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Sankar J, Das RR. The authors reply. Crit Care Med 2024; 52:e246-e247. [PMID: 38619349 DOI: 10.1097/ccm.0000000000006228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
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Gueret G, Tête X, Le Maguet P. Hyperchloremia: Cause or Consequence of Acute Kidney Injury? Crit Care Med 2024; 52:e245-e246. [PMID: 38619348 DOI: 10.1097/ccm.0000000000006190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Gildas Gueret
- Anesthesiology department, centre hospitalier de Cornouaille, Quimper, France
| | - Xavier Tête
- Anesthesiology Department, Military Teaching Hospital Clermont Tonnerre, Brest, France
| | - Pascale Le Maguet
- Anesthesiology department, centre hospitalier de Cornouaille, Quimper, France
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Easter JS, Rose E. Advances in pediatric emergency from 2023. Am J Emerg Med 2024; 80:77-86. [PMID: 38518545 DOI: 10.1016/j.ajem.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024] Open
Abstract
Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).
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Affiliation(s)
- Joshua S Easter
- Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Emily Rose
- Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Wang L, Dixon C, Nhan J, Kakajiwala A. A balancing act: drifting away from the reflexive use of "ab"normal saline. Pediatr Nephrol 2024:10.1007/s00467-023-06271-8. [PMID: 38233719 DOI: 10.1007/s00467-023-06271-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.
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Affiliation(s)
- Linda Wang
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA.
| | - Celeste Dixon
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Jennifer Nhan
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
| | - Aadil Kakajiwala
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
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Weiss SL, Fitzgerald JC. Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes. Pediatrics 2024; 153:e2023062967. [PMID: 38084084 PMCID: PMC11058732 DOI: 10.1542/peds.2023-062967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 01/02/2024] Open
Abstract
Sepsis and septic shock are major causes of morbidity, mortality, and health care costs for children worldwide, including >3 million deaths annually and, among survivors, risk for new or worsening functional impairments, including reduced quality of life, new respiratory, nutritional, or technological assistance, and recurrent severe infections. Advances in understanding sepsis pathophysiology highlight a need to update the definition and diagnostic criteria for pediatric sepsis and septic shock, whereas new data support an increasing role for automated screening algorithms and biomarker combinations to assist earlier recognition. Once sepsis or septic shock is suspected, attention to prompt initiation of broad-spectrum empiric antimicrobial therapy, fluid resuscitation, and vasoactive medications remain key components to initial management with several new and ongoing studies offering new insights into how to optimize this approach. Ultimately, a key goal is for screening to encompass as many children as possible at risk for sepsis and trigger early treatment without increasing unnecessary broad-spectrum antibiotics and preventable hospitalizations. Although the role for adjunctive treatment with corticosteroids and other metabolic therapies remains incompletely defined, ongoing studies will soon offer updated guidance for optimal use. Finally, we are increasingly moving toward an era in which precision therapeutics will bring novel strategies to improve outcomes, especially for the subset of children with sepsis-induced multiple organ dysfunction syndrome and sepsis subphenotypes for whom antibiotics, fluid, vasoactive medications, and supportive care remain insufficient.
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Affiliation(s)
- Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, DE, USA
- Departments of Pediatrics & Pathology, Anatomy, and Cell Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Akrama O, Armstrong L, Desai MK, Horner Le Riche A, Keating L, Knowles C, Perera Y, Porter T, Hirst R. Journal update monthly top five. Emerg Med J 2023; 40:678-679. [PMID: 37611954 DOI: 10.1136/emermed-2023-213505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Osama Akrama
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Luke Armstrong
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | | | | | - Liza Keating
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Charlotte Knowles
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Yanithra Perera
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Thomas Porter
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Robert Hirst
- Emergency Department, North Bristol NHS Trust, Bristol, UK
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Fernández-Sarmiento J, Casas-Certain C, Ferro-Jackaman S, Solano-Vargas FH, Domínguez-Rojas JÁ, Pilar-Orive FJ. A brief history of crystalloids: the origin of the controversy. Front Pediatr 2023; 11:1202805. [PMID: 37465421 PMCID: PMC10351043 DOI: 10.3389/fped.2023.1202805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023] Open
Abstract
Fluid resuscitation with crystalloids has been used in humans for more than 100 years. In patients with trauma, sepsis or shock of any etiology, they can help modify the clinical course of the illness. However, these solutions are medications which are not side-effect free. Recently, they have been questioned in terms of quantity (fluid overload) and their composition. The most frequently used crystalloids, both in high and low-income countries, are 0.9% normal saline (NS) and Ringer's lactate. The first descriptions of the use of sodium and water solutions in humans date from the cholera epidemic which spread throughout Europe in 1831. The composition of the fluids used by medical pioneers at that time differs greatly from the 0.9% NS used routinely today. The term "physiological solution" referred to fluids which did not cause red blood cell hemolysis in amphibians in in vitro studies years later. 0.9% NS has an acid pH, a more than 40% higher chloride concentration than plasma and a strong ion difference of zero, leading many researchers to consider it an unbalanced solution. In many observational studies and clinical trials, this 0.9% NS composition has been associated with multiple microcirculation and immune response complications, acute kidney injury, and worse clinical outcomes. Ringer's lactate has less sodium than plasma, as well as other electrolytes which can cause problems in patients with traumatic brain injury. This review provides a brief summary of the most important historical aspects of the origin of the most frequently used intravenous crystalloids today.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Carolina Casas-Certain
- Department of Pediatrics, Universidad del Rosario, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sarah Ferro-Jackaman
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Fabian H. Solano-Vargas
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | | | - Francisco Javier Pilar-Orive
- Department of Pediatrics and Critical Care, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
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