A Clinical and Physiological Prospective Observational Study on the Management of Pediatric Shock in the Post-Fluid Expansion as Supportive Therapy Trial Era.
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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一项关于液体扩张后作为支持性治疗试验时代儿科休克管理的临床和生理前瞻性观察研究。
DOI：
10.1097/pcc.0000000000002968
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发表时间：
2022-07-01
期刊：
影响因子：
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通讯作者：
Maitland K
中科院分区：
文献类型：
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作者：
Obonyo NG;Olupot-Olupot P;Mpoya A;Nteziyaremye J;Chebet M;Uyoga S;Muhindo R;Fanning JP;Shiino K;Chan J;Fraser JF;Maitland K
液体团注复苏在非洲儿童中是有害的。很少有研究评估了仅维持液体策略的生理效应。我们使用病死率、血流动力学和心肌功能终点来描述脓毒性休克液体保守复苏的疗效。乌干达姆巴莱地区转诊医院和肯尼亚基利菲县医院的儿科病房，2013年10月至2015年7月进行。分析了2016年8月至2019年7月的数据。患有严重发热性疾病和灌注受损临床体征的儿童（≥ 60天至≤ 12岁）。IV维持液体（4 mL/kg/hr），除非儿童出现世界卫生组织（WHO）定义的休克（≥ 3个体征），如果休克持续，则接受两次液体推注（20 mL/kg）和输血。在就诊时、复苏期间和第28天收集临床、心电图、超声心动图和实验室数据。结果指标为48小时死亡率、血流动力学正常化和心脏生物标志物。招募了30名儿童（70%为男性），其中6名患有WHO休克，全部死亡（6/6），而非WHO休克中24名死亡中有3名死亡。存活者和非存活者接受的中位液体量相似（13 [四分位距（IQR），9-32] vs 30 mL/kg [28-61 mL/kg]，z = 1.62，p = 0.23）。到24小时，我们观察到中位（IQR）每搏输出量指数（39 mL/m2 [32-42 mL/m2]至47 mL/m2 [41-49 mL/m2]）和收缩功能指标增加：缩短分数从基线的30（27-33）增加至34（31-38），包括无推注治疗的儿童。WHO休克患儿入院时心肌肌钙蛋白（t = 3.58; 95%CI，1.24-1.43; p = 0.02）和α-心房利钠肽（t = 16.5; 95%CI，2.80-67.5; p < 0.01）的平均水平高于非WHO休克患儿。肌钙蛋白升高（> 0.1 μg/mL）和高乳酸血症（> 4 mmol/L）是预测预后的假定指标。仅维持液体治疗使休克中的临床和心肌扰动正常化，而不影响心脏或血流动力学功能，而WHO休克的液体推注管理导致高死亡率。肌钙蛋白和乳酸的心功能不全的生物标志物可能是有希望的结果预测在资源有限的环境中，小儿感染性休克。
Fluid bolus resuscitation in African children is harmful. Little research has evaluated physiologic effects of maintenance-only fluid strategy. We describe the efficacy of fluid-conservative resuscitation of septic shock using case-fatality, hemodynamic, and myocardial function endpoints. 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. Children (≥ 60 d to ≤ 12 yr) with severe febrile illness and clinical signs of impaired perfusion. 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. 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. 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.