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      Improving fluid resuscitation in pediatric shock with LifeFlow ®: a retrospective case series and review of the literature

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          Abstract

          Rapid delivery of an intravenous fluid bolus is commonly used in pediatric emergency care for the treatment of shock and hypotension. Early fluid delivery targeted at shock reversal results in improved patient outcomes, yet current methods of fluid resuscitation often limit the ability of providers to achieve fluid delivery goals. We report on the early clinical experience of a new technique for rapid fluid resuscitation. The LifeFlow ® infuser is a manually operated device that combines a syringe, automatic check valve, and high-flow tubing set with an ergonomic handle to enable faster and more efficient delivery of fluid by a single health care provider. LifeFlow is currently FDA-cleared for the delivery of crystalloid and colloids. Four cases are presented in which the LifeFlow device was used for emergent fluid resuscitation: a 6-month-old with septic shock, a 2-year-old with intussusception and shock, an 11-year-old with pneumonia and septic shock, and a 15-year-old with trauma and hemorrhagic shock.

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          Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome.

          M J Westerman, R. Orr, Michelle Dragotta … (2003)
          Experimental and clinical studies of septic shock support the concept that early resuscitation with fluid and inotropic therapies improves survival in a time-dependent manner. The new American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines for hemodynamic support of newborns and children in septic shock recommend this therapeutic approach. The objective of this study was to determine whether early septic shock reversal and use of resuscitation practice consistent with the new ACCM-PALS Guidelines by community physicians is associated with improved outcome. A 9-year (January 1993-December 2001) retrospective cohort study was conducted of 91 infants and children who presented to local community hospitals with septic shock and required transport to Children's Hospital of Pittsburgh. Shock reversal (defined by return of normal systolic blood pressure and capillary refill time), resuscitation practice concurrence with ACCM-PALS Guidelines, and hospital mortality were measured. Overall, 26 (29%) patients died. Community physicians successfully achieved shock reversal in 24 (26%) patients at a median time of 75 minutes (when the transport team arrived at the patient's bedside), which was associated with 96% survival and >9-fold increased odds of survival (9.49 [1.07-83.89]). Each additional hour of persistent shock was associated with >2-fold increased odds of mortality (2.29 [1.19-4.44]). Nonsurvivors, compared with survivors, were treated with more inotropic therapies (dopamine/dobutamine [42% vs 20%] and epinephrine/norepinephrine [42% vs 6%]) but not increased fluid therapy (median volume; 32.9 mL/kg vs 20.0 mL/kg). Resuscitation practice was consistent with ACCM-PALS Guidelines in only 27 (30%) patients; however, when practice was in agreement with guideline recommendations, a lower mortality was observed (8% vs 38%). Early recognition and aggressive resuscitation of pediatric-neonatal septic shock by community physicians can save lives. Educational programs that promote ACCM-PALS recommended rapid, stepwise escalations in fluid as well as inotropic therapies may have value in improving outcomes in these children.
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            Adherence to PALS Sepsis Guidelines and Hospital Length of Stay.

            Raina Paul, Mark Neuman, Michael C Monuteaux … (2012)
            Few studies have evaluated sepsis guideline adherence in a tertiary pediatric emergency department setting. We sought to evaluate (1) adherence to 2006 Pediatric Advanced Life Support guidelines for severe sepsis and septic shock (SS), (2) barriers to adherence, and (3) hospital length of stay (LOS) contingent on guideline adherence. Prospective cohort study of children presenting to a large urban academic pediatric emergency department with SS. Adherence to 5 algorithmic time-specific goals was reviewed: early recognition of SS, obtaining vascular access, administering intravenous fluids, delivery of vasopressors for fluid refractory shock, and antibiotic administration. Adherence to each time-defined goal and adherence to all 5 components as a bundle were reviewed. A detailed electronic medical record analysis evaluated adherence barriers. The association between guideline adherence and hospital LOS was evaluated by using multivariate negative binomial regression. A total of 126 patients had severe sepsis (14%) or septic shock (86%). The median age was 9 years (interquartile range, 3-16). There was a 37% and 35% adherence rate to fluid and inotrope guidelines, respectively. Nineteen percent adhered to the 5-component bundle. Patients who received 60 mL/kg of intravenous fluids within 60 minutes had a 57% shorter hospital LOS (P = .039) than children who did not. Complete bundle adherence resulted in a 57% shorter hospital LOS (P = .009). Overall adherence to Pediatric Advanced Life Support sepsis guidelines was low; however, when patients were managed within the guideline's recommendations, patients had significantly shorter duration of hospitalization.
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              Role of early fluid resuscitation in pediatric septic shock.

              J Carcillo, A Zaritsky, J. Davis (1991)
              To examine the association of the volume of fluid administered at 1 and 6 hours after presentation, with survival and the occurrence of the adult respiratory distress syndrome, cardiogenic pulmonary edema, and persistent hypovolemia during the resuscitation of children with septic shock. All pediatric patients with septic shock presenting to the emergency department over a 6-year period and having a pulmonary artery catheter inserted by 6 hours after presentation were identified. Patients were analyzed together and in three groups based on fluid volume in the first hour: group 1, less than 20 mL/kg; group 2, 20 to 40 mL/kg; and group 3, more than 40 mL/kg. Adult respiratory distress syndrome was diagnosed by the presence of alveolar infiltrates, hypoxemia, and a pulmonary capillary wedge pressure of 15 mm Hg or less. Cardiogenic pulmonary edema was diagnosed similarly, except the pulmonary capillary wedge pressure was greater than 15 mm Hg. Hypovolemia was diagnosed by the presence of oliguria, hypotension, and a pulmonary capillary wedge pressure of 8 mm Hg or less 6 hours after presentation. We identified 34 patients (median age, 13.5 months). At 1 and 6 hours, respectively, group 1 (n = 14) received 11 +/- 6 and 71 +/- 29 mL/kg (mean +/- SD) of fluid; group 2 received 32 +/- 5 and 108 +/- 54 mL/kg of fluid; and group 3 received 69 +/- 19 and 117 +/- 29 mL/kg of fluid. Survival in group 3 (eight of nine patients) was significantly better than in group 1 (six of 14 patients) or group 2 (four of 11 patients). Adult respiratory distress syndrome developed in 11 patients (32%) and cardiogenic pulmonary edema developed in five patients (15%). Having adult respiratory distress syndrome was associated with increased mortality, but adult respiratory distress syndrome was not increased in any group. Similarly, cardiogenic pulmonary edema was not associated with the fluid volume received or with decreased survival. Hypovolemia occurred in six patients in group 1 and two patients in group 2; all eight subsequently died. Rapid fluid resuscitation in excess of 40 mL/kg in the first hour following emergency department presentation was associated with improved survival, decreased occurrence of persistent hypovolemia, and no increase in the risk of cardiogenic pulmonary edema or adult respiratory distress syndrome in this group of pediatric patients with septic shock.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Open Access Emerg Med
                Journal ID (iso-abbrev): Open Access Emerg Med
                Journal ID (publisher-id): OAEM
                Journal ID (pmc): oaem
                Title: Open Access Emergency Medicine : OAEM
                Publisher: Dove
                ISSN (Electronic): 1179-1500
                Publication date (Electronic): 24 April 2019
                Publication date Collection: 2019
                Volume: 11
                Pages: 87-93
                Affiliations
                [1 ]Department of Pediatrics, Division of Pediatric Critical Care, WakeMed Health and Hospitals , Raleigh, NC, USA
                [2 ]410 Medical, Inc , Durham, NC, USA
                [3 ]Department of Pediatrics, University of North Carolina School of Medicine , Chapel Hill, NC, USA
                [4 ]Department of Pediatrics, Duke University School of Medicine , Durham, NC, USA
                [5 ]Department of Emergency Medicine, University of North Carolina School of Medicine , Chapel Hill, NC, USA
                Author notes
                Correspondence: Mark PiehlWakeMed Health and Hospitals , 3024 New Bern Avenue, Raleigh, NC27610, USATel +1 919 350 8545Fax +1 919 350 8677Email mpiehl@ 123456wakemed.org
                Author information
                http://orcid.org/0000-0001-6483-3317
                http://orcid.org/0000-0002-5397-9182
                http://orcid.org/0000-0001-9584-0579
                Article
                Publisher ID: 188110
                DOI: 10.2147/OAEM.S188110
                PMC ID: 6503651
                SO-VID: 9e4323f1-83bb-4421-931b-45515fed7a60
                Copyright © © 2019 Piehl et al.
                License:

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                Date received : 19 September 2018
                Date accepted : 28 February 2019
                Page count
                Figures: 2, References: 40, Pages: 7
                Categories
                Subject: Case Series

                Keywords: hypotension,sepsis,septic shock,fluid therapy
                Data availability:
                Keywords: hypotension, sepsis, septic shock, fluid therapy

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