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Parsons Leigh J, Brundin-Mather R, Moss SJ, Nickel A, Parolini A, Walsh D, Bigham BL, Carter AJE, Fox-Robichaud A, Fiest KM. Public awareness and knowledge of sepsis: a cross-sectional survey of adults in Canada. Crit Care 2022; 26:337. [PMID: 36329489 PMCID: PMC9632573 DOI: 10.1186/s13054-022-04215-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022] Open
Abstract
Background Sepsis is a life-threatening complication of the body’s response to infection. The financial, medical, and psychological costs of sepsis to individuals and to the healthcare system are high. Most sepsis cases originate in the community, making public awareness of sepsis essential to early diagnosis and treatment. There has been no comprehensive examination of adult’s sepsis knowledge in Canada. Methods We administered an online structured survey to English- or French-literate adults in Canada. The questionnaire comprised 28 questions in three domains: awareness, knowledge, and information access. Sampling was stratified by age, sex, and geography and weighted to 2016 census data. We used descriptive statistics to summarize responses; demographic differences were tested using the Rao–Scott correction for weighted chi-squared tests and associations using multiple variable regression. Results Sixty-one percent of 3200 adults sampled had heard of sepsis. Awareness differed by respondent’s residential region, sex, education, and ethnic group (p < 0.001, all). The odds of having heard of sepsis were higher for females, older adults, respondents with some or completed college/university education, and respondents who self-identified as Black, White, or of mixed ethnicity (p < 0.01, all). Respondent’s knowledge of sepsis definitions, symptoms, risk factors, and prevention measures was generally low (53.0%, 31.5%, 16.5%, and 36.3%, respectively). Only 25% of respondents recognized vaccination as a preventive strategy. The strongest predictors of sepsis knowledge were previous exposure to sepsis, healthcare employment, female sex, and a college/university education (p < 0.001, all). Respondents most frequently reported hearing about sepsis through television (27.7%) and preferred to learn about sepsis from healthcare providers (53.1%). Conclusions Sepsis can quickly cause life-altering physical and psychological effects and 39% of adults sampled in Canada have not heard of it. Critically, a minority (32%) knew about signs, risk factors, and strategies to lower risk. Education initiatives should focus messaging on infection prevention, employ broad media strategies, and use primary healthcare providers to disseminate evidence-based information. Future work could explore whether efforts to raise public awareness of sepsis might be bolstered or hindered by current discourse around COVID-19, particularly those centered on vaccination. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04215-6.
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Affiliation(s)
- Jeanna Parsons Leigh
- Faculty of Health, School of Health Administration, Dalhousie University, Halifax, NS, Canada. .,Department of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada.
| | | | - Stephana Julia Moss
- Faculty of Health, School of Health Administration, Dalhousie University, Halifax, NS, Canada.,Department of Critical Care, CRISMA Center, University of Pittsburgh, Pittsburgh, PA, 15260, USA
| | - Angie Nickel
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Ariana Parolini
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Deirdre Walsh
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Blair L Bigham
- Division of Critical Care, Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Alix J E Carter
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada.,Emergency Health Services Nova Scotia, Halifax, NS, Canada
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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202
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Toews JR, Leonard JC, Shi J, Lloyd JK. Implementation of an Automated Sepsis Screening Tool in a Children's Hospital Emergency Department: A Cost Analysis. J Pediatr 2022; 250:38-44.e1. [PMID: 35772510 DOI: 10.1016/j.jpeds.2022.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 06/09/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters. STUDY DESIGN This retrospective cohort study used propensity score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters. RESULTS The overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657). CONCLUSIONS The median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.
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Affiliation(s)
- Jason R Toews
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH; Division of Emergency Medicine, Dayton Children's Hospital, Dayton, OH
| | - Julie C Leonard
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Junxin Shi
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Julia K Lloyd
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH.
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203
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McCahill C, Laycock HC, Guris RJD, Chigaru L. State-of-the-art management of the acutely unwell child. Anaesthesia 2022; 77:1288-1298. [PMID: 36089884 PMCID: PMC9826095 DOI: 10.1111/anae.15816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 01/11/2023]
Abstract
Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.
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Affiliation(s)
- C. McCahill
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK
| | - H. C. Laycock
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK,Department of Surgery and CancerImperial CollegeLondonUK
| | - R. J. Daly Guris
- Department of Anesthesiology and Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA,Department of Anesthesiology and Critical CareUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - L. Chigaru
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK,Children's Acute Transport ServiceLondonUK
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204
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Toltzis P. The Costs of Automated Sepsis Screening Tools. J Pediatr 2022; 250:12-13. [PMID: 35934130 DOI: 10.1016/j.jpeds.2022.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022]
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205
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Al Ghafri M, Al Badi H, Al Hadhrami S. Extubation Failure in Infants with Modified Blalock-Taussig Shunt: The Incidence, Predictors, and Outcomes. J Cardiothorac Vasc Anesth 2022; 36:4032-4036. [PMID: 35850754 DOI: 10.1053/j.jvca.2022.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/18/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Infants with congenital heart diseases often require mechanical ventilation and a prolonged intensive care unit (ICU) stay due to complex cardiopulmonary complications. The primary objective of the study was to determine the incidence and predictors of tracheal extubation failure in infants undergoing modified Blalock-Taussig shunt (MBTS). The secondary objective was to evaluate if extubation failure was associated with increased mortality and longer ICU and hospital stays. DESIGN Single-center, retrospective, cohort study. SETTING Tertiary center pediatric cardiac ICU. PARTICIPANTS Infants who underwent MBTS between January 2010 and December 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The demographic data and details related to the preoperative, intraoperative, and pretracheal extubation clinical conditions in the ICU were compared between the 2 study arms. Statistically significant predictors were analyzed using multivariate analysis. The p value was based on the Student's -t test for continuous variables and the chi-square test for categorical variables. A total of 146 infants were recruited for the study. Extubation failure occurred in 27 infants (18.5%), resulting in longer ICU and hospital stays. Extubation failure was deemed to be positively associated with preoperative mechanical ventilation duration, the need for escalation of the inotropic score, diaphragmatic paralysis, and systolic blood pressure ≤50th percentile at the time of extubation. CONCLUSIONS The incidence rate of extubation failure after placement of MBTS was 18.5%. Preoperative mechanical ventilation, diaphragmatic paralysis, the need for escalation of the inotropic score, and systolic blood pressure ≤50th percentile could be considered predictors of extubation failure in these infants.
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Affiliation(s)
- Mohammed Al Ghafri
- Department of Cardiac Intensive Care Unit,National Heart Center, Royal Hospital, Muscat, Oman.
| | - Hamid Al Badi
- Department of Pediatrics, Ibri hospital, Muscat, Oman
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206
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辛 美, 吴 敬, 王 小, 韩 蕾. [Changes in the disease spectrum in the pediatric intensive care units within 2 years before and after the outbreak of coronavirus disease 2019]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:1098-1103. [PMID: 36305109 PMCID: PMC9627991 DOI: 10.7499/j.issn.1008-8830.2205074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/02/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To investigate the changes in the disease spectrum among hospitalized children in the pediatric intensive care units (PICU) within 2 years before and after the outbreak of coronavirus disease 2019 (COVID-19). METHODS The related data on disease diagnosis were collected from all children who were hospitalized in the PICU of Affiliated Hospital of Jining Medical College from January 2018 to December 2019 (pre-COVID-19 group) and from January 2020 to December 2021 (post-COVID-19 group). A statistical analysis was performed for the disease spectrum of the two groups. RESULTS There were 2 368 children in the pre-COVID-19 group and 1 653 children in the post-COVID-19 group. The number of children in the post-COVID-19 group was reduced by 30.19% compared with that in the pre-COVID-19 group. There was a significant difference in age composition between the two groups (P<0.05). The top 10 diseases in the pre-COVID-19 group by number of cases were respiratory diseases, neurological diseases, sepsis, critical illness, circulatory system diseases, severe neurosurgical diseases, digestive system diseases, unintentional injuries, endocrine system diseases, and tumors. The top 10 diseases in the post-COVID-19 group by number of cases were respiratory diseases, neurological diseases, sepsis, circulatory system diseases, unintentional injuries, endocrine system diseases, severe neurosurgical diseases, acute abdomen, trauma surgical diseases, and digestive system diseases. The proportions of respiratory diseases, critical illness and severe neurosurgical diseases in the post-COVID-19 group were lower than those in the pre-COVID-19 group (P<0.05), while the proportions of unintentional injuries, acute abdomen, endocrine system diseases, trauma surgical diseases and sepsis were higher than those in the pre-COVID-19 group (P<0.05). CONCLUSIONS COVID-19 epidemic has led to a significant reduction in the number of children admitted to the PICU, and there are significant changes in the disease spectrum within 2 years before and after the outbreak of COVID-19. Relevant prevention and control measures taken during the COVID-19 epidemic can reduce the incidence of respiratory diseases, neurological diseases, and other critical illness in children, but it is necessary to strengthen the prevention of unintentional injuries and chronic disease management during the epidemic.
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207
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Setyaningtyas A, Soetjipto S, Endaryanto A, Pudjiadi AH. The Correlations of Human Atrial Natriuretic Peptide on Cardiac Function and Hemodynamics in Pediatric Septic Shock. Open Access Emerg Med 2022; 14:525-534. [PMID: 36185950 PMCID: PMC9525027 DOI: 10.2147/oaem.s379543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/19/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose We aimed to determine the correlations of human Atrial Natriuretic Peptide (ANP) on cardiac function and hemodynamics in pediatric septic shock. Patients and Methods We conducted an observational and prospective study on 30 children with septic shock. Measurement of the level of human atrial natriuretic peptide was determined in the serum of patients. Cardiac power (CP) is a cardiac function parameter measured with cardiac output (cardiovascular flow) and mean arterial (intravascular) pressure. Cardiac output and mean arterial pressure were monitored using pressure recording analytical methods (PRAM). Hemodynamic status was represented by a vasoactive inotropic score. Results Thirty pediatric septic shock patients fulfilled the eligibility criteria. The human ANP level was not significantly different in pediatric septic shock on three days of examination. Cardiac power was significantly different in pediatric septic shock on three days of examination. There was a correlation between human ANP and cardiac power on day 3 and human ANP and VIS on day 2. Conclusion There was a significant correlation between human ANP level and cardiac power on day 3 and ANP level and VIS on day 2. The cardiac power on day 3 and VIS on 48 hours can be alternatives to evaluate the hemodynamic status and cardiac function concerning human ANP in pediatric septic shock.
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Affiliation(s)
- Arina Setyaningtyas
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia.,Department of Child Health, Dr. Soetomo General Academic Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Soetjipto Soetjipto
- Department of Medical Biochemistry, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Anang Endaryanto
- Department of Child Health, Dr. Soetomo General Academic Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Antonius Hocky Pudjiadi
- Department of Child Health, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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208
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Feng S, Cui Y, Zhou Y, Shao L, Miao H, Dou J, Liu T, Wang C, Zhang Y. Continuous renal replacement therapy attenuates polymorphonuclear myeloid-derived suppressor cell expansion in pediatric severe sepsis. Front Immunol 2022; 13:990522. [PMID: 36263056 PMCID: PMC9575946 DOI: 10.3389/fimmu.2022.990522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Myeloid-derived suppressor cells (MDSCs) expansion is an important mechanism underlying immunosuppression during sepsis. Though continuous renal replacement therapy (CRRT) may attenuate hyperinflammatory response in sepsis, its role in regulating MDSCs is unknown. The aim of this study was to assess the potential role of CRRT involved in sepsis-induced MDSCs expansion in pediatric sepsis. Method The proportion of polymorphonuclear MDSCs (PMN-MDSCs) was detected before CRRT (pre-CRRT), at 24 hours after CRRT (CRRT 1st day) and on the 7th day after CRRT (CRRT 7th day). The correlation analyses were performed to elucidate the relationship of MDSCs with clinical indexes in sepsis. Results Totally 22 pediatric patients with sepsis were enrolled [median age 44 (IQR15, 83) months]. PMN-MDSCs were expanded in pediatric sepsis compared with healthy controls (4.30% vs. 0.37%, P=0.04). The proportion of PMN-MDSCs showed a decreased tendency on the CRRT 7th day compared with that on the CRRT 1st day in survivors (2.29% vs.5.32%, P = 0.088). There was no significant difference in the proportion of PMN-MDSCs between survivors and non-survivors before CRRT (4.51% vs. 3.33%, P=0.745). The levels of interleukin 6 (IL-6) was decreased on the CRRT 7th day compared with CRRT 1st day in survivors. In the subgroups of patients with significantly decreased IL-6 levels after CRRT, the proportion of PMN-MDSCs on the CRRT 7th day were also significantly decreased compared with that on the CRRT 1st day (2.21% vs. 6.67%, P = 0.033). Conclusion The proportion of PMN-MDSCs was down-regulated on the CRRT 7th day in survivors with sepsis. The reduced PMN-MDSCs expansion may relate to decreased IL-6 level.
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Affiliation(s)
- Shuyun Feng
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Cui
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yiping Zhou
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Lujing Shao
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huijie Miao
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Tiantian Liu
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Unit, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Yucai Zhang, ; Chunxia Wang,
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yucai Zhang, ; Chunxia Wang,
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209
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Scott HF, Kempe A, Bajaj L, Lindberg DM, Dafoe A, Dorsey Holliman B. "These Are Our Kids": Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care. Ann Emerg Med 2022; 80:347-357. [PMID: 35840434 PMCID: PMC9529081 DOI: 10.1016/j.annemergmed.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. METHODS In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. RESULTS Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. CONCLUSION Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO.
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO
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Nickel AJ, Hunter RB, Jiang S, Boulet JR, Hanks J, Napolitano N, Nadkarni VM, Nishisaki A. Comparison of Bedside and Video-Based Capillary Refill Time Assessment in Children. Pediatr Emerg Care 2022; 38:506-510. [PMID: 36083194 DOI: 10.1097/pec.0000000000002836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Capillary refill time (CRT) to assess peripheral perfusion in children with suspected shock may be subject to poor reproducibility. Our objectives were to compare video-based and bedside CRT assessment using a standardized protocol and evaluate interrater and intrarater consistency of video-based CRT (VB-CRT) assessment. We hypothesized that measurement errors associated with raters would be low for both standardized bedside CRT and VB-CRT as well as VB-CRT across raters. METHODS Ninety-nine children (aged 1-12 y) had 5 consecutive bedside CRT assessments by an experienced critical care clinician following a standardized protocol. Each CRT assessment was video recorded on a black background. Thirty video clips (10 with bedside CRT < 1 s, 10 with CRT 1-2 s, and 10 with CRT > 2 s) were randomly selected and presented to 10 clinicians twice in randomized order. They were instructed to push a button when they visualized release of compression and completion of a capillary refill. The correlation and absolute difference between bedside and VB-CRT were assessed. Consistency across raters and within each rater was analyzed using the intraclass correlation coefficient (ICC). A Generalizability study was performed to evaluate sources of variation. RESULTS We found moderate agreement between bedside and VB-CRT observations (r = 0.65; P < 0.001). The VB-CRT values were shorter by 0.17 s (95% confidence interval, 0.09-0.25; P < 0.001) on average compared with bedside CRT. There was moderate agreement in VB-CRT across raters (ICC = 0.61). Consistency of repeated VB-CRT within each rater was moderate (ICC = 0.71). Generalizability study revealed the source of largest variance was from individual patient video clips (57%), followed by interaction of the VB-CRT reviewer and patient video clip (10.7%). CONCLUSIONS Bedside and VB-CRT observations showed moderate consistency. Using video-based assessment, moderate consistency was also observed across raters and within each rater. Further investigation to standardize and automate CRT measurement is warranted.
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Affiliation(s)
| | - Ryan Brandon Hunter
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shen Jiang
- Nihon Kohden Innovation Center, Boston, MA
| | - John R Boulet
- National Board of Osteopathic Medical Examiners, Conshohocken
| | - Jasmine Hanks
- Clinical Research Support Office, Children's Hospital of Philadelphia
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211
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Moreira A, Jain P. Genomics and Pediatric Sepsis. Pediatr Ann 2022; 51:e387-e389. [PMID: 36215090 DOI: 10.3928/19382359-20220803-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2023]
Abstract
Sepsis is a clinical syndrome manifested by a dysregulation of the immune system triggered by an infection. The severity of illness is variable, which can include mild symptoms with no organ dysfunction to severe symptoms and multiorgan failure, eventually leading to death. Advances in bioinformatics have elucidated distinct sepsis endotypes and have allowed for a better understanding of the pathophysiologic mechanisms. As we learn more about these sepsis endotypes, more precise therapies will emerge for use as adjuncts to antibiotics. [Pediatr Ann. 2022;51(10):e387-e389.].
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Argent AC, Ranjit S, Peters MJ, Andre-von Arnim AVS, Chisti MJ, Jabornisky R, Musa NL, Kissoon N. Factors to be Considered in Advancing Pediatric Critical Care Across the World. Crit Care Clin 2022; 38:707-720. [PMID: 36162906 DOI: 10.1016/j.ccc.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This article reviews the many factors that have to be taken into account as we consider the advancement of pediatric critical care (PCC) in multiple settings across the world. The extent of PCC and the range of patients who are cared for in this environment are considered. Along with a review of the ongoing treatment and technology advances in the PCC setting, the structures and systems required to support these services are also considered. Finally the question of how PCC can be made sustainable in a volatile world with the impacts of global crises such as climate change is addressed.
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Affiliation(s)
- Andrew C Argent
- Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Suchitra Ranjit
- Pediatric ICU, Apollo Children's Hospital, 15, Shafee Mhd Road, Chennai 600006, India
| | - Mark J Peters
- University College London Great Ormond Street Institute of Child Health, London, WC1N 3JH, UK; Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, WC1N 1EH, UK
| | - Amelie von Saint Andre-von Arnim
- Department of Pediatrics, Division of Pediatric Critical Care, University of Washington, Seattle Children's, 4800 Sand Point Way NorthEast, Seattle, WA 98105, USA; Department of Global Health, University of Washington, Seattle Children's, 4800 Sand Point Way NorthEast, Seattle, WA 98105, USA
| | - Md Jobayer Chisti
- ARI Ward, Dhaka Hospital, Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Roberto Jabornisky
- Universidad Nacional Del Nordeste, Argentina. Pediatric Intensive Care Unit (Hospital Juan Pablo II and Hospital Olga Stuky) Argentina, Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, LARed Network, Universidad Nacional Del Nordeste, 1420 Mariano Moreno, Corrientes 3400, Argentina
| | - Ndidiamaka L Musa
- Paediatric Critical Care, University of Washington, 4800 Sand Point Way NorthEast, Seattle, WA 98105, USA
| | - Niranjan Kissoon
- British Columbia Children's Hospital and The University of British Columbia, Vancouver, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
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213
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Iramain R, Ortiz J, Jara A, Bogado N, Morinigo R, Cardozo L, Kissoon N. Fluid Resuscitation and Inotropic Support in Patients With Septic Shock Treated in Pediatric Emergency Department: An Open-Label Trial. Cureus 2022; 14:e30029. [PMID: 36225249 PMCID: PMC9541896 DOI: 10.7759/cureus.30029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Fluid resuscitation and inotropic support are essential interventions to improve cardiovascular function in patients with septic shock. However, the optimal volume of fluids and the timing of inotropic support to achieve the resolution of shock are controversial. They may depend on the availability of critical care support services. Aims To compare early versus the delayed start of epinephrine administration after fluids bolus in children with septic shock. Methods We conducted an open-label randomized trial in which patients under 18 years of age diagnosed with septic shock and arterial hypotension were treated in two Pediatric Emergency Departments in Paraguay (Hospital de Clinicas of Universidad Nacional de Asunción and Instituto Privado del Niño) between 2015 and 2020. Septic shock was defined according to the American College of Critical Care Medicine (ACCM) guidelines. All patients received antibiotics and 40 ml/kg of fluids (two boluses of 20ml/kg if there were no signs of fluid overload) during the first hour. They were then divided into two groups: Group 1 received epinephrine infusion and maintenance fluids. Group 2 received an additional 20 ml/kg of fluids and then was started on epinephrine infusion. Results Of 229 patients screened, 63 patients were included in the study. The mean age was 2.8±3.5 years. A total of 52% were female. Group 1 comprised 33 patients, and group 2 comprised a total of 30. Significant differences were found between group 1 and group 2 in the following: mortality (10% vs. 33%, p: 0.026, RR: 3.1, CI: 95%: 1-10), need for mechanical ventilation (10% vs. 41%, p: 0.006, RR: 4, CI: 95%: 1.3-12), and altered vascular hypoperfusion after one hour of interventions (7% vs. 59%, p<0,001, RR: 8.2, CI: 95%: 2-32). Conclusions Early administration of epinephrine infusion after initial fluid therapy was associated with better clinical outcomes than delayed administration.
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Affiliation(s)
| | - Jorge Ortiz
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Alfredo Jara
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Norma Bogado
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Rocío Morinigo
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Laura Cardozo
- Emergency Department, Hospital de Clínicas, Asunción, PRY
| | - Niranjan Kissoon
- Pediatrics and Emergency Medicine Department, University of British Columbia, Vancouver, CAN
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214
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Fung JST, Hwang B, Dunsmuir D, Suiyven E, Nwankwor O, Tagoola A, Trawin J, Ansermino JM, Kissoon N. A 2-Phase Survey to Assess a Facility's Readiness for Pediatric Essential Emergency and Critical Care in Resource-Limited Settings: A Literature Review and Survey Development. Pediatr Emerg Care 2022; 38:532-539. [PMID: 35981329 DOI: 10.1097/pec.0000000000002826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Infectious diseases, including pneumonia, malaria, and diarrheal diseases, are the leading causes of death in children younger than 5 years worldwide. The vast majority of these deaths occur in resource-limited settings where there is significant variation in the availability and type of human, physical, and infrastructural resources. The ability to identity gaps in healthcare systems that may hinder their ability to deliver care is an important step to determining specific interventions for quality improvement. Our study objective was to develop a comprehensive, digital, open-access health facility survey to assess facility readiness to provide pediatric critical care in resource-limited settings (eg, low- and lower middle-income countries). METHODS A literature review of existing facility assessment tools and global guidelines was conducted to generate a database of survey questions. These were then mapped to one of the following 8 domains: hospital statistics, services offered, operational flow, facility infrastructure, staff and training, medicines and equipment, diagnostic capacity, and quality of clinical care. A 2-phase survey was developed and an iterative review process of the survey was undertaken with 12 experts based in low- and middle-income countries. This was built into the REDCap Mobile Application for electronic data capture. RESULTS The literature review process yielded 7 facility assessment tools and 7 global guidelines for inclusion. After the iterative review process, the final survey consisted of 11 sections with 457 unique questions in the first phase, "environmental scan," focusing on the infrastructure, availability, and functionality of resources, and 3 sections with 131 unique questions in the second phase, "observation scan," focusing on the level of clinical competency. CONCLUSIONS A comprehensive 2-phase survey was created to evaluate facility readiness for pediatric critical care. Results will assist hospital administrators and policymakers to determine priority areas for quality improvement, enabling them to implement a Plan-Do-Study-Act cycle to improve care for the critically ill child.
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Affiliation(s)
| | - Bella Hwang
- From the Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Elvis Suiyven
- Cameroon Association of Critical Care Nurses, Bamenda, Cameroon
| | | | | | - Jessica Trawin
- From the Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
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215
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Goussard P. Do all children in South Africa have access to dedicated paediatric intensive care? Afr J Thorac Crit Care Med 2022; 28:10.7196/AJTCCM.2022.v28i3.272. [PMID: 36285009 PMCID: PMC9551703 DOI: 10.7196/ajtccm.2022.v28i3.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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216
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Thadani S, Fogarty T, Mottes T, Price JF, Srivaths P, Bell C, Akcan-Arikan A. Hemodynamic instability during connection to continuous kidney replacement therapy in critically ill pediatric patients. Pediatr Nephrol 2022; 37:2167-2177. [PMID: 35118547 DOI: 10.1007/s00467-022-05424-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/23/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emerging data suggest evidence of organ hypoperfusion during continuous kidney replacement therapy (CKRT). To facilitate kidney and global recovery, we must understand the hemodynamic risks associated with CKRT. We aimed to investigate frequency of hemodynamic instability and association with patient outcomes in pediatric CKRT. METHODS In a single-center study of CKRT patients between September 2016 and October 2018, we collected hemodynamic data using archived high-resolution physiologic data before and after connection. Primary outcome was hypotension defined as ≥ 20% decrease in baseline mean arterial pressure (MAP) for ≥ 2 consecutive minutes in the 60 min following connection. Secondary outcomes were tachycardia (≥ 20% increase in heart rate (HR)) and hemodynamic interventions. RESULTS Seventy-one patients median age 54 months (IQR 7-144), weight 16.7 kg (IQR 8-41), on hemodiafiltration had 304 filter connections, 4 (IQR 1-7) filters per patient; the median duration of CKRT was 9 days (IQR 3-20). The most common CKRT indication was AKI with fluid overload (48/71, 69%). There were 78 (27%) hypotension and 42 (14%) tachycardia events; cumulative duration of hypotension was 14 min IQR (3-31.75). Teams provided intervention in 17/304 (6%) of connections. Pediatric Logistic Organ Dysfunction 2 was the only independent predictor of hypotension (aOR 2.12 (CI 1.02-4.41)). CONCLUSIONS One in four and one in six pediatric CKRT filter connections were complicated by hypotension and tachycardia, respectively. Higher illness severity at CKRT initiation was independently associated with hypotension. Impact of CKRT-associated hemodynamic instability on global patient outcomes requires further targeted study. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sameer Thadani
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Thomas Fogarty
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Theresa Mottes
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jack F Price
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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217
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Fustiñana A, Yock-Corrales A, Casson N, Galvis L, Iramain R, Lago P, Da Silva APP, Paredes F, Zamarbide MP, Aprea V, Kohn-Loncarica G. Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America. Pediatr Emerg Care 2022; 38:e1496-e1502. [PMID: 35802481 DOI: 10.1097/pec.0000000000002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.
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218
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de Souza TB, Rubio AJ, Carioca FDL, Ferraz IDS, Brandão MB, Nogueira RJN, de Souza TH. Carotid doppler ultrasonography as a method to predict fluid responsiveness in mechanically ventilated children. Paediatr Anaesth 2022; 32:1038-1046. [PMID: 35748620 DOI: 10.1111/pan.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/31/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
AIMS The aim of this study was to investigate whether respiratory variations in carotid and aortic blood flows measured by Doppler ultrasonography could accurately predict fluid responsiveness in critically ill children. METHODS This was a prospective single-center study including mechanically ventilated children who underwent fluid replacement at the discretion of the attending physician. Response to fluid load was defined by a stroke volume increase of more than 15%. Maximum and minimum values of velocity peaks were determined over one controlled respiratory cycle before and after volume expansion. Respiratory changes in velocity peak of the carotid (∆Vpeak_Ca) and aortic (∆Vpeak_Ao) blood flows were calculated as the difference between the maximum and minimum values divided by the mean of the two values and were expressed as a percentage. RESULTS A total of 30 patients were included, of which twelve (40%) were fluid responders and 18 (60%) non-responders. Before volume expansion, both ∆Vpeak_Ca and ∆Vpeak_Ao were higher in responders than in non-responders (17.1% vs 4.4%; p < .001 and 22.8% vs 6.4%; p < .001, respectively). ∆Vpeak_Ca could effectively predict fluid responsiveness (AUC 1.00, 95% CI 0.88-1.00), as well as ∆Vpeak_Ao (AUC 0.94, 95% CI 0.80-0.99). The best cutoff values were 10.6% for ∆Vpeak_Ca (sensitivity, specificity, positive predictive value and negative predictive value of 100%) and 18.2% for ∆Vpeak_Ao (sensitivity, 91.7%; specificity, 88.9%; positive predictive value, 84.6%; negative predictive value, 94.1%). Volume expansion-induced changes in stroke volume correlated with the ∆Vpeak_Ca and ∆Vpeak_Ao before volume expansion (ρ of 0.70 and 0.61, respectively; p < .001 for both). CONCLUSIONS Analysis of respiratory changes in carotid and aortic blood flows are accurate methods for predicting fluid responsiveness in children under invasive mechanical ventilation.
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Affiliation(s)
- Thalita Belato de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Aline Junqueira Rubio
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fernando de Lima Carioca
- Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Isabel de Siqueira Ferraz
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Marcelo Barciela Brandão
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Roberto José Negrão Nogueira
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Tiago Henrique de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
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219
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Khanthathasiri S, Kriengsoontornkij W, Monsomboon A, Phongsamart W, Lapphra K, Wittawatmongkol O, Rungmaitree S, Chokephaibulkit K. Outcomes of Single-Dose Empirical Antibiotic Treatment in Children With Suspected Sepsis Implemented in the Emergency Department. Pediatr Emerg Care 2022; 38:426-430. [PMID: 35766872 PMCID: PMC9426726 DOI: 10.1097/pec.0000000000002775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Implementing a single-dose empirical antibiotic (SDEA) strategy at the emergency department (ED) in children with suspected sepsis may improve outcomes. We aim to evaluate the outcomes of the SDEA strategy for children with suspected sepsis at the ED in a tertiary care center in Bangkok. METHODS Children who met the predefined checklist screening criteria for suspected sepsis were administered single-dose intravenous cefotaxime 100 mg/kg, or meropenem 40 mg/kg if they were immunocompromised or recently hospitalized. The medical records of children diagnosed with sepsis and septic shock caused by bacterial or organ-associated bacterial infections before and after implementation of the SDEA strategy were reviewed. RESULTS A total of 126 children with sepsis before and 127 after implementation of the SDEA strategy were included in the analysis. The time from hospital arrival to antibiotic initiation was significantly reduced after implementation of the SDEA strategy: median, 241 (110-363) minutes before versus 89 (62-132) minutes after ( P < 0.001), with an increased number of patients starting antibiotics within 3 hours of hospital arrival: 42.1% vs 85.0% ( P < 0.001). Comparing before and after SDEA implementation, children receiving SDEA had a shorter median duration of antibiotic therapy: 7 (5-13.3) versus 5 (3-7) days ( P = 0.001), shorter length of hospital stay: 10 (6-16.3) versus 7 (4-11) days ( P = 0.001), and fewer intensive care unit admissions: 30 (23.8%) versus 17 (13.4%; P = 0.036); however, mortality was not different: 3 (2.4%) in both groups. In multivariate analysis, SDEA strategy was the independent factor associated with reduced intensive care unit admission or death. Adherence to SDEA was 91.4%. Single-dose empirical antibiotic was retrospectively considered not necessary for 22 children (11.9%), mostly diagnosed with viral infections afterward. CONCLUSIONS Single-dose empirical antibiotic at the ED is an effective strategy to reduce the time from hospital arrival to antibiotic initiation and can help improve outcomes of sepsis in children.
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Affiliation(s)
| | | | | | | | | | | | | | - Kulkanya Chokephaibulkit
- From the Departments of Pediatrics
- Siririaj Institute of Clinical Research, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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220
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Menon K. Associations Between Early Corticosteroids, Pediatric Septic Shock, and Outcomes: Not a Simple Analysis. Pediatr Crit Care Med 2022; 23:749-751. [PMID: 36053035 DOI: 10.1097/pcc.0000000000003036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Pediatrics, Ottawa, ON, Canada
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221
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Parker RI. Monocyte Distribution Width: Another (Better?) Marker to Predict Sepsis? Pediatr Crit Care Med 2022; 23:752-754. [PMID: 36053036 DOI: 10.1097/pcc.0000000000003039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert I Parker
- Pediatric Hematology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
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222
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Kazi MA, Roychowdhury S, Ghosh S, Mahapatra MK, Bhakta S, Konar MC, Sarkar M. Characteristics and predictors of outcomes of critically Ill children with SARS-CoV-2 infection - the PICU experience. J Pediatr (Rio J) 2022; 98:504-512. [PMID: 35139344 PMCID: PMC8801309 DOI: 10.1016/j.jped.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/23/2021] [Accepted: 12/14/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To describe the clinical characteristics, laboratory parameters, treatment, and predictors of an unfavorable outcome of critically ill children with SARS-CoV-2 infection. METHOD This was a prospective observational study performed in a pediatric intensive care unit (PICU) of a tertiary care COVID referral hospital among critically ill children in the age group 1 month - 12 years admitted due to SARS-CoV-2 infection from June to December 2020. Demographic, clinical profile, pSOFA and PRISM III scores, laboratory parameters, treatment, and outcomes of the patients were recorded. Children who had a prolonged PICU stay (>14 days) or died were compared with those who were discharged from PICU within 14 days to assess predictors of unfavorable outcomes. RESULTS PICU admission rate among hospitalized SARS-CoV-2 infected children was 22.1% (92/416). Infants comprised the majority of the ICU population. Invasive mechanical ventilation and inotropic support were required for 28.3% and 37% of patients, respectively. Remdesivir, IVIg, and steroids were administered to 15.2%, 26.1%, and 54.3% of the subjects, respectively. The mortality rate was 7.6 %. MIS-C patients were older, less comorbid, and required less ventilator support but more inotrope support than acute severe COVID-19 patients. Predictors of unfavorable outcomes were age < 1 year, fever duration > 5 days, respiratory distress, shock, comorbidity, elevated CRP (> 50 mg/L), procalcitonin (> 6 ng/L), D-dimer (> 6 µg/L) and arterial lactate (> 2 mmol/L). CONCLUSION Critically ill children with unfavorable outcomes were predominantly infants, comorbid, prolonged fever, respiratory distress, shock and elevated inflammatory markers, D-dimer and lactate. These factors may be useful for watchful monitoring and early intervention.
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Affiliation(s)
- Maha Ashraf Kazi
- Department of Pediatrics, Medical College and Hospital, Kolkata, India
| | | | - Sanajit Ghosh
- Department of Pediatrics, Medical College and Hospital, Kolkata, India
| | | | - Subhajit Bhakta
- PICU Unit, Department of Pediatrics, Medical College and Hospital, Kolkata, India
| | - Mithun Chandra Konar
- PICU Unit, Department of Pediatrics, Medical College and Hospital, Kolkata, India
| | - Mihir Sarkar
- PICU Unit, Department of Pediatrics, Medical College and Hospital, Kolkata, India.
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Gardner Yelton SE, Ramos LC, Reuland CJ, Evangelista PPG, Shilkofski NA. Implementation and evaluation of a shock curriculum using simulation in Manila, Philippines: a prospective cohort study. BMC MEDICAL EDUCATION 2022; 22:606. [PMID: 35932072 PMCID: PMC9354294 DOI: 10.1186/s12909-022-03669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Shock causes significant morbidity and mortality in children living in resource-limited settings. Simulation has been successfully used as an educational tool for medical professionals internationally. We sought to improve comfort and knowledge regarding shock recognition and fluid management by implementing a pediatric shock curriculum using simulation as an assessment for trainees in Manila, Philippines. METHODS We assessed a shock curriculum focused on patients with malnutrition in a prospective cohort study, using a written test and a videotaped simulation-based objective standardized clinical examination. Implementation occurred in March 2020 with 24 Filipino pediatric residents at a single institution in Manila. Outcomes included time to initiation of fluid resuscitation, improvement in confidence, knowledge on a written assessment, and performance in simulation. Results were compared pre- and post-intervention using Wilcoxon signed-rank test. RESULTS The time to initiation of fluids did not change between the baseline simulation (median [interquartile range] = 71.5 seconds [52-116.5]) and the final simulation (68 seconds [52.5-89]; P = 0.42). Confidence in identifying shock and malnutrition, managing hypovolemic shock, managing septic shock, and placing intraosseous access all increased (P < 0.01) post-intervention. Written test scores showed no improvement, but performance in simulation, measured using a checklist, improved from a total score of 10 [8.5-11] to 15 [13-16] (P < 0.01). CONCLUSION In our study of a simulation-based shock education program, we showed improvement in confidence and knowledge as measured by a resuscitation checklist. It is feasible to establish a successful simulation-based education program in a low-resource setting.
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Affiliation(s)
- Sarah E Gardner Yelton
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1, Baltimore, MD, 21287, USA.
| | - Lorelie Cañete Ramos
- Department of Pediatric Critical Care, Philippine Children's Medical Center, Quezon City, Philippines
| | | | - Paula Pilar G Evangelista
- Department of Pediatric Critical Care, Philippine Children's Medical Center, Quezon City, Philippines
| | - Nicole A Shilkofski
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1, Baltimore, MD, 21287, USA
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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224
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Peripheral and Central/Intraosseous Vasoactive Infusions During and After Pediatric Critical Care Transport: Retrospective Cohort Study of Extravasation Injury. Pediatr Crit Care Med 2022; 23:626-634. [PMID: 35481954 DOI: 10.1097/pcc.0000000000002972] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the prevalence of adverse events related to vasoactive drug infusions administered via a peripheral venous catheter versus a central venous or intraosseous catheter. DESIGN Retrospective observational study. SETTING A pediatric critical care transport team, and the PICUs and regional hospitals within the North Thames and East Anglia regions of the United Kingdom. PATIENTS Children (up to 18 yr old) transported by the Children's Acute Transport Service receiving an infusion of a vasoactive drug (epinephrine, dobutamine, dopamine, norepinephrine, and vasopressin). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The medical records of all children transported between April 2017 and May 2020 receiving a vasoactive drug infusion were reviewed and cross-referenced with the service critical incident database. The outcome measure was anatomic catheter-related adverse events (including extravasation) reported during transport or in the first 24 hours on the PICU. During the study period, the service undertook 3,836 transports. Vasoactive drugs were administered during 558 patient transports (14.5%). During 198 of 558 transports (35.5%), vasoactive drugs were administered via a peripheral venous catheter, with seven of 198 (3.5%) adverse events. One extravasation event resulted in tissue necrosis. The median time to injury after the infusion was commenced was 60 minutes (interquartile range, 30-60 min). During 360 of 558 transports (64.5%), vasoactive infusions were administered by central venous or intraosseous catheter, with nine of 360 (2.5%) adverse events. CONCLUSIONS During pediatric critical care transport, we did not find a difference in prevalence of adverse events following the administration of vasoactive drugs via peripheral venous catheters or via central venous and intraosseous catheters.
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225
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Alexander EC, Deep A. Therapeutic plasma exchange in children with acute liver failure (ALF): is it time for incorporation into the ALF armamentarium? Pediatr Nephrol 2022; 37:1775-1788. [PMID: 34647173 PMCID: PMC9239959 DOI: 10.1007/s00467-021-05289-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
Paediatric acute liver failure (PALF) is a rare but devastating condition with high mortality. An exaggerated inflammatory response is now recognised as pivotal in the pathogenesis and prognosis of ALF, with cytokine spill from the liver to systemic circulation implicated in development of multi-organ failure associated with ALF. With advances in medical management, especially critical care, there is an increasing trend towards spontaneous liver regeneration, averting the need for emergency liver transplantation or providing stability to the patient awaiting a graft. Hence, research is ongoing for therapies, including extracorporeal liver support devices, that can bridge patients to transplant or spontaneous liver recovery. Considering the immune-related pathogenesis and inflammatory phenotype of ALF, plasma exchange serves as an ideal liver assist device as it performs both the excretory and synthetic functions of the liver and, in addition, works as an immunomodulatory therapy by suppressing the early innate immune response in ALF. After a recent randomised controlled trial in adults demonstrated a beneficial effect of high-volume plasma exchange on clinical outcomes, this therapy was incorporated in European Association for the Study of Liver (EASL) recommendations for managing adult patients with ALF, but no guidelines exist for PALF. In this review, we discuss rationale, timing, practicalities, and existing evidence regarding the use of plasma exchange as an immunomodulatory treatment in PALF. We discuss controversies in delivery of this therapy as an extracorporeal device, and practicalities of use of plasma exchange as a 'hybrid' therapy alongside other extracorporeal liver assist devices, before finally reviewing outstanding research questions for the future.
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Affiliation(s)
- Emma C Alexander
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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Levy RA, Reiter PD, Spear M, Santana A, Silveira L, Cox S, Mourani PM, Maddux AB. Peripheral Vasoactive Administration in Critically Ill Children With Shock: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2022; 23:618-625. [PMID: 35446810 PMCID: PMC9529765 DOI: 10.1097/pcc.0000000000002970] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Management of fluid refractory pediatric shock requires prompt administration of vasoactive agents. Although delivery of vasoactive therapy is generally provided via a central venous catheter, their placement can delay drug administration and is associated with complications. We characterize peripheral vasoactive administration in a cohort of critically ill children with shock, evaluate progression to central venous catheter placement, and describe complications associated with extravasation. DESIGN Retrospective cohort study. SETTING Single-center, quaternary PICU (January 2010 to December 2015). PATIENTS Children (31 d to 18 yr) who received epinephrine, norepinephrine, or dopamine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared patients based on the initial site of vasoactive infusion: peripheral venous access (PVA) or central venous access (CVA) and, within the PVA group, compared patients based on subsequent placement of a central catheter for vasoactive infusion. We also characterized peripheral extravasations. We evaluated 756 patients: 231 (30.6%) PVA and 525 (69.4%) CVA patients. PVA patients were older, had lower illness severity, and more frequently had vasoactive therapy initiated at night compared with CVA patients. In PVA patients, 124 (53.7%) had a central catheter placed after a median of 140 minutes (interquartile range, 65-247 min) of peripheral treatment. Patients who avoided central catheter placement had lower illness severity. Of the 93 patients with septic shock, 44 (47.3%) did not have a central catheter placed. Extravasations occurred in four of 231 (1.7% [95% CI, 0.03-3.4]) PVA patients, exclusively in the hand. Three patients received pharmacologic intervention, and none had long-term disabilities. CONCLUSIONS In our experience, peripheral venous catheters can be used for vasoactive administration. In our series, the upper limit of the 95% CI for extravasation is approximately 1-in-30, meaning that this route may be an appropriate option while evaluating the need for central access, particularly in patients with low illness severity.
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Affiliation(s)
- Robert A. Levy
- Department of Pediatrics, Section of Critical Care Medicine, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA
| | - Pamela D. Reiter
- Department of Pharmacy, Children’s Hospital Colorado and Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medial Campus, Aurora, CO
| | - Matthew Spear
- Department of Pediatrics, Dell Children’s Medical Center of Central Texas, Austin, TX
| | - Alison Santana
- Department of Pediatric Critical Care, Rocky Mountain Hospital for Children, Denver, CO
| | - Lori Silveira
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Shaina Cox
- PediPlace Pediatric Primary Care Clinic, Dallas, TX
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, AR
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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227
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Robertson A, Burger K, Hagan L, McAllister M. Improving time to administration of time-critical medications in the pediatric emergency department. Am J Emerg Med 2022; 62:116-117. [DOI: 10.1016/j.ajem.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 10/15/2022] Open
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Role of fluid status markers as risk factors for suboptimal vancomycin concentration during continuous infusion in neonates: an observational study. Eur J Pediatr 2022; 181:2935-2942. [PMID: 35581390 DOI: 10.1007/s00431-022-04500-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Vancomycin is widely used in neonatal sepsis but proportion of newborn reaching recommended concentration is variable. Fluid status impact on vancomycin level remains understudied. We aimed to study fluid factors impacting vancomycin concentration at 24 h of treatment. We performed a prospective and retrospective observational monocentric study of NICU patients requiring a vancomycin treatment. We used a continuous infusion protocol, with age-appropriate loading and maintenance doses. Vancomycin target serum concentration after 24 h (C24h) was above 20 mg/L. Demographic, infections, and organ failure variables were analyzed as potential predictors of C24h. Over the study period, 70 infective episodes in 52 patients were included. At treatment initiation, the median post-natal age was 12.5 days (IQR 7-23), post menstrual age 30 weeks (IQR 28-35), and median weight 1140 g (IQR 835-1722). Germs isolated were mainly gram-positive with 73.5% being coagulase-negative Staphylococci. Median C24h was 18.7 mg/L (IQR 15.4-22.4). Overall, 41 (58.6%) treatments had a C24h < 20 mg/L. After multivariate analysis, higher creatinine level (OR 1.03 (95% CI 1.002-1.06)) was associated with C24h ≥ 20 mg/L; weight gain the day before infection (OR 0.21 (95% CI 0.05-0.79)) and positive biomarkers of inflammation (OR 0.22 (0.05-0.94)) were associated with C24h < 20 mg/L. CONCLUSION Vancomycin C24h was underdosed in 60% of patients and factors linked to changes in vancomycin pharmacokinetic such as volume of distribution and clearance, linked to creatinine level, inflammation, or weight gain, were identified. WHAT IS KNOWN • Adjustment of vancomycin regimen remains difficult due to inter- and intra-individual variability of vancomycin pharmacokinetics. • Impact of fluid status on vancomycin concentration in critically ill neonates is incompletely studied. WHAT IS NEW • Proportion of patients with adequate vancomycin concentration using a target adapted to nosocomial gram-positive bacteria MIC is low. • We confirmed the role of creatinine level and report two new factors associated with low vancomycin concentration: presence of systemic inflammation and weight gain.
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229
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Witting CS, Simon NJE, Lorenz D, Murphy JS, Nelson J, Lehnig K, Alpern ER. Sepsis Electronic Decision Support Screen in High-Risk Patients Across Age Groups in a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1479-e1484. [PMID: 35383693 DOI: 10.1097/pec.0000000000002709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to compare the performance of a pediatric decision support algorithm to detect severe sepsis between high-risk pediatric and adult patients in a pediatric emergency department (PED). METHODS This is a retrospective cohort study of patients presenting from March 2017 to February 2018 to a tertiary care PED. Patients were identified as high risk for sepsis based on a priori defined criteria and were considered adult if 18 years or older. The 2-step decision support algorithm consists of (1) an electronic health record best-practice alert (BPA) with age-adjusted vital sign ranges, and (2) physician screen. The difference in test characteristics of the intervention for the detection of severe sepsis between pediatric and adult patients was assessed at 0.05 statistical significance. RESULTS The 2358 enrolled subjects included 2125 children (90.1%) and 233 adults (9.9%). The median ages for children and adults were 3.8 (interquartile range, 1.2-8.6) and 20.1 (interquartile range, 18.2-22.0) years, respectively. In adults, compared with children, the BPA alone had significantly higher sensitivity (0.83 [95% confidence interval {CI}, 0.74-0.89] vs 0.72 [95% CI, 0.69-0.75]; P = 0.02) and lower specificity (0.11 [95% CI, 0.07-0.19] vs 0.48 [95% CI, 0.45-0.51; P < 0.001). With the addition of provider screen, sensitivity and specificity were comparable across age groups, with a lower negative predictive value in adults compared with children (0.66 [95% CI, 0.58-0.74] vs 0.77 [95% CI, 0.75-0.79]; P = 0.005). CONCLUSIONS The BPA was less specific in adults compared with children. With the addition of provider screen, specificity improved; however, the lower negative predictive value suggests that providers may be less likely to suspect sepsis even after automated screen in adult patients. This study invites further research aimed at improving screening algorithms, particularly across the diverse age spectrum presenting to a PED.
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Affiliation(s)
| | - Norma-Jean E Simon
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Doug Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Julia S Murphy
- From the Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jill Nelson
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Katherine Lehnig
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
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230
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Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Selwyn College, Cambridge University, Cambridge, United Kingdom
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231
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232
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Paulsen JA, Wang KM, Masler IM, Hicks JF, Green SN, Loberger JM. Beyond Vital Signs: Pediatric Sepsis Screening that Includes Organ Failure Assessment Detects Patients with Worse Outcomes. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1753536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
AbstractPediatric sepsis screening is recommended. The 2005 Goldstein criteria, the basis of our institutional sepsis screening tool (ISST), correlate poorly with clinically diagnosed sepsis. The study objective was to retrospectively evaluate the ISST sensitivity compared with the Pediatric Sequential Organ Failure Assessment (pSOFA). This was a single-center retrospective cohort study. The primary outcome was pSOFA score and ISST sensitivity for severe sepsis. Secondary outcomes included clinical outcome measures. In this severe sepsis cohort (N = 491), pSOFA and ISST sensitivity were 57.6 and 61.1%, respectively. In regression analysis for a positive pSOFA, positive blood culture (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1–4.3, p = 0.025), older age (OR 1.006, 95% CI 1.003–1.009, p < 0.001), and pulmonary infectious source (OR 3.3, 95% CI 1.6–6.5, p = 0.001) demonstrated independent association. In regression analysis for a positive ISST, older age (OR 1.003, 95% CI 1–1.006, p = 0.031) and intra-abdominal infectious source (OR 0.3, 95% CI 0.1–0.8, p = 0.014) demonstrated independent association. A negative ISST was associated with higher intensive care unit (ICU) admission prevalence (p = 0.01) and fewer ICU-free days (p = 0.018). A positive pSOFA score was associated with higher ICU admission prevalence, vasopressor requirement, and vasopressor days as well as fewer ICU, hospital, and mechanical ventilation-free days (all p < 0.001). Exploratory analysis combining the ISST and pSOFA into a hybrid screen demonstrated superior sensitivity (84.3%) and outcome discrimination. The pSOFA demonstrated noninferior sensitivity to a Goldstein-based institutional sepsis screening model. Further, pSOFA was a better discriminator of poor clinical outcomes. An exploratory hybrid screening model shows superior performance but will require prospective study.
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Affiliation(s)
- Jesseca A. Paulsen
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Karen M. Wang
- Department of Pediatrics, Pediatric Residency Program, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Isabella M. Masler
- Department of Pediatrics, Pediatric Residency Program, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Jessica F. Hicks
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, Alabama, United States
| | - Sherry N. Green
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, Alabama, United States
| | - Jeremy M. Loberger
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
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233
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Jacquet-Lagrèze M, Wiart C, Schweizer R, Didier L, Ruste M, Coutrot M, Legrand M, Baudin F, Javouhey E, Dépret F, Fellahi JL. Capillary refill time for the management of acute circulatory failure: a survey among pediatric and adult intensivists. BMC Emerg Med 2022; 22:131. [PMID: 35850662 PMCID: PMC9290243 DOI: 10.1186/s12873-022-00681-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Recent studies have shown the prognostic value of capillary refill time (CRT) and suggested that resuscitation management guided by CRT may reduce morbidity and mortality in patients with septic shock. However, little is known about the current use of CRT in routine clinical practice. This study aimed to assess the modalities of CRT use among French adult and pediatric intensivists. METHODS A cross-sectional survey exploring CRT practices in acute circulatory failure was performed. The targeted population was French adult and pediatric intensivists (SFAR and GFRUP networks). An individual invitation letter including a survey of 32 questions was emailed twice. Descriptive and analytical statistics were performed. RESULTS Among the 6071 physicians who received the letter, 418 (7%) completed the survey. Among all respondents, 82% reported using CRT in routine clinical practice, mainly to diagnose acute circulatory failure, but 45% did not think CRT had any prognostic value. Perfusion goal-directed therapy based on CRT was viewed as likely to improve patient outcome by 37% of respondents. The measurement of CRT was not standardized as the use of a chronometer was rare (3%) and the average of multiple measurements rarely performed (46%). Compared to adult intensivists, pediatric intensivists used CRT more frequently (99% versus 76%) and were more confident in its diagnostic value and its ability to guide treatment. CONCLUSION CRT measurement is widely used by intensivists in patients with acute circulatory failure but most often in a non-standardized way. This may lead to a misunderstanding of CRT reliability and clinical usefulness.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France.
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France.
- CarMeN Laboratory, INSERM UMR 1060, University Claude Bernard Lyon 1, Lyon, France.
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69394, Lyon, Cedex, France.
| | - Cléo Wiart
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
| | - Rémi Schweizer
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
| | - Léa Didier
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
| | - Martin Ruste
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
| | - Maxime Coutrot
- FHU PROMICE, DMU Parabol, Département d'anesthésie-réanimation, Hôpital Saint Louis, Assistance publique des Hôpitaux de Paris, Paris, France
- Faculté de médecine Paris, Université Paris France, Paris, France
| | - Matthieu Legrand
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco & F-CRIN-INI-CRCT Network, Nancy, France
| | - Florent Baudin
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
- Service de Réanimation et Urgences Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, F-69500, Bron, France
| | - Etienne Javouhey
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
- Service de Réanimation et Urgences Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, F-69500, Bron, France
| | - François Dépret
- FHU PROMICE, DMU Parabol, Département d'anesthésie-réanimation, Hôpital Saint Louis, Assistance publique des Hôpitaux de Paris, Paris, France
- Faculté de médecine Paris, Université Paris France, Paris, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
- CarMeN Laboratory, INSERM UMR 1060, University Claude Bernard Lyon 1, Lyon, France
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Evren G, Karaarslan U, Yildizdas D, Şik G, Azapağası E, Konca C, Kendirli T, Udurgucu M, Koroglu TF. Epidemiology of pediatric severe sepsis and septic shock in Turkey: Prevalence, Results and Treatments Study. Acta Paediatr 2022; 111:1995-2003. [PMID: 35818128 DOI: 10.1111/apa.16484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
AIM This study was aimed at characterizing the prevalence, management, and outcomes of pediatric severe sepsis and septic shock in tertiary pediatric intensive care units (PICUs) in Turkey. METHODS A point prevalence study was conducted on five days over the course of one year in 29 PICUs in Turkey. Outcomes included severe sepsis and septic shock point prevalence, therapies used, duration of PICU stay, and mortality at day 28. RESULTS Of the 1757 children who were admitted to the PICU during the study period, 141 (8.0%) children met the consensus criteria for severe sepsis and 23 (1.3%) children met the criteria for septic shock. Pediatric severe sepsis and septic shock accounted for 8% and 1.3% of all PICU admissions, respectively. The median age of the patients was 2.6 years (interquartile range (IQR), 0.7-8.6 years). Enteral nutrition (79.3%) was preferred compared to parenteral nutrition (31.1%) for the first 3 days after PICU admission. A total of 39 patients died while in the PICU, for a 23.8% mortality rate, which did not vary by age. CONCLUSION The mortality rate was similar to that in other studies. Hematologic-immunologic comorbidity, parenteral nutrition and the use of vasoactive drugs were independently associated with mortality.
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Affiliation(s)
- Gultac Evren
- Dokuz Eylul University Hospital, Pediatric ICU, Pediatrics, Izmir, Turkey
| | - Utku Karaarslan
- Behcet Uz Hospital, Pediatric ICU, Pediatrics, Izmir, Turkey
| | | | - Guntulu Şik
- Istanbul University, Pediatric ICU, Pediatrics, Istanbul, Turkey
| | - Ebru Azapağası
- Sami Ulus Hospital, Pediatric ICU, Pediatrics, Ankara, Turkey
| | - Capan Konca
- Adiyaman University, Pediatric ICU, Pediatrics, Adiyaman, Turkey
| | - Tanil Kendirli
- Ankara University, Pediatric ICU, Pediatrics, Ankara, Turkey
| | | | - Tolga F Koroglu
- Dokuz Eylul University Hospital, Pediatric ICU, Pediatrics, Izmir, Turkey
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS Clinical Practice Guideline 2021. J Intensive Care 2022; 10:32. [PMID: 35799288 PMCID: PMC9263056 DOI: 10.1186/s40560-022-00615-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html ). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Tokai, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kyoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Kameda Medical Center Department of Infectious Diseases, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Abstract
OBJECTIVES Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC. METHODS We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected. RESULTS We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC. CONCLUSIONS Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.
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McDonald CR, Leligdowicz A, Conroy AL, Weckman AM, Richard-Greenblatt M, Ngai M, Erice C, Zhong K, Namasopo S, Opoka RO, Hawkes MT, Kain KC. Immune and endothelial activation markers and risk stratification of childhood pneumonia in Uganda: A secondary analysis of a prospective cohort study. PLoS Med 2022; 19:e1004057. [PMID: 35830474 PMCID: PMC9328519 DOI: 10.1371/journal.pmed.1004057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/27/2022] [Accepted: 06/23/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the global burden of pneumonia, reliable triage tools to identify children in low-resource settings at risk of severe and fatal respiratory tract infection are lacking. This study assessed the ability of circulating host markers of immune and endothelial activation quantified at presentation, relative to currently used clinical measures of disease severity, to identify children with pneumonia who are at risk of death. METHODS AND FINDINGS We conducted a secondary analysis of a prospective cohort study of children aged 2 to 59 months presenting to the Jinja Regional Hospital in Jinja, Uganda between February 2012 and August 2013, who met the Integrated Management of Childhood Illness (IMCI) diagnostic criteria for pneumonia. Circulating plasma markers of immune (IL-6, IL-8, CXCL-10/IP-10, CHI3L1, sTNFR1, and sTREM-1) and endothelial (sVCAM-1, sICAM-1, Angpt-1, Angpt-2, and sFlt-1) activation measured at hospital presentation were compared to lactate, respiratory rate, oxygen saturation, procalcitonin (PCT), and C-reactive protein (CRP) with a primary outcome of predicting 48-hour mortality. Of 805 children with IMCI pneumonia, 616 had severe pneumonia. Compared to 10 other immune and endothelial activation markers, sTREM-1 levels at presentation had the best predictive accuracy in identifying 48-hour mortality for children with pneumonia (AUROC 0.885, 95% CI 0.841 to 0.928; p = 0.03 to p < 0.001) and severe pneumonia (AUROC 0.870, 95% CI 0.824 to 0.916; p = 0.04 to p < 0.001). sTREM-1 was more strongly associated with 48-hour mortality than lactate (AUROC 0.745, 95% CI 0.664 to 0.826; p < 0.001), respiratory rate (AUROC 0.615, 95% CI 0.528 to 0.702; p < 0.001), oxygen saturation (AUROC 0.685, 95% CI 0.594 to 0.776; p = 0.002), PCT (AUROC 0.650, 95% CI 0.566 to 0.734; p < 0.001), and CRP (AUROC 0.562, 95% CI 0.472 to 0.653; p < 0.001) in cases of pneumonia and severe pneumonia. The main limitation of this study was the unavailability of radiographic imaging. CONCLUSIONS In this cohort of Ugandan children, sTREM-1 measured at hospital presentation was a significantly better indicator of 48-hour mortality risk than other common approaches to risk stratify children with pneumonia. Measuring sTREM-1 at clinical presentation may improve the early triage, management, and outcome of children with pneumonia at risk of death. TRIAL REGISTRATION The trial was registered at clinicaltrial.gov (NCT04726826).
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Affiliation(s)
- Chloe R. McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Aleksandra Leligdowicz
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Department of Medicine, Division of Critical Care Medicine, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Andrea L. Conroy
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, Indiana, United States of America
| | - Andrea M. Weckman
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Melissa Richard-Greenblatt
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Public Health Ontario Laboratory, Toronto, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Clara Erice
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Kathleen Zhong
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Sophie Namasopo
- Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kawempe, Kampala, Uganda
| | - Michael T. Hawkes
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Kevin C. Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
- * E-mail:
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238
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Resuscitating Children With Sepsis and Impaired Perfusion With Maintenance Fluids: An Evolving Concept. Pediatr Crit Care Med 2022; 23:563-565. [PMID: 35797572 DOI: 10.1097/pcc.0000000000002990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sarkar M, Ghosh A, Konar MC, Roy O, Mahapatra MK, Nandi M. Clinical Characteristics of Children With SARS-CoV-2 Infection During the Third Wave of the Pandemic: Single Center Experience. Indian Pediatr 2022. [PMID: 35596647 PMCID: PMC9379889 DOI: 10.1007/s13312-022-2554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background To determine the clinical presentation and outcome of children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the third wave of the pandemic in India. Method A review of hospital records was done at a tertiary care hospital, for children seen between 1 and 25 January, 2022. Result Out of total 112 SARS-CoV-2 positive patients, 17 were hospitalized and 95 were treated in the outpatient department. Among non-hospitalized children, fever was the commonest feature (72, 75.7%), followed by sneezing, and loss of appetite. The median (IQR) duration of symptoms was 2.5 (1.5) days. Among hospitalized children, 10 had co-morbidities and one-third required intensive care unit admission. MIS-C was diagnosed in four patients. Out of 4 mechanically ventilated patients, two had coronavirus disease (COVID) pneumonia. The mean (SD) length of hospital stay was 7.5 (2.5) days. One child with leukemia died during management. Conclusion During the third wave of the pandemic, most children had symptomatic illnesses, but recovery was fast among non-hospitalized children.
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Affiliation(s)
- Mihir Sarkar
- Department of Pediatrics, Medical College and Hospital, Kolkata. Correspondence to: Dr Mihir Sarkar, 88, College Street, Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal 700 073.
| | - Ananya Ghosh
- Department of Pediatrics, Medical College and Hospital, Kolkata
| | | | - Oishik Roy
- Department of Pediatrics, Medical College and Hospital, Kolkata
| | | | - Mousumi Nandi
- Department of Pediatrics, Medical College and Hospital, Kolkata
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Mullan PC, Pruitt CM, Levasseur KA, Macias CG, Paul R, Depinet H, Nguyen ATH, Melendez E. Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:375-384. [PMID: 35924031 PMCID: PMC9342868 DOI: 10.2147/oaem.s368442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients and Methods Results Conclusion
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Affiliation(s)
- Paul C Mullan
- Department of Pediatrics, Division of Emergency Medicine, Eastern Virginia Medical School, Children’s Hospital of the King’s Daughters, Norfolk, VA, USA
- Correspondence: Paul C Mullan, Email
| | - Christopher M Pruitt
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly A Levasseur
- Pediatric Emergency Medicine, Beaumont Children’s Hospital, Royal Oak, MI, USA
| | - Charles G Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies and Children’s, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raina Paul
- Department of Emergency Medicine, Advocate Children’s Hospital, Park Ridge, IL, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Anh Thy H Nguyen
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Elliot Melendez
- Division of Pediatric Critical Care, Connecticut Children’s Medical Center, University of Connecticut, Hartford, CT, USA
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241
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Nallasamy K, Poddar B. Ultrasound in Refractory Septic Shock: Have We Pitched and Pictured It Correctly Yet? Indian J Crit Care Med 2022; 26:773-774. [PMID: 36864874 PMCID: PMC9973181 DOI: 10.5005/jp-journals-10071-24269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Nallasamy K, Poddar B. Ultrasound in Refractory Septic Shock: Have We Pitched and Pictured It Correctly Yet? Indian J Crit Care Med 2022;26(7):773-774.
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Affiliation(s)
- Karthi Nallasamy
- Pediatric Emergency and Intensive Care Unit, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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242
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Yan AP, Zipursky AR, Capraro A, Harper M, Eisenberg M. Pediatric Emergency Department Sepsis Screening Tool Accuracy During the COVID-19 Pandemic. Pediatrics 2022; 150:186991. [PMID: 35502122 DOI: 10.1542/peds.2022-057492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Automated sepsis alerts in pediatric emergency departments (EDs) can identify patients at risk for sepsis, allowing for earlier intervention with appropriate therapies. The impact of the COVID-19 pandemic on the performance of pediatric sepsis alerts is unknown. METHODS We performed a retrospective cohort study of 59 335 ED visits before the pandemic and 51 990 ED visits during the pandemic in an ED with an automated sepsis alert based on systemic inflammatory response syndrome criteria. The sensitivity, specificity, negative predictive value, and positive predictive value of the sepsis algorithm were compared between the prepandemic and pandemic phases and between COVID-19-negative and COVID-19-positive patients during the pandemic phase. RESULTS The proportion of ED visits triggering a sepsis alert was 7.0% (n = 4180) before and 6.1% (n = 3199) during the pandemic. The number of sepsis alerts triggered per diagnosed case of hypotensive septic shock was 24 in both periods. There was no difference in the sensitivity (74.1% vs 72.5%), specificity (93.2% vs 94.0%), positive predictive value (4.1% vs 4.1%), or negative predictive value (99.9% vs 99.9%) of the sepsis alerts between these periods. The alerts had a lower sensitivity (60% vs 73.3%) and specificity (87.3% vs 94.2%) for COVID-19-positive versus COVID-19-negative patients. CONCLUSIONS The sepsis alert algorithm evaluated in this study did not result in excess notifications and maintained adequate performance during the COVID-19 pandemic in the pediatric ED setting.
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Affiliation(s)
- Adam P Yan
- Division of Hematology and Oncology, Boston Children's Hospitaland Harvard Medical School, Boston, Massachusetts.,Divisions of Hematology and Oncology
| | - Amy R Zipursky
- Emergency Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.,Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Capraro
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marvin Harper
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthew Eisenberg
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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243
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Li Z, Zhang C, Liu Y, Wang F, Zhao B, Yang J, Zhao Y, Zhao H, Wang G. Diagnostic and Predictive Values of Ferroptosis-Related Genes in Child Sepsis. Front Immunol 2022; 13:881914. [PMID: 35844488 PMCID: PMC9281550 DOI: 10.3389/fimmu.2022.881914] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/26/2022] [Indexed: 12/29/2022] Open
Abstract
BackgroundEarly diagnosis of sepsis in children was essential to reducing mortality. This study aimed to explore the value of ferroptosis-related genes in children with sepsis.MethodsWe screened the septic children microarray dataset from the GEO database and analyzed the ferroptosis-related differentially expressed genes (DEGs). A functional analysis of ferroptosis-related DEGs was performed. The protein–protein interaction network was used to identify hub genes. We explored the immune landscape of sepsis and controls. The value of hub genes in diagnosing sepsis was tested in the training (GSE26440) and validation sets (GSE13904), and ELISA was used to verify their diagnostic value in children with sepsis in our hospital.ResultsA total of 2,103 DEGs in GSE26440 were obtained, of which ferroptosis-related DEGs were 34. Enrichment analysis showed significant enrichment in the ferroptosis and hypoxia pathways (i.e., HIF-1 pathway). The top three genes (HMOX1, MAPK14, TLR4) were selected as hub genes. Immunological analysis suggested that 10 cell types (i.e., CD8/CD4 T cells) were lower in sepsis. Immune checkpoint-related genes CD274 (PD-L1), HAVCR2 (TIM3), and SIGLEC15 were overexpressed in sepsis. The AUROC for the diagnosis of sepsis for HMOX1 and TLR4 ranged from 0.77 to 0.81, while the AUROC of MAPK14 reached 0.935 and 0.941 in the training and validation sets. Serum ELISA results of HMOX1 and TLR4 showed no significant difference in differentiating sepsis. The AUROC of MAPK14 was 0.877. When the diagnostic threshold was 74.852 ng/ml, the sensitivity and specificity were 0.906 and 0.719, respectively.ConclusionFerroptosis-related gene MAPK14 is of considerable value in the early diagnosis of sepsis in children.
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Affiliation(s)
- Zhi Li
- Department of Infectious Diseases, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Chi Zhang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Yiqi Liu
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Fang Wang
- Department of Infectious Diseases, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Baoling Zhao
- Department of Infectious Diseases, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junmei Yang
- Department of Laboratory Medicine, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yongjing Zhao
- Department of Laboratory Medicine, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hong Zhao
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
- Department of Infectious Diseases, Peking University International Hospital, Beijing, China
- *Correspondence: Guiqiang Wang, ; ; Hong Zhao,
| | - Guiqiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
- Department of Infectious Diseases, Peking University International Hospital, Beijing, China
- *Correspondence: Guiqiang Wang, ; ; Hong Zhao,
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS clinical practice guideline 2021. Respir Investig 2022; 60:446-495. [PMID: 35753956 DOI: 10.1016/j.resinv.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Aichi, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Department of Infectious Diseases, Kameda Medical Center, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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245
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Fernández-Sarmiento J, Molina CF, Salazar-Pelaez LM, Flórez S, Alarcón-Forero LC, Sarta M, Hernández-Sarmiento R, Villar JC. Biomarkers of Glycocalyx Injury and Endothelial Activation are Associated with Clinical Outcomes in Patients with Sepsis: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 38:95-105. [PMID: 35722738 DOI: 10.1177/08850666221109186] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Sepsis is one of the main causes of morbidity and mortality worldwide. Microcirculatory impairment, especially damage to the endothelium and glycocalyx, is often not assessed. The objective of this systematic review and meta-analysis was to summarize the available evidence of the risk of unsatisfactory outcomes in patients with sepsis and elevated glycocalyx injury and endothelial activation biomarkers. DESIGN A systematic search was carried out on PubMed/MEDLINE, Embase, Cochrane and Google Scholar up to December 31, 2021, including studies in adults and children with sepsis which measured glycocalyx injury and endothelial activation biomarkers within 48 hours of hospital admission. The primary outcome was the risk of mortality from all causes and the secondary outcomes were the risk of developing respiratory failure (RF) and multiple organ dysfunction syndrome (MODS) in patients with elevations of these biomarkers. MEASUREMENTS AND MAIN RESULTS A total of 17 studies (3,529 patients) were included: 11 evaluated syndecan-1 (n=2,397) and 6 endocan (n=1,132). Syndecan-1 was higher in the group of patients who died than in those who survived [255 ng/mL (IQR: 139-305) vs. 83 ng/mL (IQR:40-111); p=0.014]. Patients with elevated syndecan-1 had a greater risk of death (OR 2.32; 95% CI 1.89, 3.10: p<0.001), MODS (OR 3.3; 95% CI 1.51, 7.25: p=0.003;), or RF (OR 7.53; 95% CI 1.86-30.45: p=0.005). Endocan was higher in patients who died [3.1 ng/mL (IQR 2.3, 3.7) vs. 1.62 ng/mL (IQR 1.2, 5.7); OR 9.53; 95% CI 3.34, 27.3; p<0.001], who had MODS (OR 8.33; 95% CI 2.07, 33.58; p=0.003) and who had RF (OR 9.66; 95% CI 2.26, 43.95; p=0.002). CONCLUSION Patients with sepsis and abnormal glycocalyx injury and endothelial activation biomarkers have a greater risk of developing respiratory failure, multiple organ failure, and death. Microcirculatory impairment should be routinely evaluated in patients with sepsis, using biomarkers to stratify risk groups.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia.,113097Universidad CES Graduate School, Medellín, Colombia
| | | | | | - Steffanie Flórez
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia
| | - Laura Carolina Alarcón-Forero
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia
| | - Mauricio Sarta
- Department of Pediatrics and Intensive Care, Universidad del Rosario, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Ricardo Hernández-Sarmiento
- Department of Pediatrics and Intensive Care, 42705Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia
| | - Juan Carlos Villar
- Departament of Research, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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246
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Chen Y, Hu Y, Li X, Chen P, Wang C, Wang J, Wu J, Sun Y, Zheng G, Lu Y, Guo Y. Clinical Features and Factors Associated With Sepsis-Associated Encephalopathy in Children: Retrospective Single-Center Clinical Study. Front Neurol 2022; 13:838746. [PMID: 35711261 PMCID: PMC9196026 DOI: 10.3389/fneur.2022.838746] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background Sepsis-associated encephalopathy (SAE) is a common complication in septic patients with a higher ICU and hospital mortality in adults and poorer long-term outcomes. Clinical presentation may range from mild confusion to convulsions and deep coma; however, little is known about SAE in children. We aimed to retrospectively analyze the data for children with sepsis, to illustrate the epidemiology, performance, and adverse outcome, and to evaluate the association between risk factors and SAE in children. Methods All children with sepsis who were admitted to the Department of Pediatrics, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China from January 2010 to December 2020 were retrospectively analyzed. Results A total of 210 patients with sepsis were retrospectively assigned to the SAE and non-SAE groups, of which 91 (43.33%) were diagnosed with SAE with a mortality of 6.70% (14/210). Significant differences were observed in the level of white blood platelet, platelets, international normalized ratio, prothrombin time, activated partial thromboplastin time, total protein, Ccr, UREA, blood urea nitrogen, alanine transaminase, aspartate transaminase, creatine kinase, creatine kinase isoenzymes, lactate dehydrogenase, procalcitonin, and lactic acid (p < 0.05). In the risk assessment scales, significant differences were observed in the modified Glasgow Coma score, PCIS, Pediatric Logistic Organ Dysfunction Score 2 (PELOD-2), Pediatric Sequential Organ Failure Assessment Score, and Pediatric Risk of Mortality III (p < 0.05). The incidence of septic shock, acute kidney disease, liver dysfunction, and coagulation disorder were higher in the SAE group (p < 0.05). The mechanical ventilation time ([6.57 d ± 16.86 d] vs. [2.05 d ± 5.79 d]; p < 0.001), CRRT time ([1.74 d ± 6.77 d] vs. [0.11 d ± 0.63 d]; p < 0.001), ICU stay time ([299.90 h ± 449.50 h] vs. [177.67 h ± 245.36 h]); p < 0.001 was longer than that of non-SAE. Both the PCT, Ca2+, septic shock, PELOD-2, and midazolam were identified as independent risk factors, and fentanyl was a protective factor for SAE in pediatric patients (p < 0.05). The main clinical neurological symptoms consisted of agitation, hypnosia, hypnosis alternates agitated, anterior fontanelle full/bulging/high tension, coma, muscle hypertonia, muscle hypotonia, hyperreflexia, focal seizure, and generalized seizure. Conclusions The incidence of SAE in children was found high and the prognosis poor. In this retrospective study, the identified patients were more susceptible to SAE, with an inflammatory storm with hypocalcemia or septic shock. The use of midazolam will increase the occurrence of SAE, whereas fentanyl will reduce the incidence of SAE, and PELOD-2 may predict the occurrence of SAE.
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Affiliation(s)
- Yihao Chen
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yan Hu
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xufeng Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Peiling Chen
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chun Wang
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jing Wang
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiaxing Wu
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yueyu Sun
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guilang Zheng
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yiyun Lu
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuxiong Guo
- Pediatric Intensive Care Unit, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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247
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Blythe R, Lister P, Seaton R, Harley A, Schlapbach LJ, McPhail S, Venkatesh B, Irwin A, Raman S. Patient and economic impact of implementing a paediatric sepsis pathway in emergency departments in Queensland, Australia. Sci Rep 2022; 12:10113. [PMID: 35710798 PMCID: PMC9203710 DOI: 10.1038/s41598-022-14226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/02/2022] [Indexed: 11/12/2022] Open
Abstract
We examined systems-level costs before and after the implementation of an emergency department paediatric sepsis screening, recognition and treatment pathway. Aggregated hospital admissions for all children aged < 18y with a diagnosis code of sepsis upon admission in Queensland, Australia were compared for 16 participating and 32 non-participating hospitals before and after pathway implementation. Monte Carlo simulation was used to generate uncertainty intervals. Policy impacts were estimated using difference-in-difference analysis comparing observed and expected results. We compared 1055 patient episodes before (77.6% in-pathway) and 1504 after (80.5% in-pathway) implementation. Reductions were likely for non-intensive length of stay (− 20.8 h [− 36.1, − 8.0]) but not intensive care (–9.4 h [− 24.4, 5.0]). Non-pathway utilisation was likely unchanged for interhospital transfers (+ 3.2% [− 5.0%, 11.4%]), non-intensive (− 4.5 h [− 19.0, 9.8]) and intensive (+ 7.7 h, [− 20.9, 37.7]) care length of stay. After difference-in-difference adjustment, estimated savings were 596 [277, 942] non-intensive and 172 [148, 222] intensive care days. The program was cost-saving in 63.4% of simulations, with a mean value of $97,019 [− $857,273, $1,654,925] over 24 months. A paediatric sepsis pathway in Queensland emergency departments was associated with potential reductions in hospital utilisation and costs.
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Affiliation(s)
- Robin Blythe
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD, 4059, Australia.
| | - Paula Lister
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,Paediatric Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, Australia
| | - Robert Seaton
- Department of Health, Clinical Excellence Queensland, Brisbane, QLD, Australia
| | - Amanda Harley
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Critical Care Nursing Management Team, Queensland Children's Hospital, Brisbane, QLD, Australia.,School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Steven McPhail
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane, QLD, 4059, Australia.,Digital Health and Informatics, Metro South Health, Brisbane, QLD, Australia
| | - Bala Venkatesh
- The George Institute for Global Health, Sydney, NSW, Australia.,Department of Intensive Care Medicine, Wesley Hospital, Brisbane, QLD, Australia.,The University of Queensland, Brisbane, QLD, Australia
| | - Adam Irwin
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Sainath Raman
- Queensland Paediatric Sepsis Program, Children's Health and Youth Network, Children's Health Queensland, Brisbane, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
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248
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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249
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Abstract
Coronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. More than 5 million children have been infected in the United States. Risk factors for more severe disease progression include obesity, pulmonary disease, gastrointestinal disorders, and neurologic comorbidities. Children with COVID-19 are admitted to the pediatric intensive care unit because of severe acute COVID-19 illness or COVID-19-associated multisystem inflammatory syndrome in children. The delta surge of 2021 was responsible for an increased disease burden in children and points to the key role of vaccinating children against this sometimes-deadly disease.
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Affiliation(s)
- Meena Kalyanaraman
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, C-5, 201 Lyons Avenue, Newark, NJ 07112, USA.
| | - Michael R Anderson
- Children's National Hospital, George Washington University School of Medicine and Health Sciences
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250
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Otte A, Schindler E, Neumann C. [Hemodynamic monitoring in pediatric anesthesia]. DIE ANAESTHESIOLOGIE 2022; 71:417-425. [PMID: 35925144 DOI: 10.1007/s00101-022-01125-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Perioperative mortality and morbidity in childhood essentially depend on the quality of the anesthesia. The Safe Anesthesia for every Tot (SafeTots) initiative takes this into account and has defined normotension, normovolemia and normal heart rate as quality criteria in pediatric anesthesia. Appropriate monitoring of pediatric hemodynamics is necessary to fulfil these criteria. This article provides an overview of currently used methods and techniques for instrumental and non-instrumental cardiovascular monitoring in children. The current study situation, recommendations and guidelines on the application as well as practical aspects of the measurement methods are explained as far as possible. For a better understanding, procedures not routinely used in clinical practice are described in more detail.
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Affiliation(s)
- Andreas Otte
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Ehrenfried Schindler
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Claudia Neumann
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland
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