Pediatric Sepsis Guidelines: Summary for resource-limited countries

Bacterial etiology and antimicrobial resistance in bloodstream infections at the University of Gondar Comprehensive Specialized Hospital: a cross-sectional study

Background

Bacterial bloodstream infections are a major global health concern, particularly in resource-limited settings including Ethiopia. There is a lack of updated and comprehensive data that integrates microbiological data and clinical findings. Therefore, this study aimed to characterize bacterial profiles, antimicrobial susceptibility, and associated factors in patients suspected of bloodstream infections at the University of Gondar Comprehensive Specialized Hospital.

Methods

A cross-sectional study analyzed electronic records from January 2019 to December 2021. Sociodemographic, clinical, and blood culture data were analyzed. Descriptive statistics and binary logistic regression were employed to identify factors associated with bloodstream infections. Descriptive statistics such as frequency and percentage were computed. Furthermore, a binary and multivariable logistic regression model was fitted to determine the relationship between BSI and associated factors. Variables with p-values of <0.05 from the multivariable logistic regression were used to show the presence of statistically significant associations.

Results

A total of 4,727 patients' records were included in the study. Among these, 14.8% (701/4,727) were bacterial bloodstream infections, with Gram-negative bacteria accounting for 63.5% (445/701) of cases. The most common bacteria were Klebsiella pneumoniae (29.0%), Staphylococcus aureus (23.5%), and Escherichia coli (8.4%). The study revealed a high resistance level to several antibiotics, with approximately 60.9% of the isolates demonstrating multidrug resistance. Klebsiella oxytoca, Klebsiella pneumoniae, and Escherichia coli exhibited high levels of multidrug resistance. The study identified emergency OPD [AOR = 3.2; (95% CI: 1.50-6.74)], oncology ward [AOR = 3.0; (95% CI: 1.21-7.17)], and surgical ward [AOR = 3.3; (95% CI: 1.27-8.43)] as factors associated with increased susceptibility to bloodstream infections.

Conclusion

The overall prevalence of bacterial isolates was high with concerning levels of multi-drug resistance. The study identified significant associations between bloodstream infections with age groups and presentation in specific clinical settings, such as the emergency OPD, oncology ward, and surgical ward. Strict regulation of antibiotic stewardship and the implementation of effective infection control programs should be enforced.

Hyper- and hypomagnesemia as an initial predictor of outcomes in septic pediatric patients in Egypt

BACKGROUND

Critically ill septic children are susceptible to electrolyte abnormalities, including magnesium disturbance, which can easily be neglected. This study examined the potential correlation between serum magnesium levels upon admission to the pediatric intensive care unit (PICU) and the outcomes of critically ill septic patients.

METHODS

This prospective study, conducted from May 2023 to November 2023, included 76 children with sepsis who underwent clinical and lab assessments that included initial magnesium levels. The outcome of sepsis was documented. Predictors of mortality were identified through multivariate logistic regression models, with discrimination and calibration assessed using the area under the curve (AUC).

RESULTS

The median magnesium level upon PICU admission was 2.0 mg/dl (range 1.1-4.9), and it was slightly higher in non-survivors than survivors (2.1 mg/dl; interquartile range [IQR], 1.9-2.5 vs. 2.0; IQR, 1.8-2.6, respectively), Hypermagnesemia was observed to have a negative effect on critically ill septic patients. It was also found that hypermagnesemia was associated with low C-reactive protein levels (P=0.043). With a cutoff of 5.5, the pediatric Sequential Organ Failure Assessment score strongly predicted mortality (AUC=0.717, P<0.001), with a sensitivity of 64.3% and specificity of 68.8%.

CONCLUSIONS

As an initial predictor of mortality, the serum magnesium level cannot be used alone; however, hypermagnesemia has a negative impact on critically ill septic patients. Thus, healthcare professionals should be cautious with magnesium administration.

Role of diagnostic tests for sepsis in children: a review

Paediatric sepsis has a significant global impact and highly heterogeneous clinical presentation. The clinical pathway encompasses recognition, escalation and de-escalation. In each aspect, diagnostics have a fundamental influence over outcomes in children. Biomarkers can aid in creating a larger low-risk group of children from those in the clinical grey area who would otherwise receive antibiotics 'just in case'. Current biomarkers include C reactive protein and procalcitonin, which are limited in their clinical use to guide appropriate and rapid treatment. Biomarker discovery has focused on single biomarkers, which, so far, have not outperformed current biomarkers, as they fail to recognise the complexity of sepsis. The identification of multiple host biomarkers that may form a panel in a clinical test has the potential to recognise the complexity of sepsis and provide improved diagnostic performance. In this review, we discuss novel biomarkers and novel ways of using existing biomarkers in the assessment and management of sepsis along with the significant challenges in biomarker discovery at present. Validation of biomarkers is made less meaningful due to methodological heterogeneity, including variations in sepsis diagnosis, biomarker cut-off values and patient populations. Therefore, the utilisation of platform studies is necessary to improve the efficiency of biomarkers in clinical practice.

High Dependency Units (HDUs) in Pediatrics: Need of the Hour in Resource-Limited Settings

Background Critically ill children, being vulnerable and having higher mortality as compared to adults, require specialized intensive care. However, the focus of critical care remains on adults, especially in resource-limited countries. Limited beds in the pediatric intensive care unit (PICU) along with the limitation of infrastructure and staff add to the challenge in pediatric critical care. In such scenarios, high-dependency units (HDUs) can help save a few more lives, who could not be provided with the PICU facility. HDU provides a level of care that is intermediate to that of the PICU and the general ward providing close observation, monitoring, and intervention to children who are critically ill. Our study highlighted that critically ill children can be given a chance of survival in resource-limited settings through HDU care. Materials and methods In our single-center prospective observational study, 204 children (less than 18 years) admitted to the HDU over 11 months and fulfilling the inclusion criteria were included. Blood samples were drawn for baseline investigations. The child's clinical course in the HDU along with the total duration of stay were recorded in a proforma. Children were reviewed for the requirement of invasive, non-invasive respiratory support along with inotropic support. Various parameters of the pediatric risk of mortality (PRISM) IV score were recorded within a time period of two hours prior and four hours following admission to HDU. The final outcome of the children was recorded. All data were analyzed and reviewed. Results Among the 204 patients admitted to HDU 136 (66.7%) children were treated successfully, whereas 63 (30.9%) children succumbed to their disease and complications, and five children were transferred to the PICU. Among various factors of age less than one year, the primary indication of admission being respiratory distress, the need of >2 inotropes had higher odds of mortality. Odds of mortality were eight times in patients with shock and altered sensorium, three times in children with respiratory distress, and two times in those having seizures. Those patients with a PRISM IV score of >15 had almost 100 times higher odds of mortality as compared to those with a score of <15. Conclusion In a resource-limited setting like ours, there's a scarcity of PICU beds for the provision of critical care. We envisage that providing intensive care in HDU will help save a few more lives, who could not be provided PICU facility for any reason.

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center

Introduction

Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes.

Methods

This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts.

Results

4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities.

Conclusion

Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center.

Level of evidence

Level IV, retrospective study.

Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit

Background

Sepsis is one of the major causes of admission to the pediatric intensive care unit (PICU), as well as a primary cause of poor outcomes. Glycemic variation may occur because of sepsis resulting in either hypoglycemia or hyperglycemia. Measuring the random blood glucose (RBG) level of patients presenting with sepsis in PICU is an easy way to assess their prognosis.

Objectives

A prospective study was done from February 2023 to June 2023 to evaluate the relation between the outcome of pediatric septic patients and blood glucose level upon PICU admission.

Patients and methods

One hundred three children diagnosed with sepsis underwent clinical assessment upon admission to the PICU and initial labs including blood glucose levels were done. Pediatric Sequential Organ Failure Assessment (pSOFA) was calculated for every patient. The outcome of sepsis including length of stay, review of body systems, and mortality was documented.

Results

Hypoglycemic patients had the highest percentage of non-survivors (20.4%). They had a higher pSOFA score with a median of 11 (interquartile range-IQR 7-15), shorter PICU stay with a median of 2 (IQR 1-6) days, lower RBG with a median of 95 (45-120), a higher percentage of ventilation (55.1%), and a higher percentage of inotropic support (87.8%) with statistical significance with p-value (< 0.001, < 0.001, 0.001, < 0.001, 0.002), respectively.

Conclusion

Critically ill patients with abnormal random blood sugar (RBS) had a higher possibility of non-survival particularly those with hypoglycemia. Accordingly, RBS measurement is a rapid and cheap method that could be used in any emergency and as an early indicator to detect outcome.

How to cite this article

Mohamed AO, Abd El-Megied MA, Hosni YA. Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(10):754-758.

Capacity Building for Health Care Workers and Support Staff in Pediatric Emergency Triage Assessment and Treatment (ETAT) at Primary Health Care Level in Resource Limited Settings: Experiences from Malawi

Primary health care facilities offer an entry point to the health care system in Malawi. Challenges experienced by these facilities include limited resources (both material and human), poor or inadequate knowledge, skills and attitudes of health care workers in emergency management, and delay in referral from primary care level to other levels of care. These contribute to poor outcomes including children dying within the first 24 hours of hospital admission. Training of health care workers and support staff in Emergency Triage Assessment and Treatment (ETAT) at primary care levels can help improve care of children with acute and severe illnesses. Health care workers and support staff in the primary care settings were trained in pediatric ETAT. The training package for health care workers was adapted from the Ministry of Health ETAT training for district and tertiary health care. Content for support staff focused on non-technical responsibility for lifesaving in emergency situations. The primary health care facilities were provided with a minimum treatment package comprising emergency equipment, supplies and drugs. Supportive supervisory visits were conducted quarterly. The training manual for health care workers was adapted from the Ministry of Health package and the support staff training manual was developed from the adapted package. Eight hundred and seventy-seven participants were trained (336 health care workers and 541 support staff). Following the training, triaging of patients improved and patients were managed as emergency, priority or non-urgent. This reduced the number of referral cases and children were stabilized before referral. Capacity building of health care workers and support staff in pediatric ETAT and the provision of a basic health center package improved practice at the primary care level. The practice was sustained through institutional mentorship and pre-service and in-service training. The practice of triage and treatment including stabilization of children with dangerous signs at the primary health care facility improves emergency care of patients, reduces the burden of patients on referral hospitals and increases the number of successful referrals.

Prevalence and Management of Septic Shock among Children Admitted at the Kenyatta National Hospital, Longitudinal Survey

BACKGROUND

Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital.

METHODS

A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12.

RESULTS

The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7-11.0), p = 0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively).

CONCLUSION

The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.

Aetiology of invasive bacterial infection and antimicrobial resistance in neonates in sub-Saharan Africa: a systematic review and meta-analysis in line with the STROBE-NI reporting guidelines

BACKGROUND

Aetiological data for neonatal infections are essential to inform policies and programme strategies, but such data are scarce from sub-Saharan Africa. We therefore completed a systematic review and meta-analysis of available data from the African continent since 1980, with a focus on regional differences in aetiology and antimicrobial resistance (AMR) in the past decade (2008-18).

METHODS

We included data for microbiologically confirmed invasive bacterial infection including meningitis and AMR among neonates in sub-Saharan Africa and assessed the quality of scientific reporting according to Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI) checklist. We calculated pooled proportions for reported bacterial isolates and AMR.

FINDINGS

We included 151 studies comprising data from 84 534 neonates from 26 countries, almost all of which were hospital-based. Of the 82 studies published between 2008 and 2018, insufficient details were reported regarding most STROBE-NI items. Regarding culture positive bacteraemia or sepsis, Staphylococcus aureus, Klebsiella spp, and Escherichia coli accounted for 25% (95% CI 21-29), 21% (16-27), and 10% (8-10) respectively. For meningitis, the predominant identified causes were group B streptococcus 25% (16-33), Streptococcus pneumoniae 17% (9-6), and S aureus 12% (3-25). Resistance to WHO recommended β-lactams was reported in 614 (68%) of 904 cases and resistance to aminoglycosides in 317 (27%) of 1176 cases.

INTERPRETATION

Hospital-acquired neonatal infections and AMR are a major burden in Africa. More population-based neonatal infection studies and improved routine surveillance are needed to improve clinical care, plan health systems approaches, and address AMR. Future studies should be reported according to standardised reporting guidelines, such as STROBE-NI, to aid comparability and reduce research waste.

FUNDING

Uduak Okomo was supported by a Medical Research Council PhD Studentship.

Validation of a wearable biosensor device for vital sign monitoring in septic emergency department patients in Rwanda

Objective

Critical care capabilities needed for the management of septic patients, such as continuous vital sign monitoring, are largely unavailable in most emergency departments (EDs) in low- and middle-income country (LMIC) settings. This study aimed to assess the feasibility and accuracy of using a wireless wearable biosensor device for continuous vital sign monitoring in ED patients with suspected sepsis in an LMIC setting.

Methods

This was a prospective observational study of pediatric (≥2 mon) and adult patients with suspected sepsis at the Kigali University Teaching Hospital ED. Heart rate, respiratory rate and temperature measurements were continuously recorded using a wearable biosensor device for the duration of the patients’ ED course and compared to intermittent manually collected vital signs.

Results

A total of 42 patients had sufficient data for analysis. Mean duration of monitoring was 32.8 h per patient. Biosensor measurements were strongly correlated with manual measurements for heart rate (r = 0.87, p < 0.001) and respiratory rate (r = 0.75, p < 0.001), although were less strong for temperature (r = 0.61, p < 0.001). Mean (SD) differences between biosensor and manual measurements were 1.2 (11.4) beats/min, 2.5 (5.5) breaths/min and 1.4 (1.0)°C. Technical or practical feasibility issues occurred in 12 patients (28.6%) although were minor and included biosensor detachment, connectivity problems, removal for a radiologic study or exam, and patient/parent desire to remove the device.

Conclusions

Wearable biosensor devices can be feasibly implemented and provide accurate continuous heart rate and respiratory rate monitoring in acutely ill pediatric and adult ED patients with sepsis in an LMIC setting.

Assessment of clinical outcome of children with sepsis outside the intensive care unit

In 2016, in order to identify adult patients with sepsis who are likely to have poor outcomes, the Third International Consensus Definitions Task Force introduced a new bedside index, called the quick Sepsis-related Organ Failure Assessment (qSOFA) score. However, these new criteria have not been validated in the pediatric population. In this study, we sought to assess the qSOFA score for children with sepsis, who are being treated outside the pediatric intensive care units. The qSOFA criteria were revised and applied to a study population of 89 pediatric patients with sepsis, admitted in a pediatric tertiary referral center from 2006 to 2016. The analysis of prognostic performance of qSOFA score for the prediction of severe sepsis showed a sensitivity of 46% (95% CI, 27-67%), a specificity of 74% (95% CI, 62-85%), a positive predictive value of 43% (95% CI, 34-52%), and a negative predictive value of 77% (95% CI, 71-82%). The area under ROC curve for qSOFA score ≥ 2 was 0.602 (95% CI 0.492-0.705).Conclusion: The qSOFA score showed a low accuracy to identify children in the pediatric ward at risk for severe sepsis. Clinical tools are needed to facilitate the diagnosis of impending organ dysfunction in pediatric infection outside of the ICU. What is Known: • One of the major challenges for clinicians is to identify and recognize children with sepsis and impending organ dysfunction, in the emergency and in the pediatric department. • In 2016, members of the Sepsis-3 task force proposed qSOFA, an empirically derived score using simple clinical criteria, to assist clinicians in identifying adult patients with sepsis at risk for poor outcome. What is New: • qSOFA demonstrated insufficient clinical value to be recommended as a screening tool for pediatric sepsis outside ICU. • D-dimer level and blood glucose may be useful biomarkers to identify children at risk for severe sepsis.

Clinical and Laboratory Factors Associated with Severe Dengue: A Case-Control Study of Hospitalized Children

BACKGROUND

More than half of the hospitalizations because of dengue in Brazil occurred in children <15 years of age in 2007 and 2008, an unexpected change in the epidemiological pattern. We sought to determine clinical and laboratory parameters associated with severity.

METHODS

A case-control study was conducted in three pediatric hospitals in Rio de Janeiro, Brazil; 233 laboratory-confirmed dengue patients were included: 69 cases and 164 controls. Specific clinical and laboratory factors were assessed using univariate and multivariate logistic regression models.

RESULTS

Lethargy [adjusted odds ratio (ORa): 9.15, 95% confidence interval (CI): 3.08-27.12], dyspnea (ORa: 8.24, 95% CI: 3.27-20.72) and abdominal pain (ORa: 6.78, 95% CI: 1.44-31.84) were independently associated with severe dengue in children. Lethargy and dyspnea presented as early as 72 and 48 h, respectively, before shock.

CONCLUSIONS

Abdominal pain and lethargy confirmed their role as warning signs, which along with dyspnea might be helpful in identifying cases progressing to severe dengue.

Pediatric Critical Care Medicine Training in India: Past, Present, and Future

Pediatric critical care services in India have grown with leaps and bounds. There has been a growing need of physicians specially trained in pediatric critical care medicine (PCCM) in India. Physicians returning to India after their formal training in PCCM abroad have partly supported this growing need. Development of formal PCCM training programs in India has been a huge step toward supporting the growing clinical needs. This article focuses on advances in pediatric critical care training in India and its future directions.

The Utilization of the Surviving Sepsis Campaign Care Bundles in the Treatment of Pediatric Patients with Severe Sepsis or Septic Shock in a Resource-Limited Environment: A Prospective Multicenter Trial

Background:

Sepsis is a common condition affecting the lives of infants and children worldwide. Although implementation of the surviving sepsis campaign (SSC) care bundles was once believed to be effective in reducing sepsis mortality rates, the approach has recently been questioned.

Methods:

The study was a prospective, interventional, multicenter trial. Infants and children aged 1 month to 15 years in seven different large academic centers in Thailand who had been diagnosed with severe sepsis or septic shock. They were given treatment based on the SSC care bundles.

Results:

A total of 519 children with severe sepsis or septic shock were enrolled in the study. Among these, 188 were assigned to the intervention group and 331 were recruited to the historical case–control group. There were no significant differences in the baseline clinical characteristics. The intervention group was administered a significantly higher fluid bolus than was the control group (28.3 ± 17.2 cc/kg vs. 17.7 ± 10.6 cc/kg; P = 0.02) with early vasopressor used (1.5 ± 0.7 h) compared to control group (7.4 ± 2.4 h, P < 0.05). More importantly, our sepsis mortality reduced significantly from 37% ± 20.7% during the preintervention period to 19.4% ± 14.3% during the postintervention period (P < 0.001).

Conclusion:

Our study demonstrated a significant reduction in sepsis mortality after the implementation of the SSC care bundles. Early diagnosis of the disease, optimum hemodynamic resuscitation, and timely antibiotic administration are the key elements of sepsis management.

Personalized identification of differentially expressed pathways in pediatric sepsis

Sepsis is a leading killer of children worldwide with numerous differentially expressed genes reported to be associated with sepsis. Identifying core pathways in an individual is important for understanding septic mechanisms and for the future application of custom therapeutic decisions. Samples used in the study were from a control group (n=18) and pediatric sepsis group (n=52). Based on Kauffman's attractor theory, differentially expressed pathways associated with pediatric sepsis were detected as attractors. When the distribution results of attractors are consistent with the distribution of total data assessed using support vector machine, the individualized pathway aberrance score (iPAS) was calculated to distinguish differences. Through attractor and Kyoto Encyclopedia of Genes and Genomes functional analysis, 277 enriched pathways were identified as attractors. There were 81 pathways with P<0.05 and 59 pathways with P<0.01. Distribution outcomes of screened attractors were mostly consistent with the total data demonstrated by the six classifying parameters, which suggested the efficiency of attractors. Cluster analysis of pediatric sepsis using the iPAS method identified seven pathway clusters and four sample clusters. Thus, in the majority pediatric sepsis samples, core pathways can be detected as different from accumulated normal samples. In conclusion, a novel procedure that identified the dysregulated attractors in individuals with pediatric sepsis was constructed. Attractors can be markers to identify pathways involved in pediatric sepsis. iPAS may provide a correlation score for each of the signaling pathways present in an individual patient. This process may improve the personalized interpretation of disease mechanisms and may be useful in the forthcoming era of personalized medicine.

Predictors of mortality in a paediatric intensive care unit in Kigali, Rwanda

BACKGROUND

The enormous burden of critical illness in resource-limited settings has led to a growing interest in paediatric critical care in these regions. However, published data on the practice of critical care and patient outcomes in these settings are scant.

OBJECTIVE

This study sought to identify risk factors associated with mortality in the newly established Paediatric Intensive Care Unit (PICU) at Kigali University Teaching Hospital (KUTH) in Rwanda and test the predictive ability of a newly devised mortality risk score, the modified PRISM (MP) score.

METHODS

All admissions to the PICU at KUTH from October 2012 to October 2014 were included. Demographic and physiological data on each patient were gathered and each was assigned a MP score. This prospective cross-sectional study examined the association between the characteristics and physiological status of these patients and mortality. Using logistic regression, factors associated with mortality in the PICU were analysed.

RESULTS

A total of 213 children were admitted to the PICU during the study period. Three patients were excluded because of missing data. Of this total, 59% were male, 25% were neonates and nearly 60% were moderately to severely malnourished. The overall mortality rate was 50%. On bivariate analysis, factors associated with increased mortality were male sex, use of vasoactive medications, a MP score ≥ 5, a discharge diagnosis of septic shock, and malnutrition on admission. On multivariate analysis, only the use of vasoactive drugs [odds ratio (OR) 12.24, 95% confidence interval (CI) 4.4-35.4, p < 0.001] and MP score ≥ 5 (OR 16.1, CI 6.3-40.8, p < 0.001) were associated with mortality.

CONCLUSION

The observed mortality rate was in the range reported in other resource-limited settings. The initial attempt to create and implement a risk of mortality tool for this setting determined a score that could identify those patients at higher risk of mortality. In PICUs in resource-limited settings, the gathering of data and use of severity of illness tools could improve care in a number of ways.

Implementing the Emergency Triage, Assessment and Treatment plus admission care (ETAT+) clinical practice guidelines to improve quality of hospital care in Rwandan district hospitals: healthcare workers' perspectives on relevance and challenges

Background

An emergency triage, assessment and treatment plus admission care (ETAT+) intervention was implemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Many interventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of the real-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successful implementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+ and documented potential barriers to its successful implementation.

Methods

HCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding (i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about change in their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hamper their ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care for severely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English and sometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to (if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.

Results

One hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the training was highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwives believed that the “neonatal resuscitation and feeding” components of the training were more relevant to them than other components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by using job aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+ training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelines in the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).

Conclusion

This study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelines in order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially from HCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2193-4) contains supplementary material, which is available to authorized users.

Pediatric emergency care capacity in a low-resource setting: An assessment of district hospitals in Rwanda

BACKGROUND

Health system strengthening is crucial to improving infant and child health outcomes in low-resource countries. While the knowledge related to improving newborn and child survival has advanced remarkably over the past few decades, many healthcare systems in such settings remain unable to effectively deliver pediatric advance life support management. With the introduction of the Emergency Triage, Assessment and Treatment plus Admission care (ETAT+)-a locally adapted pediatric advanced life support management program-in Rwandan district hospitals, we undertook this study to assess the extent to which these hospitals are prepared to provide this pediatric advanced life support management. The results of the study will shed light on the resources and support that are currently available to implement ETAT+, which aims to improve care for severely ill infants and children.

METHODS

A cross-sectional survey was undertaken in eight district hospitals across Rwanda focusing on the availability of physical and human resources, as well as hospital services organizations to provide emergency triage, assessment and treatment plus admission care for severely ill infants and children.

RESULTS

Many of essential resources deemed necessary for the provision of emergency care for severely ill infants and children were readily available (e.g. drugs and laboratory services). However, only 4/8 hospitals had BVM for newborns; while nebulizer and MDI were not available in 2/8 hospitals. Only 3/8 hospitals had F-75 and ReSoMal. Moreover, there was no adequate triage system across any of the hospitals evaluated. Further, guidelines for neonatal resuscitation and management of malaria were available in 5/8 and in 7/8 hospitals, respectively; while those for child resuscitation and management of sepsis, pneumonia, dehydration and severe malnutrition were available in less than half of the hospitals evaluated.

CONCLUSIONS

Our assessment provides evidence to inform new strategies to enhance the capacity of Rwandan district hospitals to provide pediatric advanced life support management. Identifying key gaps in the health care system is required in order to facilitate the implementation and scale up of ETAT+ in Rwanda. These findings also highlight a need to establish an outreach/mentoring program, embedded within the ongoing ETAT+ program, to promote cross-hospital learning exchanges.

Teaching Pediatric Life Support in Limited-Resource Settings: Contextualized Management Guidelines

Of the estimated 6.3 million global annual deaths in children younger than the age of 5 years, nearly all (99%) occur in low- to middle-income countries (LMIC). Existing management guidelines for children with emergency conditions as taught in a variety of current pediatric life support courses are mostly applicable to high-income countries with a different disease range and full resources compared with LMIC. A revised curriculum with evidence-based application to limited-resource settings would expand their potential for reducing pediatric mortality worldwide. This review provides a supplemental curriculum of standards for selected pediatric emergency conditions with attention to the context of disease range and level-specific resources in LMIC. During training sessions, contextualized management guidelines create the framework for realistic and fruitful case simulations.

The Assessment, Evaluation, and Management of the Critically Ill Child When Resources are Limited-Southeast Asian Perspective

The Southeast Asia region comprises 10 independent countries with highly divergent health systems and health status. The heterogeneity in infant and child mortality rates suggests that there is still scope for improvement in the care of critically ill children. There is, however, a paucity of published data on outcomes and processes of care that could affect planning and implementation of intervention programs. Significant challenges in the delivery of care for the critically ill child remain, especially in pre-hospital and in-hospital triaging and emergency care and inpatient hospital care. Potential areas for continued improvement include strengthening of health systems through sustained commitment by local governments, capacity building, and sharing of research output. Simple, low cost, locally available, and effective solutions should be sought. The introduction of standards and auditing tools can assist in determining effectiveness and outcomes of intervention packages that are adapted to local settings. Recognition and acknowledgment of shortfalls between expectations and outcomes is a first step to overcoming some of these obstacles necessary to achieve a seamless interface among pre-hospital, emergency, inpatient, and critical care delivery processes that would improve survival of critically ill children in this region.

Early norepinephrine decreases fluid and ventilatory requirements in pediatric vasodilatory septic shock

AIMS

We previously reported that vasodilatation was common in pediatric septic shock, regardless of whether they were warm or cold, providing a rationale for early norepinephrine (NE) to increase venous return (VR) and arterial tone. Our primary aim was to evaluate the effect of smaller fluid bolus plus early-NE versus the American College of Critical Care Medicine (ACCM) approach to more liberal fluid boluses and vasoactive-inotropic agents on fluid balance, shock resolution, ventilator support and mortality in children with septic shock. Secondly, the impact of early NE on hemodynamic parameters, urine output and lactate levels was assessed using multimodality-monitoring.

METHODS

In keeping with the primary aim, the early NE group (N-27) received NE after 30ml/kg fluid, while the ACCM group (N-41) were a historical cohort managed as per the ACCM Guidelines, where after 40-60ml/kg fluid, patients received first line vasoactive-inotropic agents. The effect of early-NE was characterized by measuring stroke volume variation(SVV), systemic vascular resistance index (SVRI) and cardiac function before and after NE, which were monitored using ECHO + Ultrasound-Cardiac-Output-Monitor (USCOM) and lactates.

RESULTS

The 6-hr fluid requirement in the early-NE group (88.9+31.3 to 37.4+15.1ml/kg), and ventilated days [median 4 days (IQR 2.5-5.25) to 1day (IQR 1-1.7)] were significantly less as compared to the ACCM group. However, shock resolution and mortality rates were similar. In the early NE group, the overall SVRI was low (mean 679.7dynes/sec/cm5/m2, SD 204.5), and SVV decreased from 23.8±8.2 to 18.5±9.7, p=0.005 with NE infusion suggesting improved preload even without further fluid loading. Furthermore, lactate levels decreased and urine-output improved.

CONCLUSION

Early-NE and fluid restriction may be of benefit in resolving shock with less fluid and ventilator support as compared to the ACCM approach.

A widened pulse pressure: a potential valuable prognostic indicator of mortality in patients with sepsis

Background

Sepsis is one of the leading causes of death in the United States and the most common cause of death among critically ill patients in non-coronary intensive care units. Previous studies have showed pulse pressure (PP) to be a predictor of fluid responsiveness in patients with sepsis. Additionally, previous studies have correlated PP to cardiovascular risk factors and increase in mortality in end-stage renal disease patients.

Objectives

To determine the correlation between PP and mortality in patients with sepsis.

Methods

A retrospective review was conducted on 5,003 patients admitted with the diagnosis of sepsis using ICD-9 codes during the time period from January 2010 to December 2014 at two community-based hospitals in central Pennsylvania.

Results

Our study findings showed significant decrease in the mortality when the PP was greater than 70 mmHg of patients with sepsis (p-value: 0.0003, odds ratio: 0.67, 95% confidence limit: 0.54–0.83).

Conclusion

Based on our findings, we suggest that PP could be a valuable clinical tool in the early assessment of patients admitted with sepsis and could be used as a prognostic factor to assess and implement management therapy for the patients with sepsis.

Severe Sepsis in Severely Malnourished Young Bangladeshi Children with Pneumonia: A Retrospective Case Control Study

BACKGROUND

In developing countries, there is no published report on predicting factors of severe sepsis in severely acute malnourished (SAM) children having pneumonia and impact of fluid resuscitation in such children. Thus, we aimed to identify predicting factors for severe sepsis and assess the outcome of fluid resuscitation of such children.

METHODS

In this retrospective case-control study SAM children aged 0-59 months, admitted to the Intensive Care Unit (ICU) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh from April 2011 through July 2012 with history of cough or difficult breathing and radiologic pneumonia, who were assessed for severe sepsis at admission constituted the study population. We compared the pneumonic SAM children with severe sepsis (cases = 50) with those without severe sepsis (controls = 354). Severe sepsis was defined with objective clinical criteria and managed with fluid resuscitation, in addition to antibiotic and other supportive therapy, following the standard hospital guideline, which is very similar to the WHO guideline.

RESULTS

The case-fatality-rate was significantly higher among the cases than the controls (40% vs. 4%; p<0.001). In logistic regression analysis after adjusting for potential confounders, lack of BCG vaccination, drowsiness, abdominal distension, acute kidney injury, and metabolic acidosis at admission remained as independent predicting factors for severe sepsis in pneumonic SAM children (p<0.05 for all comparisons).

CONCLUSION AND SIGNIFICANCE

We noted a much higher case fatality among under-five SAM children with pneumonia and severe sepsis who required fluid resuscitation in addition to standard antibiotic and other supportive therapy compared to those without severe sepsis. Independent risk factors and outcome of the management of severe sepsis in our study children highlight the importance for defining optimal fluid resuscitation therapy aiming at reducing the case fatality in such children.

Prehospital transport practices prevalent among patients presenting to the pediatric emergency of a tertiary care hospital

Background and Objectives:

Prehospital transport practices prevalent among children presenting to the emergency are under-reported. Our objectives were to evaluate the prehospital transport practices prevalent among children presenting to the pediatric emergency and their subsequent clinical course and outcome.

Methods:

In this prospective observational study we enrolled all children ≤17 years of age presenting to the pediatric emergency (from January to June 2013) and recorded their demographic data and variables pertaining to prehospital transport practices. Data was entered into Microsoft Excel and analyzed using Stata 11 (StataCorp, College Station, TX, USA).

Results:

A total of 319 patients presented to the emergency during the study period. Acute gastroenteritis, respiratory tract infection and fever were the most common reasons for presentation to the emergency. Seventy-three (23%) children required admission. Most commonly used public transport was auto-rickshaw (138, 43.5%) and median time taken to reach hospital was 22 min (interquartile range: 5, 720). Twenty-six patients were referred from another health facility. Of these, 25 were transported in ambulance unaccompanied. About 8% (25) of parents reported having difficulties in transporting their child to the hospital and 57% (181) of parents felt fellow passengers and drivers were unhelpful. On post-hoc analysis, only time taken to reach the hospital (30 vs. 20 min; relative risk [95% confidence interval]: 1.02 [1.007, 1.03], P = 0.003) and the illness nature were significant (45% vs. 2.6%; 0.58 [0.50, 0.67], P ≤ 0.0001) on multivariate analysis.

Conclusions:

In relation to prehospital transport among pediatric patients we observed that one-quarter of children presenting to the emergency required admission, the auto-rickshaw was the commonest mode of transport and that there is a lack of prior communication before referring patients for further management.

Risk factors and practices contributing to newborn sepsis in a rural district of Eastern Uganda, August 2013: a cross sectional study

Background

In Uganda, newborn deaths constituted over 38 % of all infant deaths in 2010. Despite different mitigation interventions over years, the newborn mortality rate is high at 27/1,000 and newborn sepsis contributes to 31 % of that mortality. Therefore, improved strategies that contribute to reduction of newborn sepsis need to be developed and implemented. Understanding the context relevant risk factors that determine and practices contributing to newborn sepsis will inform this process.

Methodology

A cross sectional study was conducted at Kidera Health Centre in Kidera Sub County, Buyende district between January and August 2013. A total of 174 mothers of sick newborns and 8 health workers were interviewed. Main outcome was newborn sepsis confirmed by blood culture. Independent variables included; mothers’ demographics characteristics, maternal care history and newborn care practices. The odds ratios were used to measure associations and Chi square or Fisher’s exact tests to test the associations. 95 % confidence intervals and P values for the odds ratios were determined. Logistic regression was conducted to identify predictor factors for newborn sepsis.

Results

21.8 % (38/174) of newborns had laboratory confirmed sepsis. Staphylococcus aureus was the commonest aetiological agent. Mothers not screened and treated for infections during antenatal (OR = 3.37; 95 % CI 1.23–9.22) plus inability of sick newborns to breast feed (OR = 3.9; 95 % CI 1.54–9.75) were factors associated with increased likelihood of having laboratory confirmed sepsis. Women not receiving health education during antenatal about care seeking (OR 2.22; 95 % CI 1.07–4.61) and newborn danger signs (OR 2.26; 95 % CI 1.08–4.71) was associated with laboratory confirmed newborn sepsis. The supply of antibiotics and sundries was inadequate to sufficiently control sepsis within health facility.

Conclusion

Lack of antenatal care or access to it at health facilities was likely to later result in more sick newborns with sepsis. Poor breastfeeding by sick newborns was a marker for serious bacterial infection. Therefore district sensitization programs should encourage women to attend health facility antenatal care where they will receive health education about alternative feeding practices, screening and treatment for infections to prevent spread of infections to newborns. Supply of antibiotics and sundries should be improved to sufficiently control sepsis within the health facility.

Correlation of hypocalcemia with serum parathyroid hormone and calcitonin levels in pediatric intensive care unit

OBJECTIVES

To investigate factors involved in causing hypocalcemia in critically ill patients.

METHODS

The patients aged 1 mo to 18 y, admitted to PICU at Nemazee Hospital, from May through November 2012, were reviewed. Those with impaired calcium hemostasis or on vitamin-D supplement were excluded. Calcitonin and parathyroid hormone levels were checked if ionized calcium level was less than 3.2 mg/d. Patient's demographic data, length of stay, Pediatric Risk of Mortality-III (PRISM-III) score, the need for mechanical ventilation, inotropic drug administration and outcome were recorded.

RESULTS

Among the 294 patients enrolled in the study, the incidence of ionized hypocalcemia was 20.4 %. The mortality rate was 45 % in hypocalcemic groups and 24.8 % in normocalcemic patients. Highly significant negative correlations were found between serum ionized calcium, PRISM-III score (r = -0.371, P = 0.004), and calcitonin level (r = -0.256, P = 0.049), but no significant correlation between hypocalcemia and parathyroid hormone level (P = 0.206) was found. A significant difference was observed between survivor and non-survivor groups regarding PRISM-III score (P = 0.00), ionized calcium (P = 0.00), and calcitonin (P = 0.022) but not parathyroid hormone level (P = 0.206).

CONCLUSIONS

Hypocalcemia was associated with increased mortality rate in PICU patients. A negative correlation was found between ionized calcium level and calcitonin. There was also a link between PTH level and severity of illness. It can therefore be concluded that evaluating serum ionized calcium, calcitonin, and PTH levels can be used as prognostic factors in critically ill patients.

Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock from Rohtak, Haryana: A prospective observational study

Background:

Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.

Methods:

A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.

Results:

A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).

Conclusion:

Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.

Specialist hospital study shows that septic shock and drowsiness predict mortality in children under five with diarrhoea

AIM

To evaluate the clinical characteristics and outcome in children hospitalised with diarrhoea, comparing those developed septic shock with those who did not.

METHODS

We carried out a retrospective chart review on children aged 0-59 months admitted to the Dhaka Hospital, International Centre for Diarrhoeal Diseases Research, Bangladesh, with diarrhoea between October 2010 and September 2011. They were included if they had severe sepsis defined as tachycardia plus hyperthermia or hypothermia or an abnormal white blood cell count plus poor peripheral perfusion in absence of dehydration. Patients unresponsive to fluid and boluses, who required inotropes, were categorised as having septic shock (n = 88). The controls were those without septic shock (n = 116).

RESULTS

Death was significantly higher among the children with septic shock (67%) than the controls (14%) (p < 0.001). A logistic regression analysis, adjusted for potential confounders, found that children with septic shock were more likely to be drowsy on admission and received blood transfusions and mechanical ventilation (all p < 0.05).

CONCLUSION

Children hospitalised for diarrhoea with septic shock were more likely to die, be drowsy on admission and receive blood transfusions and mechanical ventilation. A randomised clinical trial on inotropes in children with diarrhoea, severe sepsis and drowsiness may expedite their use and prevent mechanical ventilation and deaths.

Early goal-directed therapy in pediatric septic shock: comparison of outcomes "with" and "without" intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*

OBJECTIVE

To evaluate the effect of intermittent central venous oxygen saturation monitoring (ScvO(2)) on critical outcomes in children with septic shock, as continuous monitoring may not be feasible in most resource-restricted settings.

DESIGN

Prospective cohort study.

SETTING

PICU of a tertiary care teaching hospital.

PATIENTS

Consecutive children younger than 17 years with fluid refractory septic shock admitted to our ICU from November 2010 to October 2012 were included.

INTERVENTIONS

Enrolled children were subjected to subclavian/internal jugular catheter insertion. Those in whom it was successful formed the "exposed" group (ScvO(2) group), whereas the rest constituted the control group (no ScvO(2) group). In the former group, intermittent ScvO(2) monitoring at 1, 3, and 6 hours was used to guide resuscitation, whereas in the latter, only clinical variables were used.

MEASUREMENTS AND MAIN RESULTS

The major outcomes were in-hospital mortality and achievement of therapeutic goals within first 6 hours. One hundred twenty children were enrolled in the study-63 in the ScvO(2) group and 57 in the no ScvO(2) group. Baseline characteristics including the organ dysfunction and mortality risk scores were comparable between the groups. Children in the ScvO(2) group had significantly lower in-hospital mortality (33.3% vs 54%; relative risk, 0.61; 95% CI, 0.4, 0.93; number needed to treat, 5; 95% CI, 3, 27). A greater proportion of children in exposed group achieved therapeutic endpoints in first 6 hours (43% vs 23%, p = 0.02) and during entire ICU stay (71% vs 51%, p = 0.02). The mean number of dysfunctional organs was also significantly lesser in ScvO(2) group in comparison with no ScvO(2) group (2 vs 3, p < 0.001).

CONCLUSION

Early goal-directed therapy using intermittent ScvO(2) monitoring seemed to reduce the mortality rates and improved organ dysfunction in children with septic shock as compared with those without such monitoring.

Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study*

OBJECTIVES

To evaluate the cardiovascular aberrations using multimodal monitoring in fluid refractory pediatric septic shock and describe the clinical characteristics of septic myocardial dysfunction.

DESIGN

Prospective observational study of patients with unresolved septic shock after infusion of 40 mL/kg fluid in the first hour.

SETTING

Two tertiary care referral Indian PICUs.

PATIENTS

Patients aged 1 month to 16 years who had fluid refractory septic shock.

INTERVENTIONS

Changes in therapy were based on findings of clinical assessment, bedside echocardiography, and invasive blood pressure monitoring within 6 hours of recognition of septic shock.

MEASUREMENTS AND MAIN RESULTS

Over a 4-year period, 48 patients remained in septic shock despite at least 40 mL/kg fluid infusion. On clinical examination, 21 patients had cold shock and 27 had warm shock. Forty-one patients (85.5%) had vasodilatory shock on invasive blood pressure; these included 14 patients who initially presented with cold shock. The commonest echocardiography findings were impaired left ± right ventricular function in 19 patients (39.6%) and hypovolemia in 16 patients (33%). Three patients who had normal myocardial function on day 1 developed secondary septic myocardial dysfunction on day 3. Echocardio graphy, along with invasive arterial pressure monitoring, allowed fluid, inotropy, and pressors to be titrated more precisely in 87.5% of patients. Shock resolved in 46 of 48 patients (96%) and 44 patients (91.6%) survived to discharge.

CONCLUSION

Bedside echocardiography provided crucial information leading to the recognition of septic myocardial dysfunction and uncorrected hypovolemia that was not apparent on clinical assessment. With invasive blood pressure monitoring, echocardiography affords a simple noninvasive tool to determine the cause of low cardiac output and the physiological basis for adjustment of therapy in patients who remain in shock despite 40 mL/kg fluid.

Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock

OBJECTIVE

To report changes in the cardiovascular management of fluid and inotropic resistant septic shock in children based on echocardiography.

DESIGN

Retrospective case series.

SETTING

Tertiary care Pediatric Intensive Care Unit (PICU), Chennai.

PATIENTS

Twenty-two patients with unresolved septic shock after 60 ml/kg fluid plus inotropic agents in the first hour.

INTERVENTIONS

Bedside echocardiography (echo) within 6 h of admission to the PICU.

RESULTS

Over a 28-month period, of 37 patients with septic shock, 22 children remained in shock despite 60 ml/kg fluid and dopamine and/or dobutamine infusions as per guidelines. On clinical exam, 12 patients had warm shock and ten had cold shock, however, six exhibited an unusual pattern of cold shock with wide pulse pressures on invasive arterial monitoring. The most common echocardiographic finding was uncorrected hypovolemia in 12/22 patient while ten patients had impaired left ± right ventricular function. Echocardiography permitted an appreciation of the underlying disordered pathophysiology and a rationale for adjustment of treatment. Shock resolved in 17 (77%) and 16 patients (73%) survived to discharge.

CONCLUSIONS

Bedside echo provided crucial information that was not apparent on clinical assessment and affords a simple noninvasive tool to determine the cause of low cardiac output in patients who remain in shock despite 60 ml/kg fluid and inotropic support. Most patients in our series had vasodilatory shock with wide pulse pressures and most common finding on echo was uncorrected hypovolemia. The echo findings allowed adjustment of therapy which was not possible based on clinical examination alone.

Management of children with sepsis and septic shock: a survey among pediatric intensivists of the Réseau Mère-Enfant de la Francophonie

Background

Pediatric sepsis represents an important cause of mortality in pediatric intensive care units (PICU). Although adherence to published guidelines for the management of severe sepsis patients is known to lower mortality, actual adherence to these recommendations is low. The aim of this study was to describe the initial management of pediatric patients with severe sepsis, as well as to describe the main barriers to the adherence to current guidelines on management of these patients.

Methods

A survey using a case scenario to assess the management of a child with severe sepsis was designed and sent out to all PICU medical directors of the 20 institutions member of the “Réseau Mère- Enfant de la Francophonie”. Participants were asked to describe in detail the usual management of these patients in their institution with regard to investigations, fluid and catecholamine management, intubation, and specific treatments. Participants were also asked to identify the main barriers to the application of the Surviving Sepsis Campaign guidelines in their center.

Results

Twelve PICU medical directors answered the survey. Only two elements of the severe sepsis bundles had a low stated compliance rate: “maintain adequate central venous pressure” and “glycemic control” had a stated compliance of 8% and 25% respectively. All other elements of the bundles had a reported compliance of over 90%. Furthermore, the most important barriers to the adherence to Surviving Sepsis Campaign guidelines were the unavailability of continuous central venous oxygen saturation (ScvO₂) monitoring and the absence of a locally written protocol.

Conclusions

In this survey, pediatric intensivists reported high adherence to the current recommendations in the management of pediatric severe sepsis regarding antibiotic administration, rapid fluid resuscitation, and administration of catecholamines and steroids, if needed. Technical difficulties in obtaining continuous ScvO₂ monitoring and absence of a locally written protocol were the main barriers to the uniform application of current guidelines. We believe that the development of locally written protocols and of specialized teams could add to the achievement of the goal that every child in sepsis should be treated according to the latest evidence to heighten his chances of survival.

Global paediatric advanced life support: improving child survival in limited-resource settings

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

Therapeutic applications of vasopressin in pediatric patients

CONTEXT

Reports of successful use of vasopressin in various shock states and cardiac arrest has lead to the emergence of vasopressin therapy as a potentially major advancement in the management of critically ill children.

OBJECTIVE

To provide an overview of physiology of vasopressin, rationale of its use and dose schedule in different disease states with special focus on recent advances in the therapeutic applications of vasopressin.

DATA SOURCE

MEDLINE search (1966-September 2011) using terms vasopressin, terlipressin, arginine-vasopressin, shock, septic shock, vasodilatory shock, cardiac arrest, and resuscitation for reports on vasopressin/terlipressin use in children and manual review of article bibliographies. Search was restricted to human studies. Randomized controlled trials, cohort studies, evaluation studies, case series, and case reports on vasopressin/terlipressin use in children (preterm neonates to 21 years of age) were included. Outcome measures were analysed using following clinical questions: indication, dose and duration of vasopressin/terlipressin use, main effects especially on systemic blood pressure, catecholamine requirement, urine output, serum lactate, adverse effects, and mortality.

RESULTS

51 reports on vasopressin (30 reports) and terlipressin (21 reports) use in pediatric population were identified. A total of 602 patients received vasopressin/terlipressin as vasopressors in various catecholamine-resistant states (septic - 176, post-cardiotomy - 136, other vasodilatory/mixed shock - 199, and cardiac arrest - 101). Commonly reported responses include rapid improvement in systemic blood pressure, decline in concurrent catecholamine requirement, and increase in urine output; despite these effects, the mortality rates remained high.

CONCLUSION

In view of the limited clinical experience, and paucity of randomized controlled trials evaluating these drugs in pediatric population, currently no definitive recommendations on vasopressin/terlipressin use can be laid down. Nevertheless, available clinical data supports the use of vasopressin in critically ill children as a rescue therapy in refractory shock and cardiac arrest.

Pediatric rapid fluid resuscitation

PURPOSE OF REVIEW

Intravenous and enteral fluid resuscitation are frequently used therapies in the management of pediatric patients in emergency departments and critical care settings. Any state of intravascular fluid deficit, ranging from mild dehydration due to gastroenteritis to fulminant septic shock, requires careful assessment and early restoration of hemodynamic stability. Rapid fluid resuscitation has gained increased recognition since the most recent pediatric shock management guidelines. We sought to review the evidence for rapid fluid resuscitation and to outline its clinical indications, implementation, and potential associated risks.

RECENT FINDINGS

Rapid fluid resuscitation benefits pediatric patients with severe dehydration or signs of shock. Studies have proven the modality to be safe and efficacious and to reduce morbidity and mortality. Initial and frequent clinical assessments are key in reducing potential complications of overhydration or clinically significant electrolyte disturbances. Rapid enteral rehydration may be used in the uncomplicated, mildly to moderately dehydrated patient. Antiemetics may facilitate rehydration efforts by limiting further fluid losses.

SUMMARY

Rapid fluid resuscitation is most commonly used for children with moderate-to-severe dehydration, or for patients in shock to restore circulation. Concerns regarding potential for fluid overload and electrolyte disturbances and regarding the method of rehydration (i.e., enteral versus parenteral) raise some debate about the safety and efficacy of rapid fluid resuscitation in the pediatric patient. Recent studies show that early, aggressive fluid resuscitation of up to 60 ml/kg within 1-2 h may be necessary to replenish circulating intravascular fluid volume. Complications of severe electrolyte disturbances, cerebral edema, or uncontrolled hemorrhage are uncommon and can often be avoided with early clinical assessment and reassessments throughout the resuscitation. In the mildly to moderately dehydrated child, enteral fluid resuscitation with the aid of an antiemetic such as ondansetron can be as effective and efficient as intravenous fluid resuscitation.