Paediatrics (RCH) - Research Publications

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    Does fluid bolus therapy increase blood pressure in children with sepsis?
    Long, E ; Babl, FE ; Oakley, E ; Hopper, S ; Sheridan, B ; Duke, T (WILEY, 2020-02)
    OBJECTIVE: To describe the effect of fluid bolus therapy (FBT) on blood pressure in children with sepsis. Secondary outcomes included the effect of FBT on systemic vascular resistance, shock index and shock phenotype (warm or cold). METHODS: This was a prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Participants were children meeting international consensus criteria for sepsis who received FBT for tachycardia or hypotension. FBT was defined as 10-20 mL/kg of 0.9% saline. Mean blood pressure (MBP) was recorded at baseline, 5 and 60 min after FBT. Total systemic vascular resistance index (TSVRi), shock index, and shock phenotype were derived for each time point. Hypotension was defined as MBP <55 + 1.5 × age (years). Warm shock was defined as TSVRi <800 dyne s/cm5 /m2 . RESULTS: Fifty fluid boluses were recorded in 41 children. Median MBP was 78 mmHg (interquartile range [IQR] 63-86) at baseline, 72 mmHg (IQR 60-82) at 5 min, and 75 mmHg (IQR 66-84) at 60 min. Hypotension was observed in 16% at baseline, 26% at 5 min and 17% at 60 min. Median TSVRi was 1580 dyne s/cm5 /m2 (IQR 1242-2206) at baseline, 1254 dyne s/cm5 /m2 (IQR 1027-1787) at 5 min, and 1850 dyne s/cm5 /m2 (IQR 1265-2140) at 60 min. Median shock index was 1.60 (IQR 1.34-1.90) at baseline, 1.49 (IQR 1.25-1.76) at 5 min and 1.37 (IQR 1.22-1.61) at 60 min. Two percent of cases had warm shock at baseline, 12% at 5 min and 2% at 60 min. CONCLUSIONS: MBP initially decreased following FBT for paediatric sepsis, returning towards baseline over the subsequent 60 min. The utility of FBT for increasing MBP and its effect on patient-centred outcomes in children with sepsis warrants further exploration.
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    Effect of Fluid Bolus Therapy on Extravascular Lung Water Measured by Lung Ultrasound in Children With a Presumptive Clinical Diagnosis of Sepsis
    Long, E ; O'Brien, A ; Duke, T ; Oakley, E ; Babl, FE (WILEY, 2019-06)
    OBJECTIVES: Fluid bolus therapy for the treatment of sepsis may lead to the accumulation of extravascular lung water (EVLW) and result in respiratory dysfunction. We aimed to assess changes in EVLW using lung ultrasound (US) in children with a presumptive clinical diagnosis of sepsis after fluid bolus therapy and correlate these changes with respiratory signs. METHODS: This work was a prospective observational study set in the emergency department of the Royal Children's Hospital. Children meeting international consensus criteria for sepsis receiving fluid bolus therapy were included. Respiratory signs were recorded, and lung US examinations were performed immediately before, 5 minutes after, and 60 minutes after fluid bolus therapy. A pediatric emergency physician blinded to the participants' identities and timing of US calculated an EVLW score from lung US. Results-Fifty fluid boluses were recorded in 41 children. The lung US score (range, 0-8) increased over the study period: median, 1 (interquartile range, 0-2) before fluid bolus therapy, 1 (interquartile range, 0-3) 5 minutes after fluid bolus therapy, and 3 (interquartile range, 1-4) 60 minutes after fluid bolus therapy. Respiratory effort, but not the respiratory rate or the presence of rales, increased over the study period and was correlated with the lung US score (ρ = 0.33; P = .02). CONCLUSIONS: Extravascular lung water as measured by lung US increased after fluid bolus therapy in septic children and was correlated with an increase in the respiratory distress score. The respiratory rate and the presence of rales did not change over the study period. The role of lung US for titrating fluid bolus therapy in sepsis warrants further investigation.
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    Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis
    Long, E ; Duke, T ; Oakley, E ; O'Brien, A ; Sheridan, B ; Babl, FE (WILEY, 2018-08)
    OBJECTIVE: The intent of fluid bolus therapy (FBT) is to increase cardiac output and tissue perfusion, yet only 50% of septic children are fluid responsive. We evaluated respiratory variation of inferior vena cava (IVC) diameter as a predictor of fluid responsiveness. METHODS: A prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Patients were spontaneously ventilating children treated with FBT for sepsis-induced acute circulatory failure. IVC ultrasound was performed prior to FBT. Trans-thoracic echocardiography was performed prior to, 5 and 60 min after FBT. IVC collapsibility index and stroke distance were calculated by a blinded Paediatric Emergency Physician and blinded Paediatric Cardiologist, respectively. RESULTS: Thirty-nine fluid boluses were recorded in 33 children, 28/39 (72%) of which met criteria for fluid responsiveness at 5 min, which was sustained in 2/28 (7%) of initial fluid responders at 60 min. Sensitivity and specificity (95% confidence interval) of IVC collapsibility index were 0.44 (0.25-0.65) and 0.33 (0.10-0.65) with an area under the receiver operator characteristics curve (95% confidence interval) of 0.38 (0.23-0.55) at 5 min. Test characteristics 60 min after fluid bolus administration were not meaningful because of the infrequency of sustained fluid responsiveness in this patient group. There was no significant correlation between IVC collapsibility and fluid responsiveness at 5 or 60 min. CONCLUSIONS: IVC collapsibility has poor test characteristics for predicting fluid responsiveness in spontaneously ventilating children with sepsis.
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    An observational study using ultrasound to assess physiological changes following fluid bolus administration in paediatric sepsis in the emergency department
    Long, E ; Oakley, E ; Babl, FE ; Duke, T (BMC, 2016-07-15)
    BACKGROUND: Fluid bolus administration is widely recommended as part of the initial treatment of paediatric sepsis, though the physiological benefits and harms are unclear. The primary aim of this study is to determine the effect of fluid bolus administration on cardiac index (CI). Secondary aims are to determine the effect of fluid bolus administration on extra-vascular lung water (EVLW), whether fluid responsiveness can be predicted by inferior vena cava (IVC) collapsibility, and whether fluid responsiveness correlates with changes in vital signs. METHODS/DESIGN: A prospective observational study of children presenting to the Emergency Department of The Royal Children's Hospital with clinically diagnosed sepsis requiring fluid bolus administration. Prior to fluid bolus administration, an echocardiogram, lung ultrasound, and IVC ultrasound will be performed, and vital signs recorded. These will be repeated 5 min after and 60 min after fluid bolus administration. Recorded echocardiograms and lung/IVC ultrasound will be evaluated independently by a paediatric cardiologist and paediatric emergency physician, respectively, blinded to the patient identity and time of examination relative to time of fluid bolus administration. Fifty patients will be enrolled in the study based on a precision based sample size calculation. Results will be analysed for change in CI and change in EVLW 5 min after and 60 min after fluid bolus administration compared to baseline, IVC collapsibility as a predictor of fluid responsiveness, and the relationship between fluid responsiveness and changes in vital signs. DISCUSSION: This study will explore assumptions about the effect of fluid boluses on CI in children with sepsis, and will provide evidence for secondary effects on other organ systems. This may lead to novel methods for assessment and decision making in the initial resuscitation of paediatric sepsis in clinical and research settings, and will likely influence the design of future interventional studies in this arena. TRIAL REGISTRATION: The study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12614000824662; 04 August 2014).