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A clinical and physiological prospective observational study on the management of pediatric shock in the post-fluid expansion as supportive therapy trial era

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Title: A clinical and physiological prospective observational study on the management of pediatric shock in the post-fluid expansion as supportive therapy trial era
Authors: Obonyo, N
Olupot-Olupot, P
Mpoya, A
Nteziyaremye, J
Chebet, M
Uyoga, S
Muhindo, R
Fanning, J
Shiino, K
Chan, J
Fraser, JF
Maitland, K
Item Type: Journal Article
Abstract: Objectives: Fluid bolus resuscitation in African children is harmful. Little research has evaluated physiologic effects of maintenance-only fluid strategy. Design: We describe the efficacy of fluid-conservative resuscitation of septic shock using case-fatality, hemodynamic, and myocardial function endpoints. Setting: Pediatric wards of Mbale Regional Referral Hospital, Uganda, and Kilifi County Hospital, Kenya, conducted between October 2013 and July 2015. Data were analysed from August 2016 to July 2019. Patients: Children (≥ 60 d to ≤ 12 yr) with severe febrile illness and clinical signs of impaired perfusion. Interventions: IV maintenance fluid (4 mL/kg/hr) unless children had World Health Organization (WHO) defined shock (≥ 3 signs) where they received two fluid boluses (20 mL/kg) and transfusion if shock persisted. Clinical, electrocardiographic, echocardiographic, and laboratory data were collected at presentation, during resuscitation and on day 28. Outcome measures were 48-hour mortality, normalization of hemodynamics, and cardiac biomarkers. Measurement and Main Results: Thirty children (70% males) were recruited, six had WHO shock, all of whom died (6/6) versus three of 24 deaths in the non-WHO shock. Median fluid volume received by survivors and nonsurvivors were similar (13 [interquartile range (IQR), 9–32] vs 30 mL/kg [28–61 mL/kg], z = 1.62, p = 0.23). By 24 hours, we observed increases in median (IQR) stroke volume index (39 mL/m2 [32–42 mL/m2] to 47 mL/m2 [41–49 mL/m2]) and a measure of systolic function: fractional shortening from 30 (27–33) to 34 (31–38) from baseline including children managed with no-bolus. Children with WHO shock had a higher mean level of cardiac troponin (t = 3.58; 95% CI, 1.24–1.43; p = 0.02) and alpha-atrial natriuretic peptide (t = 16.5; 95% CI, 2.80–67.5; p < 0.01) at admission compared with non-WHO shock. Elevated troponin (> 0.1 μg/mL) and hyperlactatemia (> 4 mmol/L) were putative makers predicting outcome. Conclusions: Maintenance-only fluid therapy normalized clinical and myocardial perturbations in shock without compromising cardiac or hemodynamic function whereas fluid-bolus management of WHO shock resulted in high fatality. Troponin and lactate biomarkers of cardiac dysfunction could be promising outcome predictors in pediatric septic shock in resource-limited settings.
Issue Date: Jul-2022
Date of Acceptance: 19-Mar-2022
URI: http://hdl.handle.net/10044/1/96637
DOI: 10.1097/PCC.0000000000002968
ISSN: 1529-7535
Publisher: Lippincott, Williams & Wilkins
Start Page: 502
End Page: 513
Journal / Book Title: Pediatric Critical Care Medicine
Volume: 23
Issue: 7
Copyright Statement: © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Sponsor/Funder: Wellcome Trust
Wellcome Trust
Wellcome Trust
Funder's Grant Number: 105603/Z/14/Z
100693/Z/12/Z
203077/Z/16/Z (C161)
Keywords: 1110 Nursing
1114 Paediatrics and Reproductive Medicine
Pediatrics
Publication Status: Published
Online Publication Date: 2022-04-21
Appears in Collections:Department of Surgery and Cancer
Department of Infectious Diseases
Faculty of Medicine