Earlier initiation of continuous renal replacement therapy was associated with lower mortality in this cohort of critically ill children. Future studies should focus on early identification of such children who may benefit from early continuous renal replacement therapy initiation.
The presence, severity and duration of early fluid are associated with increased ICU mortality in children admitted to the pediatric ICU in shock states.
The current recommended parenteral amino acid intakes are insufficient to maintain protein balance in insulin-resistant patients during tight glucose control. During sepsis, insulin decreases protein synthesis and breakdown, and while high amino acid intake improves protein balance, its beneficial effects may be offset by enhanced endogenous glucose production and lipolysis, raising concerns that insulin resistance may have been exacerbated and that gluconeogenesis may have been favored by high amino acid intakes. Dose-response studies on the effect of the level of amino acid intakes (protein) on energy metabolism are needed.
Insulin resistance is an adaptive mechanism that prioritizes utilization of energy for immune response in the presence of infection or injury. A better understanding of the complex interactions between metabolism, inflammation and immunity in critically ill children will lead to appropriate metabolic and immune support of these patients.
In this pilot study, we evaluated the long-term neurodevelopmental outcomes in neonatal and pediatric patients supported by extracorporeal membrane oxygenation (ECMO) and aimed to identify the role of post-ECMO magnetic resonance imaging (MRI) in predicting neurodevelopmental outcomes. Twenty-nine patients were evaluated using the Ages and Stages Questionnaire, Third Edition (ASQ-3) screening tool. Thirteen were evaluated during their visit at the neurodevelopmental clinic and 16 were interviewed via phone. We also reviewed the post-ECMO MRI brain of these patients and scored the severity of their injury based on the neuroimaging findings. In our cohort of 29 patients, 10 patients (34%) had developmental delay. Of those with developmental delay, 80% were newborns. Sixty-seven percent of patients with developmental delay had moderate to severe MRI abnormalities as compared with only 18% with no developmental deficits (p = 0.03). The younger the age at the time of placement on ECMO, the higher the chances of impaired neurodevelopmental outcome. Long-term follow-up of patients who have survived ECMO, with standardized neuropsychologic testing and post-ECMO imaging, should become the standard of care to improve long-term outcomes. Significant abnormalities on brain MRIs done before discharge correlated with developmental delay on follow-up.
Disclaimer: This guideline for extracorporeal membrane oxygenation (ECMO) fluid and electrolyte management for all patient populations is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS/ECMO, but these are not necessarily consensus recommendations. The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians’ and other health professionals’ judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
Purpose of this study was to evaluate the impact of early fluid accumulation and renal dysfunction on mortality in children receiving extracorporeal membrane oxygenation (ECMO). Retrospective cohort study of neonatal and pediatric patients who received ECMO between January 2010 and December 2012 in a tertiary level multidisciplinary pediatric intensive care unit (ICU). Ninety-six patients were included, and forty-six (48%) of them received continuous renal replacement therapy (CRRT) during ECMO. Overall mortality was 38.5%. Proportion of patients with acute kidney injury (AKI) at ICU admission was 33% and increased to 47% at ECMO initiation. High-risk diagnoses, extracorporeal cardiopulmonary resuscitation (ECPR), and venoarterial (VA)-ECMO were more common among nonsurvivors. Nonsurvivors had significantly higher proportion of AKI at ICU admission (OR: 2.59, p = 0.04) and fluid accumulation on ECMO day 1 (9% vs. 1%, p = 0.05) compared with survivors. Multivariable logistic regression analysis (adjusted for a propensity score based on nonrenal factors associated with increased mortality) demonstrated that fluid accumulation on ECMO day 1 is significantly associated with increased ICU mortality (OR: 1.07, p = 0.04). Fluid accumulation within the first 24 hours after ECMO cannulation is significantly associated with increased ICU mortality in neonatal and pediatric patients. Prospective studies evaluating the impact of conservative fluid management and CRRT during the initial phase of ECMO may help further define this relationship.
» A team approach is optimal in the evaluation and treatment of musculoskeletal infection in pediatric patients given the complexity and uncertainty with which such infections manifest and progress, particularly among severely ill children.» The team approach includes emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology.» These services follow evidence-based clinical practice guidelines with integrated processes of care so that children and their families may benefit from data-driven continuous process improvement.» Important principles based on our experience in the successful treatment of pediatric musculoskeletal infection include relevant information gathering, pattern recognition, determination of the severity of illness, institutional workflow management, closed-loop communication, patient and family-centered care, ongoing dialogue among key stakeholders within and outside the context of direct patient care, and periodic data review for programmatic improvement over time.» Such principles may be useful in almost any setting, including rural communities and developing countries, with the understanding that the team composition, institutional capabilities or limitations, and specific approaches to treatment may differ substantially from one setting or team to another.
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