Dynamic parameters for fluid responsiveness in mechanically ventilated children: A systematic review.

Objective: Fluid administration is the initial step of treatment of unstable pediatric patients. Evaluation of fluid responsiveness is crucial in mechanically ventilated children to avoid fluid overload, which increases mortality. We aim to review and compare the diagnostic performance of dynamically hemodynamic parameters for predicting fluid responsiveness in mechanically ventilated children. Design: A systematic review was performed using four electronic databases, including PubMed, EMBASE, Scopus, and Central, for published articles from 1 January 2010 to 31 December 2020. Studies were included if they described diagnostic performance of dynamic parameters after fluid challenge was performed in mechanically ventilated children. Settings: Pediatric intensive and cardiac intensive care unit, and operative room. Patients: Children aged 1 month to 18 years old who were under mechanical ventilation and required an intravenous fluid challenge. Measurements and Main Results: Twenty-seven studies were included in the systematic review, which included 1,005 participants and 1,138 fluid challenges. Respiratory variation in aortic peak velocity was reliable among dynamic parameters for predicting fluid responsiveness in mechanically ventilated children. All studies of respiratory variation in aortic peak velocity showed that the area under the receiver operating characteristic curve ranged from 0.71 to 1.00, and the cutoff value for determining fluid responsiveness ranged from 7% to 20%. Dynamic parameters based on arterial blood pressure (pulse pressure variation and stroke volume variation) were also used in children undergoing congenital heart surgery. The plethysmography variability index was used in children undergoing neurological and general surgery, including the pediatric intensive care patients. Conclusions: The respiratory variation in aortic peak velocity exhibited a promising diagnostic performance across all populations in predicting fluid responsiveness in mechanically ventilated children. High sensitivity is advantageous in non-cardiac surgical patients and the pediatric intensive care unit because early fluid resuscitation improves survival in these patients. Furthermore, high specificity is beneficial in congenital heart surgery because fluid overload is particularly detrimental in this group of patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206400.

Clinical Characteristics and Outcomes of Children With Extracorporeal Membrane Oxygenation in a Developing Country: An 11-Year Single-Center Experience.

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a lifesaving procedure for patients with refractory cardiac or respiratory failure. The indications for ECMO are growing, and it is increasingly being used to support cardiopulmonary failure in children. However, the risks and benefits of ECMO should be weighed before deploying it on the patients. The objectives of this study were to identify the mortality risk factors and to determine the ECMO outcomes. Methods: The retrospective chart reviews were done for all patients aged 1 day-20 years old receiving ECMO between January 2010 and December 2020. Results: Seventy patients were enrolled in the study. The median age was 31.3 months. The incidence of VA and VV ECMO was 85.7 and 14.3%, respectively. The most common indication for ECMO was the failure to wean off cardiopulmonary bypass after cardiac surgery. Pre-existing acute kidney injury (OR 4.23; 95% CI 1.34-13.32, p = 0.014) and delayed enteral feeding (OR 3.85, 95% CI 1.23-12.02, p = 0.020), and coagulopathy (OD 12.64; 95% CI 1.13-141.13, p = 0.039) were associated with the higher rate of mortality. The rates of ECMO survival and survival to discharge were 70 and 50%, respectively. Conclusion: ECMO is the lifesaving tool for critically ill pediatric patients. Pre-existing acute kidney injury, delayed enteral feeding, and coagulopathy were the potential risk factors associated with poor outcomes in children receiving ECMO. However, ECMO setup can be done successfully in a developing country.

Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial.

AIMS: The prolonged use of benzodiazepines and opioids can lead to an increase in the incidence of withdrawal syndrome. One of the known risk factors is the lack of a sedative-weaning protocol. This study established a sedative-weaning protocol and compared this protocol with the usual care of weaning in high-risk critically ill children. MATERIALS AND METHODS: This was an open-label, randomized controlled trial in a tertiary-care hospital. We recruited children aged 1 month to 18 years who had received intravenous sedative or analgesic drugs for at least 5 days. The exclusion criteria were patients who had already experienced the withdrawal syndrome. We established a weaning protocol. Eligible patients were randomly divided into the protocolized (intervention) and usual care (control) groups. The primary objective was to determine the prevalence of the withdrawal syndrome compared between two groups. RESULTS: Thirty eligible patients were enrolled (19 in the intervention and 11 in the control group). Baseline characteristics were not significantly different between both the groups. The prevalence of the withdrawal syndrome was 84% and 81% of patients in the intervention and control group, respectively. The duration of the initial weaning phase was shorter in the intervention group than in the control group (p value = 0.026). The cumulative dose of morphine solution for rescue therapy in the intervention group was statistically lower than that in the control group (p value = 0.016). CONCLUSION: The implementation of the sedative-weaning protocol led to a significant reduction in the percentage of withdrawal days and length of intensive care unit stay without any adverse drug reactions. External validation would be needed to validate this protocol. CLINICALTRIALSGOV IDENTIFIER: NCT03018977. HOW TO CITE THIS ARTICLE: Tiacharoen D, Lertbunrian R, Veawpanich J, Suppalarkbunlue N, Anantasit N. Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial. Indian J Crit Care Med 2020;24(6):451-458.

Daily Dengue Severity Score to Assess Severe Manifestations.

BACKGROUND: The study aimed to develop dengue severity score to assess severe manifestations among hospitalized patients with dengue infection. METHOD: Children and adolescents with serologically confirmed dengue infection admitted at Ramathibodi Hospital from 2004 to 2018 and treated by an expert multidisciplinary team were recruited. Medical records were retrospectively reviewed and 14 items, related to clinical parameters and managements during hospitalization, were obtained daily as dengue severity score. RESULTS: A total of 191 patients with a mean age of 10.7 years from 2004 to 2013 were recruited. They were classified as dengue fever (35), dengue hemorrhagic fever (DHF) I (53), II (50), III (37) and IV (16). The analysis of 593 daily records revealed the range of daily severity score among patients with DHF grades III (10-20) and IV (31-47) were significantly higher than those of other groups (dengue fever, 5-13; DHF I, 2-10; DHF II, 6-11) with P-values of 0.0001. Using a validity test, a total daily score of ≥12 was an assessment tool for dengue shock syndrome with sensitivity, 86% and specificity, 84%. An additional 51 hospitalized patients with DHF grades II, III and IV with similar ages from 2014 to 2018 were recruited. The number of patients with severe manifestations, having daily score of ≥12, was significantly higher than those without severe manifestations starting from Day -3 to Day +1 of illness. CONCLUSIONS: Daily dengue severity score of ≥12 was an accurate assessment tool for severe manifestations.

Connecting two worlds: positive correlation between physicochemical approach with blood gases and pH in pediatric ICU setting.

OBJECTIVE: Physicochemical approach such as strong ion difference provides a novel concept in understanding and managing acid-base disturbance in patients. However, its application in pediatrics is limited. This study aimed to evaluate a correlation between the physicochemical approach and blood gas pH for acid-base determination in critically ill pediatric patients. RESULTS: A total of 130 pediatric patients were included, corresponding to 1338 paired measures for analyses. Of these, the metabolic subgroup (743 paired measures) was defined. Among physicochemical parameters, the effective strong ion difference showed the best correlation with the blood gas pH in the whole cohort (R = 0.398; p < 0.001) and the metabolic subgroup (R = 0.685; p < 0.001). Other physicochemical parameters (i.e., the simplified and the apparent strong ion difference, the strong ion gap, and the sodium chloride gap) and the traditional measures (standard base excess, lactate, chloride and bicarbonate) also showed varying degrees of correlation. This study revealed the positive correlation between physicochemical parameters and the blood gas pH, serving as a connecting dot for further investigations using physicochemical approach to evaluate acid-base disturbance in pediatric population.

Ultrasound Versus Traditional Palpation to Guide Radial Artery Cannulation in Critically Ill Children: A Randomized Trial.

OBJECTIVES: To identify success rates for radial artery cannulation in a pediatric critical care unit using either palpation or ultrasound guidance to cannulate the radial artery. METHODS: A prospective randomized comparative study of critically ill children who required invasive monitoring in a tertiary referral center was conducted. All patients were randomized by a stratified block of 4 to either ultrasound-guided or traditional palpation radial artery cannulation. The primary outcomes were the first attempt and total success rates. RESULTS: Eighty-four children were enrolled, with 43 randomized to the palpation technique and 41 to the ultrasound-guided technique. Demographic data between the groups were not significantly different. The total success and first attempt rates for the ultrasound-guided group were significantly higher than those for the palpation group (success ratio, 2.03; 95% confidence interval, 1.13-3.64; P = .018; and success ratio, 4.18; 95% confidence interval, 1.57-11.14; P = .004, respectively). The median time to success for the ultrasound-guided group was significantly shorter than that for the palpation group (3.3 versus 10.4 minutes; P < .001). Cannulation complications were lower in the ultrasound-guided group than the palpation group (12.5% versus 53.3%; P < .001). CONCLUSIONS: The ultrasound-guided technique could improve the success rate and allow for faster cannulation of radial artery catheterization in critically ill children.

Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial.

OBJECTIVES: To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children. DESIGN: Double-blind, placebo-controlled randomized clinical trial. SETTING: PICU in a tertiary referral center. PATIENTS: Children 1 month to 15 years old who underwent mechanical ventilation. INTERVENTIONS: Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor. MEASUREMENTS AND MAIN RESULTS: One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90-585] vs 60 [42-116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively). CONCLUSIONS: The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.

Vitamin D deficiency and adrenal function in critically ill children.

BACKGROUND: Data on interrelationship between vitamin D deficiency (VDD) and adrenal insufficiency in critically ill children are limited. OBJECTIVE: To determine vitamin D status in critically ill children and its relationship with adrenal function. MATERIAL AND METHOD: Thirty-two patients and 36 controls were included. Serum 25-hydroxyvitamin D (25-OHD) levels were measured. Pediatric Risk of Mortality (PRISM) III score, outcome and adrenal function assessed by 1-microgram adrenocorticotropic hormone test were collected. RESULTS: Median (IQR) serum 25-OHD of thepatients was less than that of the controls (16.6 (13.3-19.5) vs. 24.2 (21.0-27.9) ng/mnL, p < 0.001). Twenty-five (78%) patients and seven (19%) controls had VDD. PRISM III score, proportions of patients with shock and vasopressive drug used, length of intensive care unit stay and ventilator used, and adrenal function were not different between patients with and without VDD. Patients with serum 25-OHD of less than 12 ng/mL had higher median (IQR) PRISM III score (14 (6-20) vs. 5 (2-10), p = 0.033) and higher proportion of mortality than those with serum 25-OHD of 12 ng/mL or greater. CONCLUSION: A greater proportion of VDD in critically ill children as compared with that of the controls was demonstrated. Serum 25-OHD was not associated with adrenal function.

Accuracy of bedside glucometry in critically ill children with peripheral hypoperfusion.

The accuracy of glucose test strip in critically care has been questioned. We investigated the accuracy of glucose test strip in critically ill children. Patients, aged from 1 month to 18 years admitted in pediatric intensive care unit. Demographic data, hemodynamic parameters, and perfusion index (PI) were recorded. Glucose test strips were performed from finger stick blood [capillary blood glucose (CBG)] and from whole blood [whole blood glucose (WBG)] along with laboratory plasma blood glucose (PBG) from either arterial or venous blood samples. The accuracy of glucose test strips was defined according to ISO 15197 and Clarke error grid (CEG). One hundred and eighty one blood samplings including 117 arterial blood (CBG, WBGa, PBGa) and 64 venous blood (CBG, WBGv, PBGv) were obtained. The accuracy of WBGa was 98.3 and 95.2% when compared to the accuracy of CBG (88.7 and 83.3%. The accuracy of WBGv was 92.2% and 87.0 when compared to the accuracy of CBG which was 79.7 and 72.9% (ISO 15197: 2003 and 2013, respectively). Bland-Altman plot demonstrated bias and precision of 7.4±17.7 mg/dL in acceptable PI group compared to 30.2±23.4 mg/dL in low PI group (PI≤0.3). The CBG test strip must be interpreted carefully in critically ill children. A low PI was associated with poor CBG strip accuracy. WBG test strip from arterial blood was more appropriate for glucose monitoring in children with peripheral hypoperfusion.

Non-invasive cardiac output assessment in critically ill paediatric patients.

OBJECTIVE: Recently, non-invasive methods for cardiac output (CO) assessment have been developed including the ultrasonic cardiac output monitor (USCOM). This technique uses the same concept as Doppler echocardiography but differs in two aspects including continuous wave (CW) Doppler and estimated outflow tract diameter (OTD) used in USCOM compared to pulsed wave Doppler and directed measurement of OTD used in echocardiography. We sought to assess the agreement between CO assessment by USCOM and echocardiography in critically ill paediatric patients. METHODS: Paired measurements of CO in critically ill paediatric patients were simultaneously and independently obtained by USCOM and echocardiography. Agreement between OTD, velocity time integral (VTI), CO, and cardiac index (CI) were assessed by percentage error and Bland-Altman analysis. RESULTS: Thirty-four children (aged 7.86 +/- 5.78years, 44.1% male) had a mean OTD (1.47 +/- 0.38, 1.41 +/- 0.40), VTI (19.13 +/- 6.06, 23.53 +/- 7.31 cm), CO (3.88 +/- 2.19,4.41 +/- 2.83 l/min) and CI (4.23 +/- 1.19,4.77 +/- 1.43 l/min/m2) by echocardiography and USCOM, respectively. Bias +/- precision and percentage of error of OTD, VTI, CO, and CI were -0.07 +/- 0.20 cm, 27.80%; -4.40 +/- 3.84 cm, 31.99%; -0.53 +/- 1.23 l/min, 54.66%; and 0.54 +/- 1.03 l/min/m2, 42.32%, respectively. The bias +/- precision and percentage error were more important in patients with septic shock (n = 16). CONCLUSION: USCOM was an unreliable tool for absolute value measurement of CO and CI due to the errors of VTI by CW Doppler.

Serum free cortisol index, free cortisol, and total cortisol in critically ill children.

BACKGROUND: In critical illness, serum total cortisol (TC) may not adequately reflect adrenal function because of reduced cortisol-binding globulin (CBG). AIM: To evaluate adrenal function of critically ill children, using free cortisol index (FCI), calculated free cortisol (cFC), and TC levels. METHODS: Thirty-two critically ill and 36 healthy children were included. All children underwent the 1 microg cosyntropin test. TC and CBG levels were measured. Basal and peak TC, FCI, and cFC were determined. RESULTS: Basal and peak TC, FCI, and cFC of critically ill children were significantly higher than those of the controls. Compared with TC, both basal and peak FCI and cFC of the patients were higher than those of controls to a greater degree. Use of FCI or cFC to diagnose adrenal insufficiency (AI) reduced the frequency of diagnosis of AI by 50%. CONCLUSION: FCI and cFC better reflect the dynamic changes of adrenal function of critically ill children.