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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
File | Description | Size | Format | |
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MAPS Supplement_PCCMaccepted.docx | Supporting information | 1.4 MB | Microsoft Word | View/Open |
MAPSManuscript_Accepted_grantcodes.pdf | Accepted version | 1.02 MB | Adobe PDF | View/Open |
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 |