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Monares-Zepeda E, Barrera-Hoffmann C. ANDROMEDA-SHOCK protocol in obstetrics. Intensive Care Med 2024:10.1007/s00134-024-07468-7. [PMID: 38842729 DOI: 10.1007/s00134-024-07468-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Enrique Monares-Zepeda
- Critical Medicine, Obstetrics Intensive Care Unit, Hospital General de México "Dr. Eduardo Liceaga", Dr. Balmis 148. Col. Doctores. Alc. Cuauhtémoc, CP 06726, Mexico City, México.
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Ranjit S, Kissoon N, Argent A, Inwald D, Ventura AMC, Jaborinsky R, Sankar J, de Souza DC, Natraj R, De Oliveira CF, Samransamruajkit R, Jayashree M, Schlapbach LJ. Haemodynamic support for paediatric septic shock: a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:588-598. [PMID: 37354910 DOI: 10.1016/s2352-4642(23)00103-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/26/2023]
Abstract
Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.
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Affiliation(s)
- Suchitra Ranjit
- Paediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, India.
| | | | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - David Inwald
- Addenbrooke's Hospital, University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andréa Maria Cordeiro Ventura
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil
| | - Roberto Jaborinsky
- Northeastern National University, Corrientes, Argentina; Latin American Society of Pediatric Intensive Care (LARed Network), Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, AIIMS, New Delhi, India
| | - Daniela Carla de Souza
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil; Latin American Sepsis Institute, São Paulo, Brazil
| | - Rajeswari Natraj
- Department of Paediatric Intensive Care, Apollo Children's Hospitals, Chennai, India
| | | | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Muralidharan Jayashree
- Pediatric Emergency and Intensive Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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La Via L, Sanfilippo F, Continella C, Triolo T, Messina A, Robba C, Astuto M, Hernandez G, Noto A. Agreement between Capillary Refill Time measured at Finger and Earlobe sites in different positions: a pilot prospective study on healthy volunteers. BMC Anesthesiol 2023; 23:30. [PMID: 36653739 PMCID: PMC9847031 DOI: 10.1186/s12871-022-01920-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/21/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Capillary Refill Time (CRT) is a marker of peripheral perfusion usually performed at fingertip; however, its evaluation at other sites/position may be advantageous. Moreover, arm position during CRT assessment has not been fully standardized. METHODS We performed a pilot prospective observational study in 82 healthy volunteers. CRT was assessed: a) in standard position with participants in semi-recumbent position; b) at 30° forearm elevation, c and d) at earlobe site in semi-recumbent and supine position. Bland-Altman analysis was performed to calculate bias and limits of agreement (LoA). Correlation was investigated with Pearson test. RESULTS Standard finger CRT values (1.04 s [0.80;1.39]) were similar to the earlobe semi-recumbent ones (1.10 s [0.90;1.26]; p = 0.52), with Bias 0.02 ± 0.18 s (LoA -0.33;0.37); correlation was weak but significant (r = 0.28 [0.7;0.47]; p = 0.01). Conversely, standard finger CRT was significantly longer than earlobe supine CRT (0.88 s [0.75;1.06]; p < 0.001) with Bias 0.22 ± 0.4 s (LoA -0.56;1.0), and no correlation (r = 0,12 [-0,09;0,33]; p = 0.27]. As compared with standard finger CRT, measurement with 30° forearm elevation was significantly longer (1.17 s [0.93;1.41] p = 0.03), with Bias -0.07 ± 0.3 s (LoA -0.61;0.47) and with a significant correlation of moderate degree (r = 0.67 [0.53;0.77]; p < 0.001). CONCLUSIONS In healthy volunteers, the elevation of the forearm significantly prolongs CRT values. CRT measured at the earlobe in semi-recumbent position may represent a valid surrogate when access to the finger is not feasible, whilst earlobe CRT measured in supine position yields different results. Research is needed in critically ill patients to evaluate accuracy and precision at different sites/positions.
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Affiliation(s)
- Luigi La Via
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.8158.40000 0004 1757 1969School of Specialization in Anesthesia and Intensive Care, University of Catania, 95123 Catania, Italy
| | - Carlotta Continella
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.411489.10000 0001 2168 2547School of Specialization in Anesthesia and Intensive Care, University Magna Graecia, 88100 Catanzaro, Italy
| | - Tania Triolo
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.411489.10000 0001 2168 2547School of Specialization in Anesthesia and Intensive Care, University Magna Graecia, 88100 Catanzaro, Italy
| | - Antonio Messina
- grid.417728.f0000 0004 1756 8807Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Milan, Italy
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, 16100 Genoa, Italy
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.8158.40000 0004 1757 1969School of Specialization in Anesthesia and Intensive Care, University of Catania, 95123 Catania, Italy
| | - Glenn Hernandez
- grid.7870.80000 0001 2157 0406Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alberto Noto
- grid.10438.3e0000 0001 2178 8421Division of Anesthesia and Intensive Care, University of Messina, Policlinico’’G. Martino’’, 98121 Messina, Italy
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Lamprea S, Fernández-Sarmiento J, Barrera S, Mora A, Fernández-Sarta JP, Acevedo L. Capillary refill time in sepsis: A useful and easily accessible tool for evaluating perfusion in children. Front Pediatr 2022; 10:1035567. [PMID: 36467476 PMCID: PMC9714817 DOI: 10.3389/fped.2022.1035567] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022] Open
Abstract
The international sepsis guidelines emphasize the importance of early identification along with the combined administration of fluids, antibiotics and vasopressors as essential steps in the treatment of septic shock in childhood. However, despite these recommendations, septic shock mortality continues to be very high, especially in countries with limited resources. Cardiovascular involvement is common and, in most cases, determines the outcomes. Early recognition of hemodynamic dysfunction, both in the macro and microcirculation, can help improve outcomes. Capillary refill time (CRT) is a useful, available and easily accessible tool at all levels of care. It is a clinical sign of capillary vasoconstriction due to an excessive sympathetic response which seeks to improve blood redistribution from the micro- to the macrocirculation. An important reason for functionally evaluating the microcirculation is that, in septic shock, the correction of macrocirculation variables is assumed to result in improved tissue perfusion. This has been termed "hemodynamic coherence." However, this coherence often does not occur in advanced stages of the disease. Capillary refill time is useful in guiding fluid resuscitation and identifying more seriously affected sepsis patients. Several factors can affect its measurement, which should preferably be standardized and performed on the upper extremities. In this review, we seek to clarify a few common questions regarding CRT and guide its correct use in patients with sepsis.
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Affiliation(s)
- Shirley Lamprea
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sofía Barrera
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Alicia Mora
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Juan Pablo Fernández-Sarta
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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