Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

Abulebda, Kamal; Cvijanovich, Natalie Z.; Thomas, Neal J.; Allen, Geoffrey L.; Anas, Nick; Bigham, Michael T.; Hall, Mark W.; Freishtat, Robert J.; Sen, Anita; Meyer, Keith; Checchia, Paul A.; Shanley, Thomas P.; Nowak, Jeffrey; Quasney, Michael W.; Weiss, Scott L.; Banschbach, Sharon; Beckman, Eileen; Lindsell, Christopher J.; Wong, Hector R.

doi:10.1097/ccm.0b013e3182a64607

Cited by 73 publications

(71 citation statements)

References 37 publications

(32 reference statements)

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“…We study group included only those who were admitted to the ICU for least 48 h, with the intent to focus on a group which could potentially benefit from appropriate early fluid management. Fluid balance may not impact outcomes in patients at extremes of the severity of illness spectrum, especially those in the highrisk category for whom the risk of mortality is high irrespective of fluid balance [31]. We defined early fluid accumulation as the peak fluid accumulation occurring within the initial 3 days of ICU admission because we found that in our cohort, both survivors and non-survivors, fluid accumulation peaked on the second day.…”

Section: Discussionmentioning

confidence: 99%

Early fluid accumulation in children with shock and ICU mortality: a matched case–control study

et al. 2015

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Section: Discussionmentioning

confidence: 99%

Early fluid accumulation in children with shock and ICU mortality: a matched case–control study

et al. 2015

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“…Additionally, they noted that peak fluid overload was independently associated with longer ventilator duration (p = 0.004) and PICU length of stay (p = 0.008). Another recent study 15 found that a cumulative positive fluid balance in children with significant shock was associated with PICU mortality.…”

Section: Discussionmentioning

confidence: 96%

“…Recently, fluid overload has been associated with negative outcomes in critically ill children. 14,15 Arikan and colleagues 14 retrospectively evaluated the association between fluid overload and oxygenation in 80 children. They found that fluid overload ≥15% was independently associated with the daily oxygenation index when controlling for age, gender, and Pediatric Logistic Organ Dysfunction (p < 0.05).…”

Section: Discussionmentioning

confidence: 99%

Acute Kidney Injury in a Child Receiving Vancomycin and Piperacillin/Tazobactam

Ibach

Johnson

2016

The Journal of Pediatric Pharmacology and Therapeutics

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Recent reports have described increased risk of acute kidney injury (AKI) in adults receiving concomitant vancomycin and piperacillin/tazobactam, but few reports exist in children. We describe an 8-year-old girl who was admitted to the pediatric intensive care unit with respiratory distress secondary to pneumonia. She began treatment with vancomycin and piperacillin/tazobactam. She developed AKI, and piperacillin/ tazobactam and vancomycin were discontinued. Following a furosemide infusion, her AKI resolved and serum creatinine returned to baseline. She later resumed piperacillin/tazobactam monotherapy for multidrugresistant tracheitis with no evidence of AKI and was eventually discharged to a long-term care facility. The Naranjo probability scale supports a probable drug-related adverse event. Clinicians must be aware of the possibility of AKI with this combination and should monitor renal function and vancomycin concentrations vigilantly. Future prospective studies are needed to explore the incidence and clinical characteristics associated with AKI after this combination in children.

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“…Because of cases like this one, the initial enthusiasm for a new therapeutic strategy (early goal directed therapy) has come under further scrutiny [3]. Rapid administration of saline bolus volumes that approximate the patient's entire intravascular volume has not been uniformly successful and mortality in septic shock has not been dramatically reduced [4].…”

Section: Commentarymentioning

confidence: 99%

The On-going Challenge of Pediatric Septic Shock: Optimizing Early Identification and Accurate Resuscitation

Fisher¹

2018

J Intensive Crit Care

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CommentaryShock in the pediatric emergency department is frequently a diagnostic and therapeutic challenge. The child arrives in an undifferentiated manner and there can be dramatic clinical overlap between a variety of pathophysiologic states, caused by conditions ranging from immediately life-threatening to relatively innocuous. As a member of a small group of young pediatric emergency physicians in the 1990's, our group initiated an observational study to examine our performance utilizing standard pediatric advanced life support measures [1]. We strove to identify patients early and initiate rapid but measured fluid replacement, as well as clinically indicated vasopressor administration and antibiotics. Our patients received an average of 58 ml/kg of fluid over the course of a 4-5 h ED course. During the 8 year period of data collection, septic shock represented 57% of our cases. Hypovolemic shock, distributive and cardiogenic shock contributed 24%, 14% and 5% respectively. Our mortality was 6% overall and 5% in patients with septic shock and an identified pathogen.As we accumulated our data, early goal directed therapy and the surviving sepsis campaign began, and with it came an even more aggressive fluid resuscitation strategy. Children were to be treated with 60 ml/kg of crystalloid over the course of 30 to 60 min [2]. Given that a child's intravascular volume is 80 ml/kg, our group was hesitant with these recommendations-we had seen first-hand the potential complications of this therapy, specifically acute respiratory failure in the ED requiring emergent intubation and mechanical ventilation. One such patient enrolled late in the study period, after the Surviving Sepsis campaign had been widely disseminated and impacted our practice, is vividly recalled. This was a two month old female presented with fever for three day. The child demonstrated tachycardia, but was awake and alert with normal oxygen saturation. Pyelonephritis was quickly diagnosed. Her pulses were initially palpable, but after an initial 20 ml/kg bolus of saline and ceftriaxone administration, her extremities were cold, mottled and she had pulses that were barely palpable. Was this just transient endotoxin release that would resolve with time or did it represent dissemination of infection and worsening capillary leak? Following peripheral pulses, breath sounds and liver edge as a guide to therapy, 40 ml per kg of saline was rapidly administered. The patient developed grunting, laboured respirations and increasing oxygen requirement. The decision to initiate mechanical ventilation was made. Laryngoscopy was difficult, and the patient's decreased residual capacity and alveolar capillary leak lead to rapid oxygen desaturation. The patient was successfully intubated on the third attempt with transient bradycardia but without the need for chest compressions. The child remained intubated for a week but survived. Did we overshoot this child's resuscitative requirements, or was the respiratory failure and difficult intubation inevitable?Because of...

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Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

Cited by 73 publications

References 37 publications

Early fluid accumulation in children with shock and ICU mortality: a matched case–control study

Early fluid accumulation in children with shock and ICU mortality: a matched case–control study

Acute Kidney Injury in a Child Receiving Vancomycin and Piperacillin/Tazobactam

The On-going Challenge of Pediatric Septic Shock: Optimizing Early Identification and Accurate Resuscitation

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