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Hatherill M, Tibby SM, Sykes K, Turner C, Murdoch IA. Diagnostic markers of infection: comparison of procalcitonin with C reactive protein and leucocyte count. Arch Dis Child 1999; 81:417-21. [PMID: 10519716 PMCID: PMC1718133 DOI: 10.1136/adc.81.5.417] [Citation(s) in RCA: 177] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Procalcitonin has been advocated as a marker of bacterial infection. OBJECTIVE To evaluate diagnostic markers of infection in critically ill children, comparing procalcitonin with C reactive protein and leucocyte count in a paediatric intensive care unit (PICU). METHODS Procalcitonin, C reactive protein, and leucocyte count were measured in 175 children, median age 16 months, on admission to the PICU. Patients were classified as: non-infected controls (43); viral infection (14); localised bacterial infection without shock (25); bacterial meningitis/encephalitis (10); or septic shock (77). Six children with "presumed septic shock" (without sufficient evidence of infection) were analysed separately. Optimum sensitivity, specificity, predictive values, and area under the receiver operating characteristic (ROC) curve were evaluated. RESULTS Admission procalcitonin was significantly higher in children with septic shock (median 94.6; range 3.3-759.8 ng/ml), compared with localised bacterial infection (2.9; 0-24.3 ng/ml), viral infection (0.8; 0-4.4 ng/ml), and non-infected controls (0; 0-4.9 ng/ml). Children with bacterial meningitis had a median procalcitonin of 25.5 (7.2-118.4 ng/ml). Area under the ROC curve was 0.96 for procalcitonin, 0.83 for C reactive protein, and 0.51 for leucocyte count. Cut off concentrations for optimum prediction of septic shock were: procalcitonin > 20 ng/ml and C reactive protein > 50 mg/litre. A procalcitonin concentration > 2 ng/ml identified all patients with bacterial meningitis or septic shock. CONCLUSION In critically ill children the admission procalcitonin concentration is a better diagnostic marker of infection than C reactive protein or leucocyte count. A procalcitonin concentration of 2 ng/ml might be useful in differentiating severe bacterial disease in infants and children.
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Tibby SM, Hatherill M, Marsh MJ, Murdoch IA. Clinicians' abilities to estimate cardiac index in ventilated children and infants. Arch Dis Child 1997; 77:516-8. [PMID: 9496187 PMCID: PMC1717412 DOI: 10.1136/adc.77.6.516] [Citation(s) in RCA: 166] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate the ability of clinicians involved in the provision of paediatric intensive care to estimate cardiac index in ventilated children, based on physical examination and clinical and bedside laboratory data. METHODS Clinicians were exposed to all available haemodynamic and laboratory data for each patient, allowed to make a physical examination, and asked to first categorize cardiac index as high, high to normal, low to normal, or low, and then to quantify this further with a numerical estimate. Cardiac index was measured simultaneously by femoral artery thermodilution (coefficient of variation 5.37%). One hundred and twelve estimates were made by 27 clinicians on 36 patients (median age 34.5 months). RESULTS Measured cardiac index ranged from 1.39 to 6.84 1/min/m2. Overall, there was poor correlation categorically (kappa statistic 0.09, weighted kappa 0.169) and numerically (r = 0.24, 95% confidence interval 0.06 to 0.41), although some variation was seen among the various levels of seniority. CONCLUSION Assuming that objective measurement, and hence manipulation, of haemodynamic variables may improve outcome, these findings support the need for a safe, accurate, and repeatable technique for measurement of cardiac index in children who are critically ill.
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Tibby SM, Hatherill M, Marsh MJ, Morrison G, Anderson D, Murdoch IA. Clinical validation of cardiac output measurements using femoral artery thermodilution with direct Fick in ventilated children and infants. Intensive Care Med 1997; 23:987-91. [PMID: 9347372 DOI: 10.1007/s001340050443] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To validate clinically cardiac output (CO) measurements using femoral artery thermodilution in ventilated children and infants by comparison with CO estimated from the Fick equation via a metabolic monitor. DESIGN Prospective, comparison study. SETTING Paediatric intensive care unit of a university hospital. PATIENTS 24 ventilated infants and children, aged 0.3 to 175 months (median age 19 months). INTERVENTIONS Oxygen consumption measurements were made and averaged over a 5-min period, at the end of which arterial and mixed venous blood samples were taken and oxygen saturations measured by co-oximetry, with CO being calculated using the Fick equation. Over this 5-min period, five sets of femoral arterial thermodilution (FATD) measurements were made and averaged. One comparison of CO values was made per patient. RESULTS Mean Fick CO was 2.55 l/min (range 0.24 to 8.71 l/min) and mean FATD CO was 2.51 l/min (range 0.28-7.96 l/min). The mean bias was 0.03 l/min (95% confidence interval -0.07 to 0.14 l/min), with limits of agreement of -0.45 to 0.52 l/min. When indexed to body surface area, the mean Fick cardiac index became 3.51 l/min per m2 (1.52-6.98 l/min per m2) and mean FATD 3.49 l/min per m2 (1.74-6.84 l/min per m2). The mean bias was 0.02 l/min per m2 (95% confidence interval -0.11 to 0.15 l/min per m2) with limits of agreement of-0.57 to 0.61 l/min per m2. The mean FATD coefficient of variation was 5.8% (SEM 0.5%). CONCLUSIONS FATD compares favourably with Fick derived CO estimates in infants and children and may represent an advance in haemodynamic monitoring of critically ill children.
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Hatherill M, Tibby SM, Turner C, Ratnavel N, Murdoch IA. Procalcitonin and cytokine levels: relationship to organ failure and mortality in pediatric septic shock. Crit Care Med 2000; 28:2591-4. [PMID: 10921600 DOI: 10.1097/00003246-200007000-00068] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Procalcitonin (PCT), a marker of bacterial sepsis, may also act as a mediator of the inflammatory response to infection, and thus influence outcome. OBJECTIVE To investigate the relationship between PCT, interleukin (IL)-10, tumor necrosis factor (TNF), organ failure, and mortality in pediatric septic shock. DESIGN Prospective observational study. SETTING A 16-bed pediatric intensive care unit of a university hospital. PATIENTS A total of 75 children with septic shock having a median age of 43.1 months (range, 0.1-192 months). Children who had received antibiotics for >24 hrs were excluded. A total of 37 patients (49%) had meningococcal disease, and 72 patients (96%) required mechanical ventilation. INTERVENTIONS The pediatric risk of mortality (PRISM) score, multiple organ system failure (MOSF) score, duration of ventilation, length of ICU stay, and outcome were recorded. PCT, IL-10, and TNF were measured at admission to the intensive care unit. Sequential PCT levels were available at 0 hrs and 24 hrs in 39 patients (52%). RESULTS Observed mortality was 21/75 (28%). Data are median (range). The admission PCT (p = .0002) and TNF levels (p = .0001) were higher in children with higher MOSF scores. In survivors and nonsurvivors, the admission PCT was 82 ng/mL vs. 273 ng/mL (p = .03), IL-10 was 62 pg/mL vs. 534 pg/mL (p = .03), and TNF was 76 pg/mL vs. 480 pg/mL (p = .001), respectively. Area under the mortality receiver operating characteristic curve was 0.73 for PCT, 0.67 for IL-10, and 0.76 for TNF, compared with 0.83 for the PRISM score. Of 39 children, 16 (41%) with sequential PCT measurements showed no fall in PCT after 24 hrs treatment. These children had higher admission levels of IL-10 (p = .03), and TNF (p = .03) compared with children who demonstrated a subsequent fall in PCT. Although the former did not have a higher median PRISM (p = .28) or MOSF score (p = .19), observed mortality was 44% (7 of 16) compared with 9% (2 of 23) (p = .02). CONCLUSION The admission PCT, like TNF and IL-10, is related to the severity of organ failure and mortality in children with septic shock. A fall in PCT after 24 hrs of treatment may have favorable prognostic significance.
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Abstract
BACKGROUND Functional adrenal insufficiency has been documented in critically ill adults. OBJECTIVE To document the incidence of adrenal insufficiency in children with septic shock, and to evaluate its effect on catecholamine requirements, duration of intensive care, and mortality. SETTING Sixteen-bed paediatric intensive care unit in a university hospital. METHODS Thirty three children with septic shock were enrolled. Adrenal function was assessed by the maximum cortisol response after synthetic adrenocorticotropin stimulation (short Synacthen test). Insufficiency was defined as a post-Synacthen cortisol increment < 200 nmol/l. RESULTS Overall mortality was 33%. The incidence of adrenal insufficiency was 52% and children with adrenal insufficiency were significantly older and tended to have higher paediatric risk of mortality scores. They also required higher dose vasopressors for haemodynamic stability. In the survivor group, those with adrenal insufficiency needed a longer period of inotropic support than those with normal function (median, 3 v 2 days), but there was no significant difference in duration of ventilation (median, 4 days for each group) or length of stay (median, 5 v 4 days). Mortality was not significantly greater in children with adrenal insufficiency than in those with adequate adrenal function (6 of 17 v 5 of 16, respectively). CONCLUSION Adrenal insufficiency is common in children with septic shock. It is associated with an increased vasopressor requirement and duration of shock.
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Tibby SM, Hatherill M, Murdoch IA. Capillary refill and core-peripheral temperature gap as indicators of haemodynamic status in paediatric intensive care patients. Arch Dis Child 1999; 80:163-6. [PMID: 10325733 PMCID: PMC1717816 DOI: 10.1136/adc.80.2.163] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Capillary refill time is an important diagnostic adjunct in the acute resuscitation phase of the shocked child. This study assesses its relation to commonly measured haemodynamic parameters in the postresuscitation phase when the child has reached the intensive care unit, and compares this with core-peripheral temperature gap. METHODS Ninety standardised measurements of capillary refill time were made on 55 patients, who were divided into postcardiac surgery (n = 27), and general (n = 28), most of whom had septic shock (n = 24). A normal capillary refill time was defined as < or = 2 seconds. Measured haemodynamic variables included: cardiac index, central venous pressure, systemic vascular resistance index, stroke volume index (SVI), and blood lactate. Seventy measurements were made on patients while being treated with inotropes or vasodilators. RESULTS Capillary refill time and temperature gap both correlated poorly with all haemodynamic variables among post-cardiac surgery children. For general patients, capillary refill time was related to SVI and lactate; temperature gap correlated poorly with all variables. General patients with a prolonged capillary refill time had a lower median SVI (28 v 38 ml/m2) but not a higher lactate (1.7 v 1.1 mmol/l). A capillary refill time of > or = 6 seconds had the best predictive value for a reduced SVI. CONCLUSION Among ventilated, general intensive care patients, capillary refill time is related weakly to blood lactate and SVI. A normal value for capillary refill time of < or = 2 seconds has little predictive value and might be too conservative for this population; septic shock.
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Tibby SM, Hatherill M, Wright SM, Wilson P, Postle AD, Murdoch IA. Exogenous surfactant supplementation in infants with respiratory syncytial virus bronchiolitis. Am J Respir Crit Care Med 2000; 162:1251-6. [PMID: 11029326 DOI: 10.1164/ajrccm.162.4.9909004] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Infants with respiratory syncytial virus (RSV) bronchiolitis are deficient in surfactant, both in quantity and ability to reduce surface tension. New evidence suggests surfactant has a role in maintaining the patency of conducting airways, which has implications for RSV bronchiolitis. A randomized, controlled pilot study was undertaken to assess the effects of exogenous surfactant supplementation to RSV-positive infants on pulmonary mechanics, indices of gas exchange, and the phospholipid composition of bronchoalveolar lavage fluid (BALF). Nineteen ventilated infants (median corrected age 4 wk) received either two doses of surfactant (Survanta, 100 mg/kg) within 24 and 48 h of mechanical ventilation (n = 9), or air placebo (n = 10). Static lung compliance and resistance of infants in the placebo but not in the surfactant-treated group became progressively worse over the first 30 h following enrollment. Although no significant acute changes in gas exchange parameters were seen following surfactant, infants in the surfactant group showed a more rapid improvement in oxygenation and ventilation indices over the first 60 h of ventilation. Surfactant status was assessed from the concentration ratio in BALF of the disaturated phospholipid species dipalmitoylphosphatidylcholine to that of the monounsaturated species palmitoyloleoylphosphatidylcholine. This ratio correlated with both lung compliance (positively) and resistance (negatively), and over time increased in the treated group and declined in placebo infants. The data from this pilot study suggest that functional surfactant has a role in maintaining small airway patency as well as lung compliance in infants infected with RSV and an outcome study is now warranted.
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Hatherill M, Sajjanhar T, Tibby SM, Champion MP, Anderson D, Marsh MJ, Murdoch IA. Serum lactate as a predictor of mortality after paediatric cardiac surgery. Arch Dis Child 1997; 77:235-8. [PMID: 9370903 PMCID: PMC1717300 DOI: 10.1136/adc.77.3.235] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the value of sequential lactate measurement in predicting postoperative mortality after surgery for complex congenital heart disease in children. DESIGN Prospective observational study. SETTING Sixteen bedded paediatric intensive care unit (PICU). SUBJECTS Ninety nine children (90 survivors, nine non-survivors). MEASUREMENTS Serum lactate and base deficit were measured on admission and every six hours thereafter. Data were analysed by Mann-Whitney and Fisher's exact tests. RESULTS There was considerable overlap in initial lactate values between the survivor and non-survivor groups. Initial lactate was significantly raised in non-survivors (median 8.7, range 1.9-17.6 mmol/l) compared with survivors (median 2.4, range 0.6-13.6 mmol/l) (p = 0.0002). Twenty one patients (21.1%) with initial lactate concentrations greater than 4.5 mmol/l survived to PICU discharge. Using receiver operating characteristic analysis an initial lactate of 6 mmol/l had the optimum predictive value for mortality. Initial postoperative serum lactate > 6 mmol/l predicted mortality with sensitivity 78%, specificity 83%, and positive predictive value of only 32%. CONCLUSION Initial lactate concentrations have poor positive predictive value for mortality. The routine measurement of lactate for this purpose cannot be justified in clinical practice.
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Tibby SM, Hatherill M, Murdoch IA. Use of transesophageal Doppler ultrasonography in ventilated pediatric patients: derivation of cardiac output. Crit Care Med 2000; 28:2045-50. [PMID: 10890662 DOI: 10.1097/00003246-200006000-00061] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To ascertain if cardiac output (CO) could be derived from blood flow velocity measured in the descending aorta of ventilated children by transesophageal Doppler ultrasonography (TED) without the need for direct aortic cross sectional area measurement, and to evaluate the ability of TED to follow changes in CO when compared with femoral artery thermodilution. DESIGN Prospective, comparison study. SETTING A 16-bed pediatric intensive care unit of a university hospital. PATIENTS A total of 100 ventilated infants and children aged 4 days to 18 yrs (median age, 27 months). Diagnoses included postcardiac surgery (n = 58), sepsis/multiple organ failure (n = 32), respiratory disease (n = 5), and other (n = 5). A total of 55 patients were receiving inotropes or vasodilators. INTERVENTIONS When patients were hemodynamically stable, a TED probe was placed into the distal esophagus to obtain optimal signal, and minute distance (MD) was recorded. Five consecutive MD measurements were made concurrently with five femoral artery thermodilution measurements, and the concurrent measurements were averaged. CO was then manipulated by fluid administration or inotrope adjustment, and the readings were repeated. MEASUREMENTS AND MAIN RESULTS Femoral artery thermodilution CO ranged from 0.32 to 9.19 L/min, (median, 2.46 L/min), and encompassed a wide range of high and low flow states. Theoretical consideration revealed the optimal TED estimate for CO to be (MD x patient height2 x 10(-7)). Linear regression analysis yielded a power function model such that: estimated CO = 1.158 x (MD x height2 x 10(-7))(0.785), r2 = 0.879, standard error of the estimate = 0.266. Inclusion of a correction factor for potential changes in aortic cross-sectional area with hypo- and hypertension did not appreciably improve the predictive value of the model. MD was able to follow percentage changes in CO, giving a mean bias of 0.87% (95% confidence interval -0.85% to 2.59%), and limits of agreement of +/- 16.82%. The median coefficient of variation for MD was 3.3%. CONCLUSIONS TED provides a clinically accurate estimate of CO across the entire pediatric age range and is able to follow changes in CO.
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Hatherill M, Hawkridge T, Zar HJ, Whitelaw A, Tameris M, Workman L, Geiter L, Hanekom WA, Hussey G. Induced sputum or gastric lavage for community-based diagnosis of childhood pulmonary tuberculosis? Arch Dis Child 2009; 94:195-201. [PMID: 18829621 DOI: 10.1136/adc.2007.136929] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare the diagnostic yield of Mycobacterium tuberculosis from induced sputum (IS) and gastric lavage (GL) among children in a community setting. METHODS Specimen-collection methods for bacteriological confirmation of pulmonary tuberculosis (PTB) were compared during a tuberculosis vaccine trial near Cape Town, South Africa (2001-2006). Children with a tuberculosis contact or compatible symptoms were investigated for suspected PTB. Diagnostic yields from 764 paired IS and GL specimens were compared in 191 culture-confirmed cases. MEASUREMENTS AND MAIN RESULTS The crude yield of M tuberculosis was 10.4%, n = 108 by IS (5.8%) and n = 127 by GL (6.8%), from a total of 194 cases, of which three had incomplete IS/GL specimen pairs. Agreement between IS and GL was poor (kappa = 0.31). The comparative yield of a single IS sample (38%) was equivalent to a single GL sample (42%), with a difference in yield of -4% (95% CI -15% to +7%). The combined yield of same-day IS and GL specimens (67%) was equivalent to two consecutive GL specimens (66%), with a difference in yield of 1% (95% CI -9% to 11%), but significantly greater than two consecutive IS specimens (55%), with a difference in yield of 12% (95% CI 2% to 21%). The adjusted odds of a M tuberculosis culture were increased by a positive tuberculin skin test or chest radiograph compatible with PTB. CONCLUSIONS In this community setting, the diagnostic yield of a single IS sample was equivalent to that of a single GL sample. The optimal diagnostic yield may be obtained from paired IS and GL specimens taken on a single day or two GL specimens taken on consecutive days.
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Hatherill M, McIntyre AG, Wattie M, Murdoch IA. Early hyperlactataemia in critically ill children. Intensive Care Med 2000; 26:314-8. [PMID: 10823388 DOI: 10.1007/s001340051155] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the relationships between early hyperlactataemia, acidosis, organ failure, and mortality in children admitted to intensive care. DESIGN Prospective observational study. Children with lactate levels > 2 mmol/l were eligible for enrolment. Post-operative patients and those with inherited metabolic disease were excluded. Seven hundred and five children admitted to intensive care were screened, and 50 children with hyperlactataemia (incidence 7%), aged 20.3 months (0.1-191) were enrolled and followed up. The Paediatric Risk of Mortality (PRISM) score, Multiorgan System Failure (MOSF) score, length of ICU stay, and outcome were recorded. Data were collected for lactate (mmol/l), pH, and base excess (BE) until 24 h after admission. Data are reported as median (range) and were analysed by the Mann-Whitney, Fisher's Exact, and Kruskal-Wallis tests, and chisquared test for trend. RESULTS Overall mortality in the screening group was 70/705 (10%). In the study group (n = 50) median PRISM score was 19 (4-49), median MOSF score 2 (1-4), and observed mortality 32/50 (64%). Median duration of ICU stay was 6 days (2-32) in survivors, and median time until death 3 days (0-13) in nonsurvivors. Eleven nonsurvivors (34%) died within 24 h. In the screening group, hyperlactataemia on admission identified mortality with likelihood ratio = 15. In the study group, neither the admission lactate (3.8 vs 4.6 mmol/l, P = 0.27), pH (7.32 vs 7.30, P = 0.6), nor BE (-7.5 vs -8, P = 0.45) differed significantly between survivors and nonsurvivors. Neither the admission nor peak lactate increased with increasing MOSF score (P = 0.5 and 0.54). The median peak lactate level was 5 mmol/l (2-9.3) in survivors compared to 6.8 mmol/l (2.3-22) in nonsurvivors (P = 0.02), and the cumulative average lactate level was 2.4 mmol/l (1-4.9) in survivors, compared to 4.5 mmol/l (1.6-21) in nonsurvivors (P = 0.0003). Persistent hyperlactataemia 24 h after admission identified mortality with likelihood ratio = 7. CONCLUSION Hyperlactataemia on admission to intensive care is associated with a high mortality in children. Nonsurvivors within this group may be distinguished by the peak lactate level, or by persistent hyperlactataemia after 24 h of treatment.
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Tibby SM, Hatherill M, Durward A, Murdoch IA. Are transoesophageal Doppler parameters a reliable guide to paediatric haemodynamic status and fluid management? Intensive Care Med 2001; 27:201-5. [PMID: 11280635 DOI: 10.1007/s001340000795] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Transoesophageal Doppler (TOD) has been used in adults to optimise left ventricular filling on the basis of the waveform parameters. We wished to see if a similar relationship exists in children, specifically: (a) whether change in thermodilution stroke volume (SV) following a fluid bolus corresponded to change in Doppler stroke distance, Doppler corrected flow time (FTc), or central venous pressure (CVP); (b) whether a response to fluid challenge (defined as an increase in SV of greater than 10%) can be predicted on the basis of an absolute value for FTc or CVP prior to fluid bolus; and (c) the relationship between FTc and systemic vascular resistance index. DESIGN Prospective, comparison study. SETTING Sixteen-bed paediatric intensive care unit of a university hospital. PATIENTS Ninety-four ventilated children were studied, median (range) age 25 months (4 days- 16 years). Diagnoses included: post-cardiac surgery (n = 58), sepsis/multi-organ failure (n = 29), respiratory disease (n = 5), and other (n = 2). INTERVENTIONS A 4-MHz, 5.5-mm diameter, flexible TOD probe was placed when patients were haemodynamically stable. Five consecutive measurements of stroke distance and FTc were made and averaged, concurrently with five SV measurements by femoral artery thermodilution. SV was then augmented by administration of fluid (10 ml/kg), and haemodynamic recordings were repeated. MEASUREMENTS AND MAIN RESULTS The median (range) SV was 17 ml (2-64 ml). The median coefficients of variation were 3.9 % for SV, 3.5 % for stroke distance, and 3.1% for FTc. Changes in SV were accurately tracked by changes in stroke distance (mean bias 1.8 %, limits of agreement +/- 17%), but not by FTc or CVP. FTc was weakly inversely correlated with systemic vascular resistance (r = -0.15, P < 0.05). Among non-cardiac patients (n = 36), the optimal FTc that predicted an improvement in SV following fluid bolus was 0.394 s (area under ROC curve 0.756), giving a sensitivity of 90 %, specificity of 62 %, positive predictive value of 47 %, and a negative predictive value of 94 %. CVP was a poor predictor for all patient groups. CONCLUSIONS TOD stroke distance is able to follow changes in SV following fluid bolus amongst ventilated children, and can predict when further volume loading is unlikely to improve SV amongst general, but not cardiac ICU patients. CVP is a poor discriminator of volume status in this group of patients.
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Hatherill M, Waggie Z, Purves L, Reynolds L, Argent A. Correction of the anion gap for albumin in order to detect occult tissue anions in shock. Arch Dis Child 2002; 87:526-9. [PMID: 12456555 PMCID: PMC1755806 DOI: 10.1136/adc.87.6.526] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND It is believed that hypoalbuminaemia confounds interpretation of the anion gap (AG) unless corrected for serum albumin in critically ill children with shock. AIM To compare the ability of the AG and the albumin corrected anion gap (CAG) to detect the presence of occult tissue anions. METHODS Prospective observational study in children with shock in a 22 bed multidisciplinary paediatric intensive care unit of a university childrenrsquo;s hospital. Blood was sampled at admission and at 24 hours, for acid-base parameters, serum albumin, and electrolytes. Occult tissue anions (lactate + truly "unmeasured" anions) were calculated from the strong ion gap. The anion gap ((Na + K) - (Cl + bicarbonate)) was corrected for serum albumin using the equation of Figge: AG + (0.25 x (44 - albumin)). Occult tissue anions (TA) predicted by the anion gap were calculated by (anion gap - 15 mEq/l). Optimal cut off values of anion gap were compared by means of receiver operating characteristic (ROC) curves. Ninety three sets of data from 55 children (median age 7 months, median weight 4.9 kg) were analysed. Data are expressed as mean (SD), and mean bias (limits of agreement). RESULTS The incidence of hypoalbuminaemia was 76% (n = 42/55). Mean serum albumin was 25 g/l (SD 8). Mean AG was 15.0 mEq/l (SD 6.1), compared to the CAG of 19.9 mEq/l (SD 6.6). Mean TA was 10.2 mmol/l (SD 6.3). The AG underestimated TA with mean bias 10.2 mmol/l (4.1-16.1), compared to the CAG, mean bias 5.3 mmol/l (0.4-10.2). A clinically significant increase of TA >5 mmol/l was present in 83% (n = 77/93) of samples, of which the AG detected 48% (n = 36/77), and the CAG 87% (n = 67/77). Post hoc ROC analysis revealed optimal cut off values for detection of TA >5 mmol/l to be AG >10 mEq/l, and CAG >15.5 mEq/l. CONCLUSION Hypoalbuminaemia is common in critically ill children with shock, and is associated with a low observed anion gap that may fail to detect clinically significant amounts of lactate and other occult tissue anions. We suggest that the albumin corrected anion gap should be calculated to screen for occult tissue anions in these children.
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Tameris M, Hokey DA, Nduba V, Sacarlal J, Laher F, Kiringa G, Gondo K, Lazarus EM, Gray GE, Nachman S, Mahomed H, Downing K, Abel B, Scriba TJ, McClain JB, Pau MG, Hendriks J, Dheenadhayalan V, Ishmukhamedov S, Luabeya AKK, Geldenhuys H, Shepherd B, Blatner G, Cardenas V, Walker R, Hanekom WA, Sadoff J, Douoguih M, Barker L, Hatherill M. A double-blind, randomised, placebo-controlled, dose-finding trial of the novel tuberculosis vaccine AERAS-402, an adenovirus-vectored fusion protein, in healthy, BCG-vaccinated infants. Vaccine 2015; 33:2944-54. [PMID: 25936724 PMCID: PMC6698638 DOI: 10.1016/j.vaccine.2015.03.070] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/18/2015] [Accepted: 03/23/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Several novel tuberculosis vaccines are currently in clinical trials, including AERAS-402, an adenovector encoding a fusion protein of Mycobacterium tuberculosis antigens 85A, 85B, and TB10.4. A multicentred trial of AERAS-402 safety and immunogenicity in healthy infants was conducted in three countries in sub-Saharan Africa, using an adaptive design. METHODS In a double-blind, randomised, placebo-controlled, dose-finding trial, we enrolled BCG-vaccinated, HIV-uninfected infants aged 16-26 weeks. Infants in the safety/dose-finding phase received two doses of AERAS-402 across three dose levels, or placebo, intramuscularly on days 0 and 28. Infants in the expanded safety phase received three doses of the highest dose level, with the 3rd dose at day 280. Follow up for safety and immunogenicity was for up to two years. RESULTS We enrolled 206 infants (52 placebo and 154 AERAS-402 recipients) into the dose-finding phase and 281 (141 placebo and 140 AERAS-402 recipients) into the expanded safety phase. Safety data were acceptable across all dose levels. No vaccine-related deaths were recorded. A single serious adverse event of tachypnoea was deemed related to study vaccine. Antibodies directed largely against Ag85A and Ag85B were detected. Low magnitude CD4+ and CD8+ polyfunctional T cell responses were observed at all dose levels. The addition of a third dose of AERAS-402 at the highest dose level did not increase frequency or magnitude of antibody or CD8+ T cell responses. CONCLUSIONS AERAS-402 has an acceptable safety profile in infants and was well tolerated at all dose levels. Response rate was lower than previously seen in BCG vaccinated adults, and frequency and magnitude of antigen-specific T cells were not increased by a third dose of vaccine.
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Tibby SM, Taylor D, Festa M, Hanna S, Hatherill M, Jones G, Habibi P, Durward A, Murdoch IA. A comparison of three scoring systems for mortality risk among retrieved intensive care patients. Arch Dis Child 2002; 87:421-5. [PMID: 12390920 PMCID: PMC1763066 DOI: 10.1136/adc.87.5.421] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To assess the impact of two paediatric intensive care unit retrieval teams on the performance of three mortality risk scoring systems: pre-ICU PRISM, PIM, and PRISM II. METHODS A total of 928 critically ill children retrieved for intensive care from district general hospitals in the south east of England (crude mortality 7.8%) were studied. RESULTS Risk stratification was similar between the two retrieval teams for scores utilising data primarily prior to ICU admission (pre-ICU PRISM, PIM), despite differences in case mix. The fewer variables required for calculation of PIM resulted in complete data collection in 88% of patients, compared to pre-ICU PRISM (24%) and PRISM II (60%). Overall, all scoring systems discriminated well between survival and non-survival (area under receiver operating characteristic curve 0.83-0.87), with no differences between the two hospitals. There was a tendency towards better discrimination in all scores for children compared to infants and neonates, and a poor discrimination for respiratory disease using pre-ICU PRISM and PRISM II but not PIM. All showed suboptimal calibration, primarily as a consequence of mortality over prediction among the medium (10-30%) mortality risk bands. CONCLUSIONS PIM appears to offer advantages over the other two scores in terms of being less affected by the retrieval process and easier to collect. Recalibration of all scoring systems is needed.
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Moyo S, Isaacs F, Gelderbloem S, Verver S, Hawkridge AJ, Hatherill M, Tameris M, Geldenhuys H, Workman L, Pai M, Hussey G, Hanekom WA, Mahomed H. Tuberculin skin test and QuantiFERON® assay in young children investigated for tuberculosis in South Africa. Int J Tuberc Lung Dis 2012; 15:1176-81, i. [PMID: 21943841 DOI: 10.5588/ijtld.10.0770] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Although the literature on interferon-gamma release assays on tuberculosis (TB) in children has increased, data pertaining to young children remain relatively limited. OBJECTIVE To compare results from the tuberculin skin test (TST) and the QuantiFERON®-TB Gold In-Tube assay (QFT) in children aged <3 years investigated for TB disease. DESIGN TB suspects were evaluated by medical history and examination, TST, QFT, chest radiography, induced sputum and gastric washings for smear and culture for Mycobacterium tuberculosis. RESULTS A total of 400 children were enrolled. Among 397 children with both test results, 68 (17%) were QFT-positive and 72 (18%) were TST-positive (≥10 mm). Agreement between the tests was excellent (94%, κ = 0.79, 95%CI 0.69-0.89). TB disease was diagnosed in 52/397 (13%) participants: 3 definite, 35 probable and 14 possible TB. QFT sensitivity and specificity for TB disease were respectively 38% and 81%. TST sensitivity and specificity were respectively 35% and 84%. CONCLUSION While TST and QFT had excellent concordance in this population, both tests had much lower sensitivity for TB disease than has been reported for other age groups. Our results suggested equivalent performance of QFT and TST in the diagnosis of TB disease in young children in a high-burden setting.
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Research Support, Non-U.S. Gov't |
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Gonzalez-Angulo Y, Wiysonge CS, Geldenhuys H, Hanekom W, Mahomed H, Hussey G, Hatherill M. Sputum induction for the diagnosis of pulmonary tuberculosis: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2011; 31:1619-30. [PMID: 22095153 DOI: 10.1007/s10096-011-1485-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 10/31/2011] [Indexed: 10/15/2022]
Abstract
Sputum induction (SI) has been proposed as the optimal sample collection method for patients with paucibacillary tuberculosis (TB). Studies reporting the culture of Mycobacterium tuberculosis from SI were reviewed. A random-effects meta-analysis of diagnostic yield (numerator M. tuberculosis SI culture-positive cases; denominator all culture-positive cases) was conducted. Diagnostic yields (95% confidence intervals, CIs) were displayed as Forest plots. Heterogeneity was evaluated using Chi-squared and I-squared tests and meta-regression analysis. Ninety publications were screened, 28 full-text papers reviewed, and 17 analyzed. Collectively, n=627 SI culture-positive cases among n=975 culture-confirmed TB cases were reported. The diagnostic yield of SI ranged from 35 to 95%. The pooled diagnostic yield was 74% (CI 65-81%), with significant heterogeneity (p<0.0001, I2=86%). There were no statistically significant differences in the yield between sub-groups defined by human immunodeficiency virus (HIV) prevalence or age. Univariate analysis demonstrated that the use of fiberoptic bronchoscopy (FOB) as the comparator method was associated with a 22% reduction (CI 2-42%) in the diagnostic yield of SI. However, after adjustment for confounding, the meta-regression analysis showed that FOB usage (p=0.21) and saline concentration (p=0.31) were not independently associated with the diagnostic yield. SI will detect approximately three-quarters of M. tuberculosis culture-positive cases under study conditions. Significant heterogeneity in the diagnostic yield was not explained by HIV prevalence, age, or the use of FOB as the comparator method. The use of a particular nebulized saline concentration for SI cannot be recommended on the basis of this meta-regression analysis.
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Systematic Review |
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Case Reports |
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Abstract
OBJECTIVES To investigate the prognostic value of intramucosal pH (pHi) and the relation among pHi, arterial pH, base excess, and lactate in children with septic shock. DESIGN Children admitted to the paediatric intensive care unit with a diagnosis of septic shock were prospectively enrolled. A gastrointestinal tonometer (Tonometrics Division, Instrumentarium Corporation, Helsinki, Finland) was placed into the stomach and intramucosal pH, arterial pH, base deficit, and lactate were measured on admission and six hours later. Sequential data were analysed on 24 patients (17 survivors, seven non-survivors), median age 46 months (range: 2.8-168 months). RESULTS Median pHi on admission was 7.39 (interquartile range 7.36-7.51) in survivors compared with 7.2 (interquartile range 7.18-7.35) in non-survivors (p = 0.01). There was no significant difference in arterial pH, base excess, or lactate among survivors and non-survivors. Admission pHi < 7.32 predicted mortality with sensitivity (57%), specificity (94%), and positive predictive value (80%). Patients with admission pHi < 7.32 who failed to improve > or = 7.32 within six hours (n = 3) had 100% mortality. CONCLUSION In children with septic shock the admission pHi is significantly lower in non-survivors. pHi is a better prognostic indicator of mortality than either standard acid-base values or lactate. pHi < 7.32 that does not improve within six hours is associated with a poor prognosis.
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Ellis R, Hatherill M, Tait D, Snowden M, Churchyard G, Hanekom W, Evans T, Ginsberg A. Innovative clinical trial designs to rationalize TB vaccine development. Tuberculosis (Edinb) 2015; 95:352-7. [DOI: 10.1016/j.tube.2015.02.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/04/2015] [Accepted: 02/06/2015] [Indexed: 12/22/2022]
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Verhulst L, Waggie Z, Hatherill M, Reynolds L, Argent A. Presentation and outcome of severe anticholinesterase insecticide poisoning. Arch Dis Child 2002; 86:352-5. [PMID: 11970930 PMCID: PMC1751109 DOI: 10.1136/adc.86.5.352] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To document the patterns of presentation and outcome of severe anticholinesterase insecticide poisoning in children requiring intensive care. METHODS Retrospective case note review of all 5541 children admitted to the paediatric intensive care unit (PICU) of a university hospital during the 10 years from January 1990 to May 2000. Fifty four children (1%) with anticholinesterase insecticide poisoning were identified. Presenting features, route of exposure, treatment, complications, and mortality were recorded. Data were analysed by the Fisher's exact and Mann-Whitney tests. RESULTS More children than expected were from a rural area (46% versus 25%). Decontamination occurred in 50% of children prior to PICU admission. Enteral exposure was most common (n = 27; 50%). Median pseudocholinesterase level was 185 IU/l (range 75-7404). Median total dose of atropine required to maintain mydriasis was 0.3 mg/kg (range 0.03-16.7) over a median of 10 hours (range 1-160). Complications included coma (31%), seizures (30%), shock (9%), arrhythmias (9%), and respiratory failure requiring ventilation (35%). No significant differences were detected in incidence of seizures, cardiac arrhythmias, respiratory failure, mortality, duration of ventilation, or PICU stay, according to route of exposure, or state of decontamination. Four children died (7%). Mortality was associated with the presence of a cardiac arrhythmia (likelihood ratio 8.3) and respiratory failure (likelihood ratio 3.3). CONCLUSION The mortality and morbidity of severe anticholinesterase insecticide poisoning in childhood is not related to route of exposure, or to delay in decontamination. However, the presence of either a cardiac arrhythmia or respiratory failure is associated with a poor prognosis.
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Hatherill M, Levin M, Lawrenson J, Hsiao NY, Reynolds L, Argent A. Evolution of an adenovirus outbreak in a multidisciplinary children's hospital. J Paediatr Child Health 2004; 40:449-54. [PMID: 15265186 DOI: 10.1111/j.1440-1754.2004.00426.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the course of an evolving adenovirus outbreak in a multidisciplinary children's hospital with a high-risk patient population. METHODS Observational study in a 280-bed university hospital during June 2002. Active case finding identified children with adenovirus infection. Data are median (interquartile range) or n (%). Adenovirus infection was diagnosed in 49 children, median age 12 months (4-33). RESULTS New cases were diagnosed over 26 days and peaked on day 17 (n = 15). Total infected inpatients peaked on days 17-21 (n = 36). Twenty-three infections (47%) were community-acquired and 26 (53%) hospital-acquired. Thirty-three children (67%) had a coexistent high-risk condition. Median hospital stay before and after diagnosis was 9 days (3-18) and 9 days (4-29), respectively. Twenty-two children (45%) were admitted to PICU. Overall hospital mortality was 22% (n = 11) and mortality attributed to adenoviral disease 12% (n = 6). Hospital mortality was similar between community- and hospital-acquired infections (22% compared to 23%) (P = 1.0). Twenty children (41%) received intravenous immunoglobulin (IVIG). Children treated with IVIG had a longer hospital stay (median 40 days vs 14 days) than those who did not receive IVIG (P = 0.01). Neither PICU mortality (29% vs 12%), nor hospital mortality (35% vs 14%), differed significantly between IVIG treated and untreated children (P = 0.76 and P = 0.16, respectively). CONCLUSION The rapid spread of hospital-acquired adenovirus underlines the importance of effective infection control measures. Despite nosocomial infection amongst high-risk patients, mortality was similar to that of community-acquired infection. Administration of immunoglobulin was not associated with demonstrable benefit. A prospective randomized trial would be required to resolve this issue.
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Hatherill M, Salie S, Waggie Z, Lawrenson J, Hewitson J, Reynolds L, Argent A. Hyperchloraemic metabolic acidosis following open cardiac surgery. Arch Dis Child 2005; 90:1288-92. [PMID: 16159902 PMCID: PMC1720224 DOI: 10.1136/adc.2005.078006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To describe acid-base derangements in children following open cardiac surgery on cardiopulmonary bypass (CPB), using the Fencl-Stewart strong ion approach. METHODS Prospective observational study set in the paediatric intensive care unit (PICU) of a university children's hospital. Arterial blood gas parameters, serum electrolytes, strong ion difference, strong ion gap (SIG), and partitioned base excess (BE) were measured and calculated on admission to PICU. RESULTS A total of 97 children, median age 57 months (range 0.03-166), median weight 14 kg (range 2.1-50), were studied. Median CPB time was 80 minutes (range 17-232). Predicted mortality was 2% and there was a single non-survivor. These children showed mild metabolic acidosis (median standard bicarbonate 20.1 mmol/l, BE -5.1 mEq/l) characterised by hyperchloraemia (median corrected Cl 113 mmol/l), and hypoalbuminaemia (median albumin 30 g/l), but no significant excess unmeasured anions or cations (median SIG 0.7 mEq/l). The major determinants of the net BE were the chloride and albumin components (chloride effect -4.8 mEq/l, albumin effect +3.4 mEq/l). Metabolic acidosis occurred in 72 children (74%) but was not associated with increased morbidity. Hyperchloraemia was a causative factor in 53 children (74%) with metabolic acidosis. Three (4%) hyperchloraemic children required adrenaline for inotropic support, compared to eight children (28%) without hyperchloraemia. Hypoalbuminaemia was associated with longer duration of inotropic support and PICU stay. CONCLUSIONS In these children with low mortality following open cardiac surgery, hypoalbuminaemia and hyperchloraemia were the predominant acid-base abnormalities. Hyperchloraemia was associated with reduced requirement for adrenaline therapy. It is suggested that hyperchloraemic metabolic acidosis is a benign phenomenon that should not prompt escalation of haemodynamic support. By contrast, hypoalbuminaemia, an alkalinising force, was associated with prolonged requirement for intensive care.
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