL, C-FC, C-YC, CHC), Changhua Christian Hospital, Changhua, Taiwan; School of Medicine (Y-RL), Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine (Y-RL), Chung Shan Medical University, Taichung, Taiwan; Department of Anesthesiology (Y-JS), Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Biological Science and Technology (WB, C-YC, W-LC), National Chiao Tung University, Hsinchu, Taiwan; Interdisciplinary Graduate Program in Genetic Engineering (WB), Graduate School, Kasetsart University, Bangkhen campus, Bangkok, Thailand; Bioresource Collection and Research Center (H-EL), Food Industry Research and Development Institute, Hsinchu, Taiwan; Department of Emergency Medicine (C-JL), Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; and Department of Public Health (C-JL), College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
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Desgranges FP, Desebbe O, Pereira de Souza Neto E, Raphael D, Chassard D. Respiratory variation in aortic blood flow peak velocity to predict fluid responsiveness in mechanically ventilated children: a systematic review and meta-analysis. Paediatr Anaesth 2016; 26:37-47. [PMID: 26545173 DOI: 10.1111/pan.12803] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND Dynamic indices of preload have been shown to better predict fluid responsiveness than static variables in mechanically ventilated adults. In children, dynamic predictors of fluid responsiveness have not yet been extensively studied. AIM To evaluate the diagnostic accuracy of respiratory variation in aortic blood flow peak velocity (ΔVPeak) for the prediction of fluid responsiveness in mechanically ventilated children. METHOD PubMed, Embase, and the Cochrane Database of Systematic Reviews were screened for studies relevant to the use of ΔVPeak to predict fluid responsiveness in children receiving mechanical ventilation. Clinical trials published as full-text articles in indexed journals without language restriction were included. We calculated the pooled values of sensitivity, specificity, diagnostic odds ratio (DOR), and positive and negative likelihood ratio using a random-effects model. RESULTS In total, six studies (163 participants) met the inclusion criteria. Data are reported as point estimate with 95% confidence interval. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and DOR of ΔVPeak to predict fluid responsiveness for the overall population were 92.0% (84.1-96.7), 85.5% (75.6-92.5), 4.89 (2.92-8.18), 0.13 (0.07-0.25), and 50.44 (17.70-143.74), respectively. The area under the summary receiver operating characteristic curve was 0.94. Cutoff values for ΔVPeak to predict fluid responsiveness varied across studies, ranging from 7% to 20%. CONCLUSION Our results confirm that the ΔVPeak is an accurate predictor of fluid responsiveness in children under mechanical ventilation. However, the question of the optimal cutoff value of ΔVPeak to predict fluid responsiveness remains uncertain, as there are important variations between original publications, and needs to be resolved in further studies. The potential impact of intraoperative cardiac output optimization using goal-directed fluid therapy based on ΔVPeak on the perioperative outcome in the pediatric population should be subsequently evaluated.
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Affiliation(s)
- François-Pierrick Desgranges
- Department of Pediatric Anesthesia and Intensive Care Medicine, Femme Mère Enfant Teaching Hospital, Hospices Civils de Lyon, Claude Bernard Lyon 1 University, Lyon, France
| | - Olivier Desebbe
- Department of Anesthesia and Intensive Care Medicine, Sauvegarde Clinic, Claude Bernard Lyon 1 University, EA4169, SFR Lyon-Est Santé - INSERM US 7- CNRS UMS 3453, Lyon, France
| | - Edmundo Pereira de Souza Neto
- Department of Anesthesia, Montauban Hospital, Montauban, France.,Laboratory of Physics, Ecole Normale Supérieure de Lyon, Lyon, France.,Oeste Paulista University (UNOESTE), Presidente Prudente, São Paulo, Brasil
| | - Darren Raphael
- Department of Anesthesia and Perioperative Care, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Dominique Chassard
- Department of Pediatric Anesthesia and Intensive Care Medicine, Femme Mère Enfant Teaching Hospital, Hospices Civils de Lyon, Claude Bernard Lyon 1 University, Lyon, France
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Totapally BR. Reliable assessment of perfusion is the Holy Grail of intensive care. Indian J Crit Care Med 2015; 19:1-2. [PMID: 25624642 PMCID: PMC4296404 DOI: 10.4103/0972-5229.148626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Balagangadhar R Totapally
- Department of Pediatrics, Division of Critical Care Medicine, Miami Children's Hospital, Herberth Wertheim College of Medicine, Florida International University, Miami, Florida 33199, USA
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Mydam J, Zidan M, Chouthai NS. A comprehensive study of clinical biomarkers, use of inotropic medications and fluid resuscitation in newborns with persistent pulmonary hypertension. Pediatr Cardiol 2015; 36:233-9. [PMID: 25107548 DOI: 10.1007/s00246-014-0992-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/23/2014] [Indexed: 01/20/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is associated with high morbidity and mortality. This study evaluated clinical outcomes in PPHN in relation to echocardiographic (EC) markers, score of neonatal acute physiology, perinatal extension, version II (SNAPPE II) scores, inotropic agent use, and the amount of fluid received as boluses. In this retrospective chart analysis of 98 neonates with PPHN born at >34 weeks' gestation, we compared two cohorts of newborns: those who received inhaled nitric oxide and mechanical ventilation only, and who survived to discharge (Group 1); and those who required extracorporeal membrane oxygenation (ECMO) or who died (Group 2). Of 21 EC parameters assessed, seven were significantly different between Group 1 and Group 2. Eleven (24.4%) newborns in Group 2 had decreased left ventricular (LV) function, compared with three (5.1%) in Group 1 (p = 0.011). Median SNAPPE II scores were significantly higher in Group 2 than in Group 1 (p < 0.001). Newborns in Group 2 also received a significantly higher amount of fluid as boluses during the first 7 days of hospitalization compared with Group 1 (p = 0.018). Following logistic regression analysis, only the difference in total SNAPPE II score retained statistical significance (p < 0.001); however, the total amount of fluid administered as boluses trended higher (p = 0.087) for newborns in Group 2. Our findings show that SNAPPE II scores may help guide counseling for parents of newborns with PPHN regarding the likelihood of death or the need for ECMO. Limiting fluid boluses may improve outcomes in newborns with high SNAPPE II scores and decreased LV function.
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Affiliation(s)
- Janardhan Mydam
- Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA,
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Hemodynamic volumetry using transpulmonary ultrasound dilution (TPUD) technology in a neonatal animal model. J Clin Monit Comput 2014; 29:643-52. [PMID: 25500953 DOI: 10.1007/s10877-014-9647-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
Abstract
To analyze changes in cardiac output and hemodynamic volumes using transpulmonary ultrasound dilution (TPUD) in a neonatal animal model under different hemodynamic conditions. 7 lambs (3.5-8.3 kg) under general anesthesia received arterial and central venous catheters. A Gore-Tex(®) shunt was surgically inserted between the descending aorta and the left pulmonary artery to mimic a patent ductus arteriosus. After shunt opening and closure, induced hemorrhagic hypotension (by repetitive blood withdrawals) and repetitive volume challenges, the following parameters were assessed using TPUD: cardiac output, active circulating volume index (ACVI), central blood volume index (CBVI) and total end-diastolic volume index (TEDVI). 27 measurement sessions were analyzed. After shunt opening, there was a significant increase in TEDVI and a significant decrease in cardiac output with minimal change in CBVI and ACVI. With shunt closure, these results reversed. After progressive hemorrhage, cardiac output and all volumes decreased significantly, except for ACVI. Following repetitive volume resuscitation, cardiac output increased and all hemodynamic volumes increased significantly. Correlations between changes in COufp and changes in hemodynamic volumes (ACVI 0.83; CBVI 0.84 and TEDVI 0.78 respectively) were (slightly) better than between changes in COufp and changes in heart rate (0.44) and central venous pressure (0.7). Changes in hemodynamic volumes using TPUD were as expected under different conditions. Hemodynamic volumetry using TPUD might be a promising technique that has the potential to improve the assessment and interpretation of the hemodynamic status in critically ill newborns and children.
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Gwer S, Chacha C, Newton CR, Idro R. Childhood acute non-traumatic coma: aetiology and challenges in management in resource-poor countries of Africa and Asia. Paediatr Int Child Health 2013; 33:129-38. [PMID: 23930724 DOI: 10.1179/2046905513y.0000000068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This review examines the best available evidence on the aetiology of childhood acute non-traumatic coma in resource-poor countries (RPCs), discusses the challenges associated with management, and explores strategies to address them. METHODS Publications in English and French which reported on studies on the aetiology of childhood non-traumatic coma in RPCs are reviewed. Primarily, the MEDLINE database was searched using the keywords coma, unconsciousness, causality, aetiology, child, malaria cerebral, meningitis, encephalitis, Africa, Asia, and developing countries. RESULTS 14 records were identified for inclusion in the review. Cerebral malaria (CM) was the commonest cause of childhood coma in most of the studies conducted in Africa. Acute bacterial meningitis (ABM) was the second most common known cause of coma in seven of the African studies. Of the studies in Asia, encephalitides were the commonest cause of coma in two studies in India, and ABM was the commonest cause of coma in Pakistan. Streptococcus pneumoniae was the most commonly isolated organism in ABM. Japanese encephalitis, dengue fever and enteroviruses were the viral agents most commonly isolated. CONCLUSION Accurate diagnosis of the aetiology of childhood coma in RPCs is complicated by overlap in clinical presentation, limited diagnostic resources, disease endemicity and co-morbidity. For improved outcomes, studies are needed to further elucidate the aetiology of childhood coma in RPCs, explore simple and practical diagnostic tools, and investigate the most appropriate specific and supportive interventions to manage and prevent infectious encephalopathies.
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Affiliation(s)
- Samson Gwer
- Department of Medical Physiology, Kenyatta University, Kenya.
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Saxena R, Durward A, Puppala NK, Murdoch IA, Tibby SM. Pressure recording analytical method for measuring cardiac output in critically ill children: a validation study. Br J Anaesth 2012. [PMID: 23183320 DOI: 10.1093/bja/aes420] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pressure recording analytical method (PRAM) is a novel, arterial pulse contour-based method for measuring cardiac output (CO). Validation studies of PRAM in children are few, and have not assessed both absolute accuracy and ability to track changes in CO across a broad case mix. We aimed to compare CO as measured by PRAM with that using a transpulmonary dilution method in a cohort of critically ill children. METHODS Forty-eight, mechanically ventilated children with a median (inter-quartile) weight of 10.7 (5.5-15) kg with arterial and central venous catheters in situ were studied. CO was measured simultaneously using PRAM and the comparator method, transpulmonary ultrasound dilution (UD). Measurements were repeated before and after therapeutic interventions that were intended to augment CO (e.g. fluid bolus). RESULTS In total, 210 paired measurements were compared. The mean (sd) CO was 1.9 (1.2) litre min(-1) with UD when compared with 1.92 (0.5) litre min(-1) using PRAM. The mean bias was 0.02 litre min(-1) with wide limits of agreement: ± 2.21 litre min(-1), giving a percentage error of 116%. The concordance between PRAM and UD for measuring changes in CO was also poor, with only 37% of measurements falling within the pre-defined polar plot limits of ±30°. CONCLUSIONS There is an unacceptably poor agreement between UD and PRAM. We do not recommend the use of PRAM for measuring CO in critically ill children with the current algorithm.
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Affiliation(s)
- R Saxena
- Paediatric Intensive Care Unit, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
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Buijs EAB, Zwiers AJM, Ista E, Tibboel D, de Wildt SN. Biomarkers and clinical tools in critically ill children: are we heading toward tailored drug therapy? Biomark Med 2012; 6:239-57. [PMID: 22731898 DOI: 10.2217/bmm.12.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In pediatric critical care, validated biomarkers are essential for guiding drug therapy. The aim of this article is to present examples of current biomarker developments in its full breadth, including biochemical substances, physiological measurements and clinical scoring tools, with a focus on the field of circulatory, renal and neurophysiologic failure. Within each field we consecutively discuss the rationale for the selected biomarkers, studies in critically ill children, biomarker validation stage and biomarker use or potential use in drug studies and clinical drug dosing. This article demonstrates that there is paucity of properly validated biomarkers. Nevertheless, recent developments in, for instance, the field of sepsis, point us toward a future wherein, for critically ill children, drug therapy may be personalized using proteomic profiling instead of a small number of biomarkers, in order to establish a personal and dynamic disease profile.
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Affiliation(s)
- Erik A B Buijs
- Intensive Care & Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Abstract
This article reviews potential pediatric applications of 3 new technologies. (1) Pulse oximetry-based hemoglobin determination: Hemoglobin determination using spectrophotometric methods recently has been introduced in adults with varied success. This non-invasive and continuous technology may avoid venipuncture and unnecessary transfusion in children undergoing surgery with major blood loss, premature infants undergoing unexpected and complicated emergency surgery, and children with chronic illness. (2) Continuous cardiac output monitoring: In adults, advanced hemodynamic monitoring such as continuous cardiac output monitoring has been associated with better surgical outcomes. Although it remains unknown whether similar results are applicable to children, current technology enables the monitoring of cardiac output non-invasively and continuously in pediatric patients. It may be important to integrate the data about cardiac output with other information to facilitate therapeutic interventions. (3) Anesthesia information management systems: Although perioperative electronic anesthesia information management systems are gaining popularity in operating rooms, their potential functions may not be fully appreciated. With advances in information technology, anesthesia information management systems may facilitate bedside clinical decisions, administrative needs, and research in the perioperative setting.
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Caplow J, McBride SC, Steil GM, Wong J. Changes in cardiac output and stroke volume as measured by non-invasive CO monitoring in infants with RSV bronchiolitis. J Clin Monit Comput 2012; 26:197-205. [PMID: 22526738 DOI: 10.1007/s10877-012-9361-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/10/2012] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The primary aim of the study was to determine the changes, if any, in cardiac output (CO) and stroke volume (SV) in normal infants with RSV bronchiolitis. The secondary aim was to determine whether changes in CO (ΔCO) and SV (ΔSV) are associated with changes in respiratory rate (ΔRR). METHODS Non-invasive CO recordings were obtained within 24 h of admission and discharge. Changes in CO, SV, and HR measurements were compared using paired t-tests. The effect of fluid boluses during the first 24 h (<60 or ≥60 cc/kg) on CO was assessed by 2 way ANOVA with time and group as main effect. The relationship between ΔRR and ΔCO or ΔSV was assessed by linear regression. Data is presented as Mean ± SEM and mean differences with 95 % confidence interval (p < 0.05 considered significant). RESULTS 15 infants with RSV bronchiolitis were studied. CO (1.31 ± 0.13 to 1.11 ± 0.11 l/min (0.21 [0.04-0.37]) and SV (9.42 ± 1.10 to 7.75 ± 0.83 ml/beat (1.67 [0.21-3.12]) decreased significantly while HR (142.1 ± 4.0 to 145.2 ± 3.1 beats/min 3.0 [-5.3 to 11.3]) was unchanged. SV (p = 0.02) and CO (p = 0.04) significantly decreased only in the 7 infants that received ≥60 cc/kg. ΔRR correlated significantly with ΔCO (r (2) = 0.28, p = 0.04); but not with ΔSV (r (2) = 0.20, p = 0.09). CONCLUSIONS ∆CO was related to ΔSV and not Δ HR. The ∆CO and ΔSV were affected by fluid boluses. ΔRR correlated with ΔCO. Non-invasive CO monitoring can trend CO and SV in infants with bronchiolitis during hospitalization.
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Affiliation(s)
- Julie Caplow
- Department of Medicine Children Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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