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Bem RA, Lemson J. Evaluating fluid overload in critically ill children. Curr Opin Pediatr 2024; 36:266-273. [PMID: 38655808 DOI: 10.1097/mop.0000000000001347] [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: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review the evaluation and management of fluid overload in critically ill children. RECENT FINDINGS Emerging evidence associates fluid overload, i.e. having a positive cumulative fluid balance, with adverse outcome in critically ill children. This is most likely the result of impaired organ function due to increased extravascular water content. The combination of a number of parameters, including physical, laboratory and radiographic markers, may aid the clinician in monitoring and quantifying fluid status, but all have important limitations, in particular to discriminate between intra- and extravascular water volume. Current guidelines advocate a restrictive fluid management, initiated early during the disease course, but are hampered by the lack of high quality evidence. SUMMARY Recent advances in early evaluation of fluid status and (tailored) restrictive fluid management in critically ill children may decrease complications of fluid overload, potentially improving outcome. Further clinical trials are necessary to provide the clinician with solid recommendations.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam Academic Medical Centers, location University of Amsterdam, Amsterdam
| | - Joris Lemson
- Department of Intensive Care, Radboud university medical center, Nijmegen, The Netherlands
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Cao H, Jiang M, Zhuang Z, Wang S, Cao Q. Case report: Successful anesthesia management of noncardiac surgery in a patient with single atrium. Front Pharmacol 2024; 15:1370263. [PMID: 38756372 PMCID: PMC11097672 DOI: 10.3389/fphar.2024.1370263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024] Open
Abstract
Background Single atrium is very rare congenital cardiac anomaly in adults. The prognosis of patients with single atrium is very poor, with 50% of patients dying owing to cardiopulmonary complications in childhood. Herein, we focused on anesthesia management for noncardiac surgery in patients with single atrium. Case presentation A 58-year-old male with a history of bilateral varicocele underwent laparotomy for high-position ligation of the spermatic vein. The patient also had a history of single atrium, atrial fibrillation, chronic heart failure, pulmonary hypertension (PH), and complete right bundle branch block (CRBBB). Given the significant complications associated with general anesthesia in patients with PH, we preferred to use low-dose epidural anesthesia for this patient. Transthoracic echocardiography was used to assess cardiac function before and during surgery and guide perioperative fluid therapy. To limit the stress response, we used a regional nerve block for reducing postoperative pain. Furthermore, we used norepinephrine to appropriately increase the systemic vascular resistance in response to the reduction of systemic vascular resistance caused by epidural anesthesia. Conclusion Low-dose epidural anesthesia can be safely used in patients with single atrium and PH. The use of perioperative transthoracic echocardiography is helpful in guiding fluid therapy and effectively assessing the cardiac structure and function of patients. Prophylactic administration of norepinephrine before epidural injection may make it easier to maintain the patient's BP.
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Affiliation(s)
- Hong Cao
- Department of Anesthesia and Perioperative Medicine, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, China
| | - Mengmeng Jiang
- Department of General Medicine, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, China
| | - Zhao Zhuang
- Department of Anesthesia and Perioperative Medicine, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, China
| | - Shoushi Wang
- Department of Anesthesia and Perioperative Medicine, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, China
| | - Qianqian Cao
- Department of Anesthesia and Perioperative Medicine, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, China
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Sallee CJ, Hippensteel JA, Miller KR, Oshima K, Pham AT, Richter RP, Belperio J, Sierra YL, Schwingshackl A, Mourani PM, Schmidt EP, Sapru A, Maddux AB. Endothelial Glycocalyx Degradation Patterns in Sepsis-Associated Pediatric Acute Respiratory Distress Syndrome: A Single Center Retrospective Observational Study. J Intensive Care Med 2024; 39:277-287. [PMID: 37670670 PMCID: PMC10845819 DOI: 10.1177/08850666231200162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Sepsis-associated destruction of the pulmonary microvascular endothelial glycocalyx (EGCX) creates a vulnerable endothelial surface, contributing to the development of acute respiratory distress syndrome (ARDS). Constituents of the EGCX shed into circulation, glycosaminoglycans and proteoglycans, may serve as biomarkers of endothelial dysfunction. We sought to define the patterns of plasma EGCX degradation products in children with sepsis-associated pediatric ARDS (PARDS), and test their association with clinical outcomes. METHODS We retrospectively analyzed a prospective cohort (2018-2020) of children (≥1 month to <18 years of age) receiving invasive mechanical ventilation for acute respiratory failure for ≥72 h. Children with and without sepsis-associated PARDS were selected from the parent cohort and compared. Blood was collected at time of enrollment. Plasma glycosaminoglycan disaccharide class (heparan sulfate, chondroitin sulfate, and hyaluronan) and sulfation subtypes (heparan sulfate and chondroitin sulfate) were quantified using liquid chromatography tandem mass spectrometry. Plasma proteoglycans (syndecan-1) were measured through an immunoassay. RESULTS Among the 39 mechanically ventilated children (29 with and 10 without sepsis-associated PARDS), sepsis-associated PARDS patients demonstrated higher levels of heparan sulfate (median 639 ng/mL [interquartile range, IQR 421-902] vs 311 [IQR 228-461]) and syndecan-1 (median 146 ng/mL [IQR 32-315] vs 8 [IQR 8-50]), both p = 0.01. Heparan sulfate subtype analysis demonstrated greater proportions of N-sulfated disaccharide levels among children with sepsis-associated PARDS (p = 0.01). Increasing N-sulfated disaccharide levels by quartile were associated with severe PARDS (n = 9/29) with the highest quartile including >60% of the severe PARDS patients (test for trend, p = 0.04). Higher total heparan sulfate and N-sulfated disaccharide levels were independently associated with fewer 28-day ventilator-free days in children with sepsis-associated PARDS (all p < 0.05). CONCLUSIONS Children with sepsis-associated PARDS exhibited higher plasma levels of heparan sulfate disaccharides and syndecan-1, suggesting that EGCX degradation biomarkers may provide insights into endothelial dysfunction and PARDS pathobiology.
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Affiliation(s)
- Colin J. Sallee
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Joseph A. Hippensteel
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen R. Miller
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kaori Oshima
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Andrew T. Pham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert P. Richter
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - John Belperio
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles and Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Yamila L. Sierra
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Andreas Schwingshackl
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Peter M. Mourani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Eric P. Schmidt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Anil Sapru
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles and Mattel Children's Hospital, Los Angeles, CA, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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Bauer JK, Hocama N, Traub AC, Rutes G, Fachi MM, Moraes J, Lenzi A, Barreto HAG. Chylothorax After Heart Surgery in Children. Pediatr Cardiol 2023; 44:1847-1855. [PMID: 37561171 DOI: 10.1007/s00246-023-03250-6] [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: 05/15/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
Chylothorax is a consequence of a thoracic duct injury that can occur during surgical procedures in patients with congenital heart disease. It is associated with high rates of morbimortality and increased use of clinical and hospital resources. The aim of this study was to evaluate the risk factors, distribution, manifestations, complications, and treatments for chylothorax in patients undergoing cardiac surgery in a tertiary pediatric hospital in southern Brazil. This is a retrospective, quantitative study, in which all medical records (n = 166) of patients with chylothorax after pediatric cardiac surgery between January 2014 and December of 2020 and a matched control group (n = 166) were analyzed. Over the study period, there was an increase in incidence of chylothorax from 4.5% in 2014 to 7.6% in 2020, a trend that has been reported in the literature. After multivariate analysis, the following were identified as risk factors for the diagnosis of chylothorax: genetic syndrome (OR 2.298); prolonged cardiopulmonary bypass time (greater than 120 min) (OR 2.410); fluid overload in the immediate postoperative period (OR 1.110); and SIRS (OR 2.527). Mortality was two times greater (p = 0.021) and there was a higher rate (34.4%) of infection (p < 0.001) in patients who developed chylothorax. In addition, a sensitivity analysis was performed comparing patients with low- and high-output chylothorax (> 20 mL/kg), which confirmed unfavorable outcomes for the latter group. Herein, we show that hemodynamic alterations were important factors for diagnosis. Understanding the risk factors, outcomes, and complications helps early identification and enables the reduction of morbidity and mortality.
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Affiliation(s)
- Juliane Kuster Bauer
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Nathalia Hocama
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Anna Clara Traub
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Gabriel Rutes
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Mariana Millan Fachi
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Janaina Moraes
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Andrea Lenzi
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
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Raman S, Rahiman S, Kennedy M, Mattke A, Venugopal P, McBride C, Tu Q, Zapf F, Kuhlwein E, Woodgate J, Singh P, Schlapbach LJ, Gibbons KS. REstrictive versus StandarD FlUid Management in Mechanically Ventilated ChildrEn Admitted to PICU: study protocol for a pilot randomised controlled trial (REDUCE-1). BMJ Open 2023; 13:e076460. [PMID: 38030251 PMCID: PMC10689381 DOI: 10.1136/bmjopen-2023-076460] [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: 06/08/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Intravenous fluid therapy is the most common intervention in critically ill children. There is an increasing body of evidence questioning the safety of high-volume intravenous fluid administration in these patients. To date, the optimal fluid management strategy remains unclear. We aimed to test the feasibility of a pragmatic randomised controlled trial comparing a restrictive with a standard (liberal) fluid management strategy in critically ill children. METHODS AND ANALYSIS Multicentre, binational pilot, randomised, controlled, open-label, pragmatic trial. Patients <18 years admitted to paediatric intensive care unit and mechanically ventilated at the time of screening are eligible. Patients with tumour lysis syndrome, diabetic ketoacidosis or postorgan transplant are excluded. INTERVENTIONS 1:1 random assignment of 154 individual patients into two groups-restrictive versus standard, liberal, fluid strategy-stratified by primary diagnosis (cardiac/non-cardiac). The intervention consists of a restrictive fluid bundle, including lower maintenance fluid allowance, limiting fluid boluses, reducing volumes of drug delivery and initiating diuretics or peritoneal dialysis earlier. The intervention is applied for 48 hours postrandomisation or until discharge (whichever is earlier). ENDPOINTS The number of patients recruited per month and proportion of recruited to eligible patients are feasibility endpoints. New-onset acute kidney injury and the incidence of clinically relevant central venous thrombosis are safety endpoints. Fluid balance at 48 hours after randomisation is the efficacy endpoint. Survival free of paediatric intensive care censored at 28 days is the clinical endpoint. ETHICS AND DISSEMINATION Ethics approval was gained from the Children's Health Queensland Human Research Ethics Committee (HREC/21/QCHQ/77514, date: 1 September 2021), and University of Zurich (2021-02447, date: 17 March 2023). The trial is registered with the Australia New Zealand Clinical Trials Registry (ACTRN12621001311842). Open-access publication in high impact peer-reviewed journals will be sought. Modern information dissemination strategies will also be used including social media to disseminate the outcomes of the study. TRIAL REGISTRATION NUMBER ACTRN12621001311842. PROTOCOL VERSION/DATE V5/23 May 2023.
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Affiliation(s)
- Sainath Raman
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Sarfaraz Rahiman
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Melanie Kennedy
- Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Adrian Mattke
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Prem Venugopal
- Department for Cardiac Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Craig McBride
- General Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Quyen Tu
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, Queensland, Australia
- UQ Centre for Clinical Research, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Florian Zapf
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Eva Kuhlwein
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Jemma Woodgate
- Department of Dietetics, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Puneet Singh
- Paediatric Intensive Care, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Luregn J Schlapbach
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
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Han CH, Park M, Kim H, Roh YY, Kim SY, Kim JD, Kim MJ, Lee YJ, Kim KW, Kim YH. Radiologic Assessment of Lung Edema Score as a Predictor of Clinical Outcome in Children with Acute Respiratory Distress Syndrome. Yonsei Med J 2023; 64:384-394. [PMID: 37226565 DOI: 10.3349/ymj.2022.0653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE The radiographic assessment of lung edema (RALE) score enables objective quantification of lung edema and is a valuable prognostic marker of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the validity of RALE score in children with ARDS. MATERIALS AND METHODS The RALE score was measured for its reliability and correlation to other ARDS severity indices. ARDS-specific mortality was defined as death from severe pulmonary dysfunction or the need for extracorporeal membrane oxygenation therapy. The C-index of the RALE score and other ARDS severity indices were compared via survival analyses. RESULTS Among 296 children with ARDS, 88 did not survive, and there were 70 ARDS-specific non-survivors. The RALE score showed good reliability with an intraclass correlation coefficient of 0.809 [95% confidence interval (CI), 0.760-0.848]. In univariable analysis, the RALE score had a hazard ratio (HR) of 1.19 (95% CI, 1.18-3.11), and the significance was maintained in multivariable analysis adjusting with age, ARDS etiology, and comorbidity, with an HR of 1.77 (95% CI, 1.05-2.91). The RALE score was a good predictor of ARDS-specific mortality, with a C-index of 0.607 (95% CI, 0.519-0.695). CONCLUSION The RALE score is a reliable measure for ARDS severity and a useful prognostic marker of mortality in children, especially for ARDS-specific mortality. This score provides information that clinicians can use to decide the proper time of aggressive therapy targeting severe lung injury and to appropriately manage the fluid balance of children with ARDS.
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Affiliation(s)
- Chang Hoon Han
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mireu Park
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Hamin Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Yun Young Roh
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Jong Deok Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Min Jung Kim
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
- Department of Pediatrics, Yongin Severance Hospital, Yongin, Korea
| | - Yong Ju Lee
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
- Department of Pediatrics, Yongin Severance Hospital, Yongin, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Seoul, Korea.
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Al-Sofyani KA. Corticosteroids treatment for pediatric acute respiratory syndrome: A critical review. Saudi Med J 2023; 44:440-449. [PMID: 37182909 PMCID: PMC10187748 DOI: 10.15537/smj.2023.44.5.20220672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Approximately 25% of all pediatric consultations are due to respiratory conditions, 10% of which are for asthma. Regarding prevalence, bronchiolitis, acute bronchitis, and respiratory infections are other leading pediatric respiratory illnesses. Compared to the aforementioned diseases, pediatric acute respiratory distress syndrome (PARDS) is rare but lethal in the Intensive Care Unit patients. According to global studies, the mortality in PARDS ranges from 13.3% to 60.7%. Before the Pediatric Acute Lung Injury Consensus Conference (PALICC), adult acute respiratory distress syndrome (ARDS) management guidelines were used for PARDS. The PALICC set new criteria to identify PARDS with a different treatment and management approach. Steroids have been used to treat ARDS in some cases, although their effectiveness in treating pediatric patients is highly debated in the scientific community. This review examines steroid use in treating PARDS, emphasizes current developments in the field, and gives a broad overview of PARDS management.
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Affiliation(s)
- Khouloud A. Al-Sofyani
- From the Department of Pediatric, Pediatric Critical Care Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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9
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Gomes RADS, Azevedo LF, Simões BPC, Detomi LS, Rodrigues KEDS, Rodrigues AT, Melo MDCBD, Fonseca JGD. Fluid overload: clinical outcomes in pediatric intensive care unit. J Pediatr (Rio J) 2022; 99:241-246. [PMID: 36370749 DOI: 10.1016/j.jped.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to analyze the effects of fluid overload related to mechanical ventilation, renal replacement therapy, and evolution to discharge or death in critically ill children. METHODS A retrospective study in a Pediatric Intensive Care Unit for two years. Patients who required invasive ventilatory support and vasopressor and/or inotropic medications were considered critically ill. RESULTS 70 patients were included. The mean age was 6.8 ± 6 years. There was a tolerable increase in fluid overload during hospitalization, with a median of 2.45% on the first day, 5.10% on the third day, and 8.39% on the tenth day. The median fluid overload on the third day among those patients in pressure support ventilation mode was 4.80% while the median of those who remained on controlled ventilation was 8.45% (p = 0.039). Statistical significance was observed in the correlations between fluid overload measurements on the first, third, and tenth days of hospitalization and the beginning of renal replacement therapy (p = 0.049) and between renal replacement therapy and death (p = 0.01). The median fluid overload was 7.50% in patients who died versus 4.90% in those who did not die on the third day of hospitalization (p = 0.064). There was no statistically significant association between death and the variables sex or age. CONCLUSIONS The fluid overload on the third day of hospitalization proved to be a determinant for the clinical outcomes of weaning from mechanical ventilation, initiation of renal replacement therapy, discharge from the intensive care unit, or death among these children.
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Affiliation(s)
| | - Lorena Ferreira Azevedo
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG)/EBSERH, Belo Horizonte, MG, Brazil
| | | | - Letícia Silva Detomi
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG)/EBSERH, Belo Horizonte, MG, Brazil
| | | | - Adriana Teixeira Rodrigues
- Pediatria, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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10
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Arrahmani I, Ingelse SA, van Woensel JBM, Bem RA, Lemson J. Current Practice of Fluid Maintenance and Replacement Therapy in Mechanically Ventilated Critically Ill Children: A European Survey. Front Pediatr 2022; 10:828637. [PMID: 35281243 PMCID: PMC8906881 DOI: 10.3389/fped.2022.828637] [Citation(s) in RCA: 1] [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: 12/03/2021] [Accepted: 01/24/2022] [Indexed: 11/29/2022] Open
Abstract
Appropriate fluid management in mechanically ventilated critically ill children remains an important challenge and topic of active discussion in pediatric intensive care medicine. An increasing number of studies show an association between a positive fluid balance or fluid overload and adverse outcomes. However, to date, no international consensus regarding fluid management or removal strategies exists. The aim of this study was to obtain more insight into the current clinical practice of fluid therapy in mechanically ventilated critically ill children. On behalf of the section of cardiovascular dynamics of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) we conducted an anonymous survey among pediatric intensive care unit (PICU) specialists in Europe regarding fluid overload and management. A total of 107 study participants responded to the survey. The vast majority of respondents considers fluid overload to be a common phenomenon in mechanically ventilated children and believes this complication is associated with adverse outcomes, such as mortality and duration of respiratory support. Yet, only 75% of the respondents administers a lower volume of fluids (reduction of 20% of normal intake) to mechanically ventilated critically ill children on admission. During PICU stay, a cumulative fluid balance of more than 5% is considered to be an indication to reduce fluid intake and start diuretic treatment in most respondents. Next to fluid balance calculation, the occurrence of peripheral and/or pulmonary edema (as assessed including by chest radiograph and lung ultrasound) was considered an important clinical sign of fluid overload entailing further therapeutic action. In conclusion, fluid overload in mechanically ventilated critically ill children is considered an important problem among PICU specialists, but there is great heterogeneity in the current clinical practice to avoid this complication. We identify a great need for further prospective and randomized investigation of the effects of (restrictive) fluid strategies in the PICU.
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Affiliation(s)
- Ismail Arrahmani
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Sarah A Ingelse
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands
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11
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Black CG, Thomas NJ, Yehya N. Timing and Clinical Significance of Fluid Overload in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2021; 22:795-805. [PMID: 33965988 PMCID: PMC8416695 DOI: 10.1097/pcc.0000000000002765] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Fluid overload is associated with worse outcomes in adult and pediatric acute respiratory distress syndrome. However, the time-course of fluid overload and its relationship to outcome has not been described. We aimed to determine the relationship between the timing of fluid overload and outcomes over the first 7 days after acute respiratory distress syndrome onset in children. DESIGN Retrospective cohort study. SETTING Single tertiary care PICU. PATIENTS Intubated children with acute respiratory distress syndrome between 2011 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily and cumulative total fluid intake, total output, urine output, and fluid balance were collected for each 24-hour period from days 1 to 7 after acute respiratory distress syndrome onset. We tested the association between daily cumulative fluid metrics with PICU mortality and probability of extubation by 28 days using multivariable logistic and competing risk regression, respectively. In a subset of children, plasma was collected on day 1 and day 3 of acute respiratory distress syndrome and angiopoietin-2 quantified. Of 723 children with acute respiratory distress syndrome, 132 died (18%). In unadjusted analysis, nonsurvivors had higher cumulative fluid balance starting on day 3. In multivariable analysis, a positive cumulative fluid balance on days 5 through 7 was associated with increased mortality. Higher cumulative fluid balance on days 4 to 7 was associated with lower probability of extubation. Elevated angiopoietin-2 on day 1 predicted early (within 3 d) fluid overload greater than or equal to 10%, and elevated angiopoietin-2 on day 3 predicted late (between days 4 and 7) fluid overload. CONCLUSIONS Fluid overload after day 4 of acute respiratory distress syndrome, but not before, was associated with worse outcomes. Higher angiopoietin-2 predicted subsequent fluid overload. Our results suggest that future interventions aimed at managing fluid overload may have differential efficacy depending on when in the time-course of acute respiratory distress syndrome they are initiated.
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Affiliation(s)
- Celeste G. Black
- Children’s Hospital of Philadelphia, Department of General Pediatrics, 3401 Civic Center Boulevard, 9NW55, Philadelphia, PA 19104
| | - Neal J. Thomas
- Penn State Hershey Children’s Hospital, Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine, 500 University Drive, Hershey, PA 17033
| | - Nadir Yehya
- Children’s Hospital of Philadelphia and University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, 6040A Wood Building, 3401 Civic Center Boulevard, Philadelphia, PA 19104
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12
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Hon KL, Leung KKY, Oberender F, Leung AK. Paediatrics: how to manage acute respiratory distress syndrome. Drugs Context 2021; 10:dic-2021-1-9. [PMID: 34122589 PMCID: PMC8177958 DOI: 10.7573/dic.2021-1-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a significant cause of mortality and morbidity amongst critically ill children. The purpose of this narrative review is to provide an up-to-date review on the evaluation and management of paediatric ARDS (PARDS). Methods A PubMed search was performed with Clinical Queries using the key term "acute respiratory distress syndrome". The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. Google, Wikipedia and UpToDate were also searched to enrich the review. The search was restricted to the English literature and children. Discussion Non-invasive positive pressure ventilation, lung-protective ventilation strategies, conservative fluid management and adequate nutritional support all have proven efficacy in the management of PARDS. The Pediatric Acute Lung Injury Consensus Conference recommends the use of corticosteroids, high-frequency oscillation ventilation and inhaled nitric oxide in selected scenarios. Partial liquid ventilation and surfactant are not considered efficacious based on evidence from clinical trials. Conclusion PARDS is a serious but relatively rare cause of admission into the paediatric intensive care unit and is associated with high mortality. Non-invasive positive pressure ventilation, lung-protective ventilation strategies, conservative fluid management and adequate nutrition are advocated. As there has been a lack of progress in the management of PARDS in recent years, further well-designed, large-scale, randomized controlled trials in this field are urgently needed.
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Affiliation(s)
- Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, Australia.,Monash University, School of Clinical Sciences, Department of Paediatrics, Melbourne, Australia
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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13
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Ingelse SA, IJland MM, van Loon LM, Bem RA, van Woensel JBM, Lemson J. Early restrictive fluid resuscitation has no clinical advantage in experimental severe pediatric acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol 2021; 320:L1126-L1136. [PMID: 33826416 DOI: 10.1152/ajplung.00613.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intravenous fluids are widely used to treat circulatory deterioration in pediatric acute respiratory distress syndrome (PARDS). However, the accumulation of fluids in the first days of PARDS is associated with adverse outcome. As such, early fluid restriction may prove beneficial, yet the effects of such a fluid strategy on the cardiopulmonary physiology in PARDS are unclear. In this study, we compared the effect of a restrictive with a liberal fluid strategy on a hemodynamic response and the formation of pulmonary edema in an animal model of PARDS. Sixteen mechanically ventilated lambs (2-6 wk) received oleic acid infusion to induce PARDS and were randomized to a restrictive or liberal fluid strategy during a 6-h period of mechanical ventilation. Transpulmonary thermodilution determined extravascular lung water (EVLW) and cardiac output (CO). Postmortem lung wet-to-dry weight ratios were obtained by gravimetry. Restricting fluids significantly reduced fluid intake but increased the use of vasopressors among animals with PARDS. Arterial blood pressure was similar between groups, yet CO declined significantly in animals receiving restrictive fluids (P = 0.005). There was no difference in EVLW over time (P = 0.111) and lung wet-to-dry weight ratio [6.1, interquartile range (IQR) = 6.0-7.3 vs. 7.1, IQR = 6.6-9.4, restrictive vs. liberal, P = 0.725] between fluid strategies. Both fluid strategies stabilized blood pressure in this model, yet early fluid restriction abated CO. Early fluid restriction did not limit the formation of pulmonary edema; therefore, this study suggests that in the early phase of PARDS, a restrictive fluid strategy is not beneficial in terms of immediate cardiopulmonary effects.
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Affiliation(s)
- Sarah A Ingelse
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marloes M IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lex M van Loon
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Cardiovascular and Respiratory Physiology Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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14
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Abstract
Despite the accepted importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are often not clear, although a trial of spontaneous breathing on CPAP without pressure support seems an appropriate prerequisite in many cases. Several indexes have been developed to predict weaning and extubation success, but the available literature suggests they offer little or no improvement over clinical judgment. New techniques for assessing readiness for weaning and predicting extubation success are being developed but are far from general acceptance in pediatric practice. While there have been some excellent physiologic, observational, and even randomized controlled trials on aspects of pediatric ventilator liberation, robust research data are lacking. Given the lack of data in many areas, a determined approach that combines systematic review with consensus opinion of international experts could generate high-quality recommendations and terminology definitions to guide clinical practice and highlight important areas for future research in weaning, extubation readiness, and liberation from mechanical ventilation following pediatric respiratory failure.
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Affiliation(s)
- Christopher Jl Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. .,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
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15
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Continuous Renal Replacement Therapy in Pediatric Severe Sepsis: A Propensity Score-Matched Prospective Multicenter Cohort Study in the PICU. Crit Care Med 2020; 47:e806-e813. [PMID: 31369427 PMCID: PMC6750150 DOI: 10.1097/ccm.0000000000003901] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Supplemental Digital Content is available in the text. Continuous renal replacement therapy becomes available utilization for pediatric critically ill, but the impact of mortality rate in severe sepsis remains no consistent conclusion. The aim of the study is to assess the effect of continuous renal replacement therapy in pediatric patients with severe sepsis and the impact this therapy may have on their mortality.
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16
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Jayashree M, Vishwa CR. HFOV in Pediatric ARDS: Viable or Vestigial? Indian J Pediatr 2020; 87:171-172. [PMID: 32026303 DOI: 10.1007/s12098-020-03215-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Muralidharan Jayashree
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India.
| | - C R Vishwa
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
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17
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Miller LH, Keller F, Mertens A, Klein M, Allen K, Castellino S, Woods WG. Impact of fluid overload and infection on respiratory adverse event development during induction therapy for childhood acute myeloid leukemia. Pediatr Blood Cancer 2019; 66:e27975. [PMID: 31502412 PMCID: PMC6803045 DOI: 10.1002/pbc.27975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/03/2019] [Accepted: 07/26/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Treatment-related morbidity and mortality occur frequently in childhood acute myeloid leukemia (AML) induction. Yet the contributions of respiratory adverse events (AEs) within this population are poorly understood. Furthermore, the roles of fluid overload (FO) and infection in AML pulmonary complications have been inadequately examined. OBJECTIVES To describe the incidence, categories, and grades of respiratory AEs and to assess the associations of FO and infection on respiratory AE development in childhood AML induction. METHODS We retrospectively examined the induction courses of a cohort of de novo pediatric AML patients for any NCI CTCAE grade 2 to 5 respiratory AE, FO, and systemic/pulmonary infection occurrence. Demographic, disease, and treatment-related data were abstracted. Descriptive, univariate, survival, and multivariable analyses were conducted. RESULTS Among 105 eligible subjects from 2009 to 2016, 49.5% (n = 52) experienced 63 discrete respiratory AEs. FO occurred in 28.6% of subjects (n = 30), with half occurring within 24 hours of hospitalization. Positive FO status < 10 days (aHR 5.5, 95% CI 2.3-12.8), ≥ 10 days (aHR 13, 95% CI 4.1-41.8), and positive infection status ≥ 10 days into treatment (aHR 14.9, 5.4-41.6) were each independently associated with AE development. CONCLUSIONS We describe a higher incidence of respiratory AEs during childhood AML induction than previously illustrated. FO occurs frequently and early in this course. Late infections and FO at any time frame were strongly associated with AE development. Interventions focused on the prevention and management of FO and infectious respiratory complications could be instrumental in reducing preventable treatment-related morbidity and mortality.
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Affiliation(s)
- Lane H Miller
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Frank Keller
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Ann Mertens
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Mitchel Klein
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristen Allen
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Sharon Castellino
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA,Drs Castellino and Woods provided equal contribution as senior authors
| | - William G Woods
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA,Drs Castellino and Woods provided equal contribution as senior authors
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18
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Severity and Mortality Predictors of Pediatric Acute Respiratory Distress Syndrome According to the Pediatric Acute Lung Injury Consensus Conference Definition. Pediatr Crit Care Med 2019; 20:e464-e472. [PMID: 31274780 DOI: 10.1097/pcc.0000000000002055] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The objective of this study was to assess the prevalence, severity, and outcomes of pediatric acute respiratory distress syndrome in a resource-limited country. In addition, we sought to explore the predisposing factors that predicted the initial severity, a change from mild to moderate-severe severity, and mortality. DESIGN Retrospective study. SETTING PICU in Songklanagarind Hospital, Songkhla, Thailand. PATIENTS Children 1 month to 15 years old with acute respiratory failure admitted to the PICU from January 2013 to December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From a total of 1,738 patients admitted to PICU, 129 patients (prevalence 7.4%) were diagnosed as pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition. The patients were categorized by severity. Fifty-seven patients (44.2%) were mild, 35 (27.1%) were moderate, and 37 (28.1%) were severe. After multivariable analysis was performed, factors significantly associated with moderate to severe disease at the initial diagnosis were Pediatric Risk of Mortality III score (odds ratio, 1.08; 95% CI, 1.03-1.15; p = 0.004), underlying oncologic/hematologic disorder (odds ratio, 0.32; 95% CI, 0.12-0.77; p = 0.012), and serum albumin level (odds ratio, 0.46; 95% CI, 0.27-0.80; p = 0.006), whereas underlying oncologic/hematologic disorder (odds ratio, 5.33; 95% CI, 1.33-21.4) and hemoglobin (odds ratio, 0.63; 95% CI, 0.44-0.89) predicted the progression of this syndrome within 7 days. The 30-day all-cause mortality rate was 51.2% (66/129). The predictors of mortality were the Pediatric Risk of Mortality III score (odds ratio, 1.12; 95% CI, 1.02-1.24; p = 0.017), underlying oncologic/hematologic disorder (odds ratio, 7.81; 95% CI, 2.18-27.94; p = 0.002), receiving systemic steroids (odds ratio, 4.04; 95% CI, 1.25-13.03; p = 0.019), having air leak syndrome (odds ratio, 5.45; 95% CI, 1.57-18.96; p = 0.008), and presenting with multiple organ dysfunction (odds ratio, 7.41; 95% CI, 2.00-27.36; p = 0.003). CONCLUSIONS The prevalence and mortality rate of pediatric acute respiratory distress syndrome in a developing country are high. The oncologic/hematologic comorbidity had a significant impact on the severity of progression and mortality.
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19
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Clinical Profile and Predictors of Outcome of Pediatric Acute Respiratory Distress Syndrome in a PICU: A Prospective Observational Study. Pediatr Crit Care Med 2019; 20:e263-e273. [PMID: 31166289 DOI: 10.1097/pcc.0000000000001924] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To study the clinical profile, predictors of mortality, and outcomes of pediatric acute respiratory distress syndrome. DESIGN A prospective observational study. SETTING PICU, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. PATIENTS All children (age > 1 mo to < 14 yr) admitted in PICU with a diagnosis of pediatric acute respiratory distress syndrome (as per Pediatric Acute Lung Injury Consensus Conference definition) from August 1, 2015, to November 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out of 1,215 children admitted to PICU, 124 (11.4%) had pediatric acute respiratory distress syndrome. Fifty-six children (45.2%) died. Median age was 2.75 years (1.0-6.0 yr) and 66.9% were male. Most common primary etiologies were pneumonia, severe sepsis, and scrub typhus. Ninety-seven children (78.2%) were invasively ventilated. On multiple logistic regressions, Lung Injury Score (p = 0.004), pneumothorax (p = 0.012), acute kidney injury at enrollment (p = 0.033), FIO2-D1 (p = 0.018), and PaO2/FIO2 ratio-D7 (p = 0.020) were independent predictors of mortality. Positive fluid balance (a cut-off value > 102.5 mL/kg; p = 0.016) was associated with higher mortality at 48 hours. Noninvasive oxygenation variables like oxygenation saturation index and saturation-FIO2 ratio were comparable to previously used invasive variables (oxygenation index and PaO2/FIO2 ratio) in monitoring the course of pediatric acute respiratory distress syndrome. CONCLUSIONS Pediatric acute respiratory distress syndrome contributes to a significant burden in the PICU of a developing country and is associated with significantly higher mortality. Infection remains the most common etiology. Higher severity of illness scores at admission, development of pneumothorax, and a positive fluid balance at 48 hours predicted poor outcome.
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20
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Long E, O'Brien A, Duke T, Oakley E, Babl FE. Effect of Fluid Bolus Therapy on Extravascular Lung Water Measured by Lung Ultrasound in Children With a Presumptive Clinical Diagnosis of Sepsis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1537-1544. [PMID: 30371951 DOI: 10.1002/jum.14842] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Fluid bolus therapy for the treatment of sepsis may lead to the accumulation of extravascular lung water (EVLW) and result in respiratory dysfunction. We aimed to assess changes in EVLW using lung ultrasound (US) in children with a presumptive clinical diagnosis of sepsis after fluid bolus therapy and correlate these changes with respiratory signs. METHODS This work was a prospective observational study set in the emergency department of the Royal Children's Hospital. Children meeting international consensus criteria for sepsis receiving fluid bolus therapy were included. Respiratory signs were recorded, and lung US examinations were performed immediately before, 5 minutes after, and 60 minutes after fluid bolus therapy. A pediatric emergency physician blinded to the participants' identities and timing of US calculated an EVLW score from lung US. Results-Fifty fluid boluses were recorded in 41 children. The lung US score (range, 0-8) increased over the study period: median, 1 (interquartile range, 0-2) before fluid bolus therapy, 1 (interquartile range, 0-3) 5 minutes after fluid bolus therapy, and 3 (interquartile range, 1-4) 60 minutes after fluid bolus therapy. Respiratory effort, but not the respiratory rate or the presence of rales, increased over the study period and was correlated with the lung US score (ρ = 0.33; P = .02). CONCLUSIONS Extravascular lung water as measured by lung US increased after fluid bolus therapy in septic children and was correlated with an increase in the respiratory distress score. The respiratory rate and the presence of rales did not change over the study period. The role of lung US for titrating fluid bolus therapy in sepsis warrants further investigation.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam O'Brien
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Duke
- Pediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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21
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Can the Treatment Approach of Sepsis With Balanced Crystalloid Fluids Translate Into Therapy for Acute Respiratory Distress Syndrome if Considered as "Lung-Limited Sepsis"? Crit Care Med 2019. [PMID: 28622221 DOI: 10.1097/ccm.0000000000002466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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22
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Association of Fluid Overload With Clinical Outcomes in Critically Ill Children With Bronchiolitis: Bronquiolitis en la Unidad de Cuidados Intensivos Pediátricos (BRUCIP) Study. Pediatr Crit Care Med 2019; 20:e130-e136. [PMID: 30664037 DOI: 10.1097/pcc.0000000000001841] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Increasing evidence supports the association of fluid overload with adverse outcomes in different diseases. To our knowledge, few studies have examined the impact of fluid balance on clinical outcome in severe bronchiolitis. Our aim was to determine whether fluid overload was associated with adverse clinical outcomes in critically ill children with severe bronchiolitis. DESIGN Descriptive, prospective, multicenter study. SETTING Sixteen Spanish PICUs. PATIENTS Severe acute bronchiolitis who required admission from October 2014 to May 2015 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Total fluid intake and output were prospectively recorded during PICU assistance. Fluid balance was measured at 24, 48, and 72 hours after PICU admission. A total of 262 patients were enrolled; 54.6% were male. Median age was 1 month (interquartile range, 1-3 mo). Patients had a positive fluid balance during the first 4 days of PICU admission, reaching a neutral balance on day 4. A positive balance at 24 hours in patients admitted to the PICU with severe bronchiolitis was related with longer stay in PICU (p < 0.001), longer hospital stay (p < 0.001), longer duration of mechanical ventilation (p = 0.016), and longer duration of noninvasive ventilation (p = 0.0029). CONCLUSIONS Critically ill patients with severe acute bronchiolitis who present a positive balance in the first 24 hours of PICU admission have poorer clinical outcomes with longer PICU and hospital length of stay and duration of invasive and noninvasive mechanical ventilation.
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23
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Ingelse SA, Juschten J, Maas MAW, Matute-Bello G, Juffermans NP, van Woensel JBM, Bem RA. Fluid restriction reduces pulmonary edema in a model of acute lung injury in mechanically ventilated rats. PLoS One 2019; 14:e0210172. [PMID: 30653512 PMCID: PMC6336323 DOI: 10.1371/journal.pone.0210172] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023] Open
Abstract
Experimental acute lung injury models are often used to increase our knowledge on the acute respiratory distress syndrome (ARDS), however, existing animal models often do not take into account the impact of specific fluid strategies on the development of lung injury. In contrast, the current literature strongly suggests that fluid management strategies have a significant impact on clinical outcome of patients with ARDS. Thus, it is important to characterize the role of fluid management strategies in experimental models of lung injury. In this study we investigated the effect of two different fluid strategies on commonly used outcome variables in a short-term model of acute lung injury, in relation to age. Infant (2–3 weeks) and adult (3–4 months) Wistar rats received intratracheal instillations of lipopolysaccharide and 24 hours later were mechanically ventilated for 6 hours. During mechanical ventilation, rats from both age groups were randomized to either a standard or conservative intravenous fluid strategy. We found that the hemodynamic response in infant and adult rats was similar in both fluid strategies. Lung wet-to-dry ratios were lower in adult, but not in infant rats receiving the conservative fluid strategy as compared to the standard fluid strategy. There were age-related differences in markers of alveolar capillary barrier disruption and alveolar fluid clearance, yet these were unaffected by fluid strategy. Finally, we found significantly higher IL-1β and TNF-α concentrations in the adult rats treated with the conservative as compared to the standard fluid regimen. In conclusion, the choice of fluid strategy in mechanically ventilated rats with experimental LPS-induced acute lung injury has a significant effect on pulmonary extravascular water, an important and well-recognized lung injury marker, and on the local pro-inflammatory cytokine profiles. We advocate the use of a more uniform, conservative, fluid strategy regimen in experimental models of acute lung injury.
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Affiliation(s)
- Sarah A. Ingelse
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Jenny Juschten
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care and Research VUmc Intensive Care (REVIVE), VU Medical Center, Amsterdam, The Netherlands
| | - Martinus A. W. Maas
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Gustavo Matute-Bello
- Center for Lung Biology, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, and Medical Research Service, VA Puget Sound Healthcare System, Seattle, WA, United States of America
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Job B. M. van Woensel
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Reinout A. Bem
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
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24
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Vaewpanich J, Akcan-Arikan A, Coss-Bu JA, Kennedy CE, Starke JR, Thammasitboon S. Fluid Overload and Kidney Injury Score as a Predictor for Ventilator-Associated Events. Front Pediatr 2019; 7:204. [PMID: 31192174 PMCID: PMC6538930 DOI: 10.3389/fped.2019.00204] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/02/2019] [Indexed: 11/29/2022] Open
Abstract
Objective: The Pediatric and Neonatal Working group developed new ventilator associated events (VAE) definitions for children and neonates. VAE includes ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and ventilator-associated pneumonia (VAP). Acute kidney injury (AKI) and fluid overload (FO) have been associated with worse clinical outcomes of ventilated children. Fluid Overload and Kidney Injury Score (FOKIS) is an automatically calculated score that combines AKI and FO in one numeric quantifiable metric. This study analyzed the association between FOKIS and VAE. Design: Retrospective matched case control study. Setting: A freestanding children's hospital. Patients: A total of 168 who were ventilated > 2 days. Interventions: None. Measurements and Main Results: We identified 42 VAC cases (18 IVAC and 24 non-infection-related VAC cases). Controls were matched to cases for age, immunocompromised status and ventilator days prior to VAC. VAC cases had longer ICU days, median (IQR), 28.5 (15, 47) vs. controls 11 (6, 16), p < 0.001; longer ventilation days, 19.5 (13, 32) vs. 9 (4,13), p < 0.001; and higher hospital mortality, 45.2 vs. 18%, p < 0.001. VACs had a higher incidence of AKI, 85.7 vs. 47.3%, p < 0.001; higher peak daily FO% within 3 days preceding VAC, mean (SD), 8.1(7.8) vs. 4.1 (3.4), p < 0.005; and higher peak FOKIS, 6.4(3.8) vs. 3.7(2.8), (p < 0.001). Multivariate regression model adjusted for severity of illness identified peak FOKIS (odds ratio [OR] 1.29, 95%CI: 1.14-1.48, p < 0.001) and peak inspiratory pressure (OR 1.08, 95%CI: 1.02-1.15, p = 0.007) as risk factors for VAC. Conclusions: The FOKIS and its clinical variables were associated risk factors for ventilator-associated events. Further studies will determine the utility of FOKIS as a predictor for VAEs.
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Affiliation(s)
- Jarin Vaewpanich
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ayse Akcan-Arikan
- Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Section of Nephrology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Jorge A Coss-Bu
- Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Curtis E Kennedy
- Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Section of Infectious Disease Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Satid Thammasitboon
- Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.,Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
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25
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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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Heidemann SM, Nair A, Bulut Y, Sapru A. Pathophysiology and Management of Acute Respiratory Distress Syndrome in Children. Pediatr Clin North Am 2017; 64:1017-1037. [PMID: 28941533 PMCID: PMC9683071 DOI: 10.1016/j.pcl.2017.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome of noncardiogenic pulmonary edema and hypoxia that accompanies up to 30% of deaths in pediatric intensive care units. Pediatric ARDS (PARDS) is diagnosed by the presence of hypoxia, defined by oxygenation index or Pao2/Fio2 ratio cutoffs, and new chest infiltrate occurring within 7 days of a known insult. Hallmarks of ARDS include hypoxemia and decreased lung compliance, increased work of breathing, and impaired gas exchange. Mortality is often accompanied by multiple organ failure. Although many modalities to treat PARDS have been investigated, supportive therapies and lung protective ventilator support remain the mainstay.
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Affiliation(s)
| | - Alison Nair
- Department of Pediatrics, University of California, San Francisco, CA
| | - Yonca Bulut
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, CA
| | - Anil Sapru
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA; Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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27
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Lopes CLS, Piva JP. Fluid overload in children undergoing mechanical ventilation. Rev Bras Ter Intensiva 2017; 29:346-353. [PMID: 28977099 PMCID: PMC5632978 DOI: 10.5935/0103-507x.20170045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/03/2016] [Indexed: 12/14/2022] Open
Abstract
Patients admitted to an intensive care unit are prone to cumulated fluid overload and receive intravenous volumes through the aggressive resuscitation recommended for septic shock treatment, as well as other fluid sources related to medications and nutritional support. The liberal liquid supply strategy has been associated with higher morbidity and mortality. Although there are few prospective pediatric studies, new strategies are being proposed. This non-systematic review discusses the pathophysiology of fluid overload, its consequences, and the available therapeutic strategies. During systemic inflammatory response syndrome, the endothelial glycocalyx is damaged, favoring fluid extravasation and resulting in interstitial edema. Extravasation to the third space results in longer mechanical ventilation, a greater need for renal replacement therapy, and longer intensive care unit and hospital stays, among other changes. Proper hemodynamic monitoring, as well as cautious infusion of fluids, can minimize these damages. Once cumulative fluid overload is established, treatment with long-term use of loop diuretics may lead to resistance to these medications. Strategies that can reduce intensive care unit morbidity and mortality include the early use of vasopressors (norepinephrine) to improve cardiac output and renal perfusion, the use of a combination of diuretics and aminophylline to induce diuresis, and the use of sedation and early mobilization protocols.
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Affiliation(s)
- Clarice Laroque Sinott Lopes
- Postgraduate Program in Child and Adolescent Health, Universidade
Federal do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | - Jefferson Pedro Piva
- Postgraduate Program in Child and Adolescent Health, Universidade
Federal do Rio Grande do Sul - Porto Alegre (RS), Brazil
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre
- Porto Alegre (RS), Brazil
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28
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Early Fluid Overload Prolongs Mechanical Ventilation in Children With Viral-Lower Respiratory Tract Disease. Pediatr Crit Care Med 2017; 18:e106-e111. [PMID: 28107266 DOI: 10.1097/pcc.0000000000001060] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Viral-lower respiratory tract disease is common in young children worldwide and is associated with high morbidity. Acute respiratory failure due to viral-lower respiratory tract disease necessitates PICU admission for mechanical ventilation. In critically ill patients in PICU settings, early fluid overload is common and associated with adverse outcomes such as prolonged mechanical ventilation and increased mortality. It is unclear, however, if this also applies to young children with viral-lower respiratory tract disease induced acute respiratory failure. In this study, we aimed to investigate the relation of early fluid overload with adverse outcomes in mechanically ventilated children with viral-lower respiratory tract disease in a retrospective dataset. DESIGN Retrospective cohort study. SETTING Single, tertiary referral PICU. PATIENTS One hundred thirty-five children (< 2 yr old) with viral-lower respiratory tract disease requiring mechanical ventilation admitted to the PICU of the Academic Medical Center, Amsterdam between 2008 and 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The cumulative fluid balance on day 3 of mechanical ventilation was compared against duration of mechanical ventilation (primary outcome) and daily mean oxygen saturation index (secondary outcome), using uni- and multivariable linear regression. In 132 children, the mean cumulative fluid balance on day 3 was + 97.9 (49.2) mL/kg. Higher cumulative fluid balance on day 3 was associated with a longer duration of mechanical ventilation in multivariable linear regression (β = 0.166; p = 0.048). No association was found between the fluid status and oxygen saturation index during the period of mechanical ventilation. CONCLUSIONS Early fluid overload is an independent predictor of prolonged mechanical ventilation in young children with viral-lower respiratory tract disease. This study suggests that avoiding early fluid overload is a potential target to reduce duration of mechanical ventilation in these children. Prospective testing in a clinical trial is warranted to support this hypothesis.
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29
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Lim JKB, Lee JH, Cheifetz IM. Special considerations for the management of pediatric acute respiratory distress syndrome. Expert Rev Respir Med 2016; 10:1133-45. [PMID: 27500964 DOI: 10.1080/17476348.2016.1219656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pediatric acute respiratory distress syndrome (ARDS) remains a diagnostic and therapeutic challenge with significant mortality and morbidity. There are limited data to guide identification and management. AREAS COVERED The Pediatric Acute Lung Injury Consensus Conference recently proposed pediatric-specific definitions for ARDS and management recommendations. In this review, we discuss aspects of pediatric ARDS that have received more attention over the past few years: high frequency oscillatory ventilation, administration of corticosteroids and functional outcomes. We conducted searches on PubMed, ClinicalKey and Google Scholar using medical subject heading terms and text words related to acute lung injury and ARDS. Expert commentary: The newly proposed definition for pediatric ARDS requires validation for efficacy in diagnosis and risk stratification. At present, there is insufficient evidence to support routine use of high frequency oscillatory ventilation or corticosteroids in pediatric ARDS. Further studies are required to determine the impact of pediatric ARDS on functional outcomes.
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Affiliation(s)
- Joel Kian Boon Lim
- a Department of Pediatrics , KK Women's and Children's Hospital , Singapore
| | - Jan Hau Lee
- b Children's Intensive Care Unit, Department of Pediatric Subspecialties , KK Women's and Children's Hospital , Singapore.,c Duke-NUS School of Medicine , Singapore
| | - Ira M Cheifetz
- d Division of Pediatric Critical Care Medicine , Duke Children's Hospital , Durham , NC , USA
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