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Savorgnan F, Flores S, Loomba RS, Acosta S. Hemodynamic Response to Fluid Boluses in Patients with Single-Ventricle Parallel Circulation. Pediatr Cardiol 2022; 43:1784-1791. [PMID: 35511283 DOI: 10.1007/s00246-022-02915-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/15/2022] [Indexed: 11/26/2022]
Abstract
The purpose of this study is to assess the effect of fluid bolus in response to a hypotensive episode by evaluating high-fidelity hemodynamic data obtained from children with single-ventricle anatomy and parallel circulation. Single center, retrospective analysis of hemodynamic and oximetric data after fluid bolus administrations within the first 2 weeks post-surgery. A baseline (- 60 to - 10 min), hypotensive episode (- 10 to 0 min), and response interval (0 to 60 min) were defined to quantify the dynamics of vital signs. The responses assessed include heart rate, blood pressure, oxygen saturation, oxygen extraction ratios, and pulmonary-to-systemic flow ratios. Mixed effects models were used to account for the repeated measures over the response interval. The analysis included 67 fluid boluses. There is a decrease in heart rate and an increase in blood pressure during the response in comparison to the hypotensive time. These vitals rapidly return to the baseline values. The boluses induced a significant decrease in renal and cerebral oxygen extraction ratios, with no significant change in arterial oxygen saturation or pulmonary-to-systemic flow ratio. The type of bolus (normal saline versus albumin) did not affect the response in blood pressure. However, in comparison with albumin, normal saline had a more favorable effect on the renal and cerebral oxygen extraction ratios. This study demonstrates that fluid boluses are an effective rescue medication for hypotensive episodes in children with parallel circulation by improving hemodynamics, as well as markers of oxygen delivery. The type of bolus (normal saline versus albumin) did not affect the blood pressure response. However, normal saline had a more pronounced effect on the renal and cerebral oxygen extraction ratios than albumin.
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Affiliation(s)
- Fabio Savorgnan
- Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Saul Flores
- Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Rohit S Loomba
- Department of Pediatrics, The Heart Institute, Advocate Children's Hospital, Chicago Medical School and Rosalind Franklin University of Medicine and Science, Oak Lawn, IL, USA
| | - Sebastian Acosta
- Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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Loomba RS, Flores S. Oximetry titrated care: This is the way. Paediatr Anaesth 2022; 32:485. [PMID: 34865277 DOI: 10.1111/pan.14350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Rohit S Loomba
- Advocate Children's Hospital, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, Illinois, USA
| | - Saul Flores
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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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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Deja E, Peters MJ, Khan I, Mouncey PR, Agbeko R, Fenn B, Watkins J, Ramnarayan P, Tibby SM, Thorburn K, Tume LN, Rowan KM, Woolfall K. Establishing and augmenting views on the acceptability of a paediatric critical care randomised controlled trial (the FEVER trial): a mixed methods study. BMJ Open 2021; 11:e041952. [PMID: 33692177 PMCID: PMC7949453 DOI: 10.1136/bmjopen-2020-041952] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To explore parent and staff views on the acceptability of a randomised controlled trial investigating temperature thresholds for antipyretic intervention in critically ill children with fever and infection (the FEVER trial) during a multi-phase pilot study. DESIGN Mixed methods study with data collected at three time points: (1) before, (2) during and (3) after a pilot trial. SETTING English, Paediatric Intensive Care Units (PICUs). PARTICIPANTS (1) Pre-pilot trial focus groups with pilot site staff (n=56) and interviews with parents (n=25) whose child had been admitted to PICU in the last 3 years with a fever and suspected infection, (2) Questionnaires with parents of randomised children following pilot trial recruitment (n=48 from 47 families) and (3) post-pilot trial interviews with parents (n=19), focus groups (n=50) and a survey (n=48) with site staff. Analysis drew on Sekhon et al's theoretical framework of acceptability. RESULTS There was initial support for the trial, yet some held concerns regarding the proposed temperature thresholds and not using paracetamol for pain or discomfort. Pre-trial findings informed protocol changes and training, which influenced views on trial acceptability. Staff trained by the FEVER team found the trial more acceptable than those trained by colleagues. Parents and staff found the trial acceptable. Some concerns about pain or discomfort during weaning from ventilation remained. CONCLUSIONS Pre-trial findings and pilot trial experience influenced acceptability, providing insight into how challenges may be overcome. We present an adapted theoretical framework of acceptability to inform future trial feasibility studies. TRIAL REGISTRATION NUMBERS ISRCTN16022198 and NCT03028818.
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Affiliation(s)
- Elizabeth Deja
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK
- Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, UK
| | - Imran Khan
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Rachel Agbeko
- Paediatric Intensive Care Unit, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | | | | | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children, London, UK
| | - Shane M Tibby
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Kentigern Thorburn
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Kerry Woolfall
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Shah A, Gustafson O, Vollam S. Pilot and feasibility studies – more than just measuring metrics. Anaesthesia 2020; 75:693. [DOI: 10.1111/anae.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tume LN, Woolfall K, Arch B, Roper L, Deja E, Jones AP, Latten L, Pathan N, Eccleson H, Hickey H, Parslow R, Preston J, Beissel A, Andrzejewska I, Gale C, Valla FV, Dorling J. Routine gastric residual volume measurement to guide enteral feeding in mechanically ventilated infants and children: the GASTRIC feasibility study. Health Technol Assess 2020; 24:1-120. [PMID: 32458797 DOI: 10.3310/hta24230] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it. OBJECTIVE To answer the question: is a trial of no gastric residual volume measurement feasible in UK paediatric intensive care units and neonatal units? DESIGN A mixed-methods study involving five linked work packages in two parallel arms: neonatal units and paediatric intensive care units. Work package 1: a survey of units to establish current UK practice. Work package 2: qualitative interviews with health-care professionals and caregivers of children admitted to either setting. Work package 3: a modified two-round e-Delphi survey to investigate health-care professionals' opinions on trial design issues and to obtain consensus on outcomes. Work package 4: examination of national databases to determine the potential eligible populations. Work package 5: two consensus meetings of health-care professionals and parents to review the data and agree consensus on outcomes that had not reached consensus in the e-Delphi study. PARTICIPANTS AND SETTING Parents of children with experience of ventilation and tube feeding in both neonatal units and paediatric intensive care units, and health-care professionals working in neonatal units and paediatric intensive care units. RESULTS Baseline surveys showed that the practice of gastric residual volume measurement was very common (96% in paediatric intensive care units and 65% in neonatal units). Ninety per cent of parents from both neonatal units and paediatric intensive care units supported a future trial, while highlighting concerns around possible delays in detecting complications. Health-care professionals also indicated that a trial was feasible, with 84% of staff willing to participate in a trial. Concerns expressed by junior nurses about the intervention arm of not measuring gastric residual volumes were addressed by developing a simple flow chart and education package. The trial design survey and e-Delphi study gained consensus on 12 paediatric intensive care unit and nine neonatal unit outcome measures, and identified acceptable inclusion and exclusion criteria. Given the differences in physiology, disease processes, environments, staffing and outcomes of interest, two different trials are required in the two settings. Database analyses subsequently showed that trials were feasible in both settings in terms of patient numbers. Of 16,222 children who met the inclusion criteria in paediatric intensive care units, 12,629 stayed for > 3 days. In neonatal units, 15,375 neonates < 32 weeks of age met the inclusion criteria. Finally, the two consensus meetings demonstrated 'buy-in' from the wider UK neonatal communities and paediatric intensive care units, and enabled us to discuss and vote on the outcomes that did not achieve consensus in the e-Delphi study. CONCLUSIONS AND FUTURE WORK Two separate UK trials (one in neonatal units and one in paediatric intensive care units) are feasible to conduct, but they cannot be combined as a result of differences in outcome measures and treatment protocols, reflecting the distinctness of the two specialties. TRIAL REGISTRATION Current Controlled Trials ISRCTN42110505. 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. 24, No. 23. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Kerry Woolfall
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Barbara Arch
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Louise Roper
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Elizabeth Deja
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Lynne Latten
- Nutrition and Dietetics, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Helen Eccleson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | | | - Jennifer Preston
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), Alder Hey Children's NHS Foundation Trust, University of Liverpool, Liverpool, UK
| | - Anne Beissel
- Neonatal Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | | | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Frederic V Valla
- Paediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | - Jon Dorling
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Dewez JE, Nijman RG, Yeung S. Fluids in the management of sepsis in children: a review of guidelines in the aftermath of the FEAST trial. Arch Dis Child 2019; 104:1236. [PMID: 31326915 DOI: 10.1136/archdischild-2019-317595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Juan Emmanuel Dewez
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Ruud Gerard Nijman
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Shunmay Yeung
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.,Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
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