Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children: A 10-Year Single-Centre Experience from North India

Objective To describe the clinical and laboratory profle, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India. Methods This retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011–December 2020) including children<12 y with TSS (n=63). Results The median (interquartile range, IQR) age was 5 (2–9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12–17). The primary focus of infection was identifed in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n=11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fuid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n=17). The duration of PICU and hopsital stay was 5 (4–10) and 7 (4–11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive–inotropic score. Conclusion TSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

Risk factors of acute kindey injury in critical patients in emergency department / 中华急诊医学杂志

Objective:To investigate the incidence and risk factors of acute kidney injury in patients admitted to the resuscitation room of the Emergency Department.Methods:Patients were enrolled from the resuscitation room of our hospital from September to December 2018 by a retrospective cohort study. Patients were divided into AKI group and non-AKI group according to whether AKI occurred within seven days after admission. Demographic characteristics, APACHEⅡ score, whether to use nephrotoxic drugs,24-hour fluid volume, and patients survival time were collected. Multivariate regression analysis was used to explore the risk factors for AKI. Cox regression was used to study the effect of the occurrence of AKI on survival and to analyze the influence of AKI severity on the death risk of patients in the resuscitation room.Results:Among 238 critical patients who were finally included, 108 patients developed AKI(45.4%), 83 patients were in AKI stage 1 (34.9%), and 25 patients were in AKI stage 2-3 ( 10.5%).APACHEⅡ score>13( OR=1.11, 95% CI (1.08-1.16), P <0.01), vasoactive drugs ( OR=2.20, c95% CI (1.08-4.49), P=0.03), diabetes mellitus ( OR=2.33, 95% CI (1.23-4.42), P=0.01), and fluid load> 3 L( OR=3.10, 95% CI (1.17-8.25). P=0.02) were independent risk factors for AKI. After adjustment for APACHEⅡ score and age by multivariate COX regression, AKI remained an independent risk factor for death in emergency patients, and the severity of AKI significantly increased the risk of death in these patients(AKI 1: HR=1.45, 95% CI (1.08-2.03), P =0.04; AKI 2~3: HR=3.15, 95% CI (1.49-4.81), P=0.03). Conclusions:AKI occurred commonly in the resuscitation room of the emergency department. APACHE Ⅱ score>13, vasoactive drugs, diabetes, and fluid load>3 L were independent risk factors for AKI. The risk of death increased with the aggravation of AKI severity.

Drogas vasoativas: conhecimento da equipe de enfermagem / Drogas vaso-activas: conocimiento del equipo de enfermería / Vasoative drugs: knowledge of the nursing team

Objetivo avaliar o conhecimento da equipe de enfermagem sobre a administração de drogas vasoativas. Método estudo descritivo, transversal e quantitativo, realizado com 119 profissionais de enfermagem em sete unidades de terapia intensiva. Para a coleta de dados, foi utilizada uma ficha para caracterização da amostra e foi desenvolvido um instrumento contendo 14 questões de múltipla escolha que avaliavam o conhecimento sobre o preparo, a instalação e a manutenção da infusão das drogas vasoativas. O instrumento foi aplicado nos meses de junho e julho de 2015. Na análise das médias das respostas obtidas nas avaliações, foi considerada satisfatória uma nota igual ou superior a 5,0. Resultados as médias foram de 6,6 (dp ±1,6) para os auxiliares de enfermagem, 6,7 (dp ± 1,6) para os técnicos de enfermagem e 7,8 (dp ± 1,0) para os enfermeiros. Conclusão a equipe de enfermagem das unidades estudadas possui conhecimento sobre a administração de drogas vasoativas.

Objetivo evaluar el conocimiento del equipo de enfermería sobre la administración de drogas vaso-activas. Método estudio descriptivo, transversal y cuantitativo, realizado con 119 profesionales de enfermería en siete unidades de terapia intensiva. Para la recolección de datos, fue utilizada una ficha para caracterización de la muestra y fue desarrollado un instrumento conteniendo 14 preguntas de múltiple elección que evaluaban el conocimiento sobre la preparación, la instalación y la manutención de la infusión de las drogas vaso-activas. El instrumento fue aplicado en los meses de junio y julio de 2015. En el análisis de las medias de las respuestas obtenidas en las evaluaciones, fue considerada satisfactoria una nota igual o superior a 5,0. Resultados las medias fueron de 6,6 (dp ±1,6) para los auxiliares de enfermería, 6,7 (dp ± 1,6) para los técnicos de enfermería y 7,8 (dp ± 1,0) para los enfermeros. Conclusión el equipo de enfermería de las unidades estudiadas posee conocimiento sobre la administración de drogas vaso-activas.

Objective to evaluate the knowledge of the nursing team about the administration of vasoactive drugs. Method descriptive, cross-sectional and quantitative study, carried out with 119 nursing professionals in seven intensive care units. A sample characterization card was used to collect data, and an instrument with 14 multiple-choice questions was developed to evaluate the knowledge about the preparation, installation and maintenance of vasoactive drug infusion. The instrument was applied in the months of June and July of 2015. In the analysis of the means of the answers obtained in the evaluations, a score equal or superior to 5.0 was considered satisfactory. Results the averages were 6.6 (± 1.6 SD) for nursing assistants, 6.7 (± 1.6 SD) for nursing technicians and 7.8 (± 1.0 SD) for nurses. Conclusion the nursing team of the studied units has knowledge about the administration of vasoactive drugs.

Clinical observation and psychological intervention on the treatment of severe heart failure by pumping vasoactive drugs under ECG monitoring / 中国生化药物杂志

Objective To analyze the clinical observation and psychological intervention of the vasoactive drugs in the treatment of severe heart failure under ECG monitoring. Methods 100 patients with severe heart failure treated in our hospital from February 2015 to August 2016 were selected as the research object. They were randomly divided into the control group and the experimental group, with 50 patients in each group. The control group was treated with conventional treatment, including oxygen therapy and cardiac and diuretic therapy, the experimental group were given ECG monitoring and infusion of vasoactive drug therapy, using sodium nitroprusside drugs, and psychological intervention on the mental status of patients, strengthen communication and exchanges with patients, increasing confidence in treatment and the treatment compliance of patients. The clinical indexes of the experimental group and the control group were compared and analyzed. Results After the corresponding treatment, the number of invalid cases in the experimental group was 5 cases, the number of effective cases was 30 cases, and the number of effective cases was 15 cases. The number of invalid cases in the control group was 9 cases, the effective number was 27 cases, and the effective cases were 14 cases. The effective rate of treatment in the experimental group was 90%, which was significantly higher than that in the control group, and the effective rate was 82%, with statistical difference (P<0.05). There were no obvious adverse reactions in the experimental group and the control group. Conclusion The application of vasoactive drugs under ECG monitoring in the treatment of severe heart failure has better clinical efficacy and higher safety.

Clinical observation and psychological intervention on the treatment of severe heart failure by pumping vasoactive drugs under ECG monitoring / 中国生化药物杂志

Objective To analyze the clinical observation and psychological intervention of the vasoactive drugs in the treatment of severe heart failure under ECG monitoring. Methods 100 patients with severe heart failure treated in our hospital from February 2015 to August 2016 were selected as the research object. They were randomly divided into the control group and the experimental group, with 50 patients in each group. The control group was treated with conventional treatment, including oxygen therapy and cardiac and diuretic therapy, the experimental group were given ECG monitoring and infusion of vasoactive drug therapy, using sodium nitroprusside drugs, and psychological intervention on the mental status of patients, strengthen communication and exchanges with patients, increasing confidence in treatment and the treatment compliance of patients. The clinical indexes of the experimental group and the control group were compared and analyzed. Results After the corresponding treatment, the number of invalid cases in the experimental group was 5 cases, the number of effective cases was 30 cases, and the number of effective cases was 15 cases. The number of invalid cases in the control group was 9 cases, the effective number was 27 cases, and the effective cases were 14 cases. The effective rate of treatment in the experimental group was 90%, which was significantly higher than that in the control group, and the effective rate was 82%, with statistical difference (P<0.05). There were no obvious adverse reactions in the experimental group and the control group. Conclusion The application of vasoactive drugs under ECG monitoring in the treatment of severe heart failure has better clinical efficacy and higher safety.

Expert consensus for management of pediatric septic shock (2015):Which changes should be focused on? / 中国小儿急救医学

“Expert consensus for the diagnosis and management of septic shock( infectious shock) in children (2015)” has been published based on the “Recommended protocol for diagnosis and treatment of septic shock in children” which was published in 2006.The definition, diagnosis and early management pro-t ocol of pediatric septic shock was revised partly in the latest expert consensus.The goal of the expert consen-sus was to guide the clinical physicians on early identification and early intervention of pediatric septic shock, and reduce mortality and improve prognosis of septic shock in children.

Utilidad de las drogas vasoactivas en la paciente obstétrica en estado crítico / Usefulness of vasoactive drugs in the obstetric patient in critical state

La paciente obstétrica en estado crítico por determinadas afecciones, pueden ser tratadas con drogas vasoactivas y demandan una atención especial por parte del obstetra. Con esta revisión bibliográfica se persiguió dar a conocer las entidades clínicas que requieren la administración de estas drogas en obstetricia, entre ellas: el embolismo del líquido amniótico, el choque séptico, el tromboembolismo pulmonar y las pérdidas de sangre, con persistencia de la inestabilidad hemodinámica después de la reposición adecuada de volumen. Igualmente, se revisan las dosis y los efectos deseados de cada medicamento, según los receptores que estimula y sus posibles efectos detrimentales. La paciente en estado crítico puede presentarse en cualquier institución hospitalaria y, en muchos casos por la urgencia de la situación, puede ser necesario el empleo de las drogas vasoactivas fuera de las unidades de cuidados intensivos, por lo que es necesidad de los obstetras estar a la altura de tales conocimientos.

The obstetric patient in critical state due to certain disorders can be treated with vasoactive drugs and demands a special care by the obstetrician. With this literature review the aim was to make known the clinical entities which require the administration of these drugs in obstetrics, among them: embolism of the amniotic fluid, the septic shock, the lung thromboembolism and blood loss, with persistence of the hemodynamic unsteadiness after the appropriate replacement of volume. Equally, the doses are checked as well as the effect of each medication, according to the receptors they stimulate and their possible harmful reactions. The patient in critical state can attend any hospital institution and, in many cases due to the emergency of the situation, it can be necessary the use of the vasoactive substances outside of the intensive care units, so it is necessary that the obstetricians get to know such knowledge.

The factors affecting pulse transit time during anesthesia / 临床麻醉学杂志

Objective To investigate the factors affecting pulse transit time during anesthesia. Methods Sixty cases of gastrointestinal surgery under general anesthesia were investigated.The pulse transit time (PTT),BP and HR were measured at the time before and after intravenous anes-thesia induction,and at the time before and after the injection of vasoactive drugs,respectively. Results Compared to at the time before injection,HR,SBP and DBP increased significantly,and PTT decreased significantly (P <0.01 )at the time after injection of atropine and ephedrine.Com-pared to at the time before injection,HR and PTT increased significantly,while SBP and DBP de-creased significantly (P < 0.01 )at the time after injection of nicardipine.While HR and PTT de-creased significantly,and SBP,DBP increased significantly (P <0.01 )with the injection of pheny-lephrine.Obvious negative correlation between SBP and PTT was observed before and after induc-tion;meanwhile,only weak correlation between DBP and PTT was observed,and no obvious correla-tion between HR and PTT was detected.SBP and PTT were well negatively correlated with the injec-tion of atropine,ephedrine,nicardipine or phenylephrine.Conclusion All the PTT changes during anesthesia were found to be negatively correlated with the systolic blood pressure.

Guiding value of systemic vascular resistance index for vasoactive drugs used in septic shock patients / 重庆医学

Objective To analyze the influence of vasoactive drugs on hemodynamics in septic shock patients and to explore the guiding value of systemic vascular resistance index (SVRI) for the application of vasoactive drugs .Methods 21 cases of septic shock in ICU from March 2010 to April 2012 were retrospectively analyzed .The PiCCO monitor technique was applied to monitor the he-modynamic parameters including the cardiac index (CI) ,intrathoracic blood volume index (ITBI) ,systemic cenous resistance index (SVRI) and mean arterial pressure(MAP) ,once per 6-8 h .ITBI>850 mL/m2 was taken as the normal criterion .The data of 202 cases meeting the criterion were collected .These cases were divided into two groups according to whether MAP reach 65 mm Hg , the differences of hemodynamic parameters between the two groups were compared .The MAP≥65 mm Hg group was redivided in-to the group 1 ,2 and 3 according to SVRI .Blood characteristics of pressure ,CI and ITBI were compared among these 3 groups .Re-sults The ITBI value in the MAP<65 mm Hg group and the MAP≥65 mm Hg group was higher than the normal value .The CI and SVRI values in the MAP≥65 mm Hg group were higher than those in the MAP< 65 mm Hg group(P<0 .05) ,while the ITBI value had no difference between the two groups .The ITBI values in the three groups with different SVRI all were higher than the upper normal limit ,furthermore ,in the comparisons among 3 groups ,only comparison between the group 1 and the group 3 had sta-tistical difference(P= 0 .47) .When SVRI was lower ,the CI value was higher than the normal value .Along with the increase of SVRI ,MAP increased gradually ,and CI gradually declined .When SVRI was too high ,MAP had no significant increase ,but the CI value was lower than the lower limit .Conclusion The SVRI monitoring by PiCCO can help to guide the application of vasoactive drugs in septic shock patients ,lower SVRI means the declined vascular reaction and higher SVRI indicates the low cardiac function , moreover blood pressure can not be further enhanced by vascular excessive contraction .

Hemorragia variceal: terapia con drogas vasoactivas ¿siempre o en casos seleccionados? / Variceal hemorrhage: pharmacological therapy: always or in selected cases only?

One of the most relevant complications of portal hypertension in cirrhosis is the development of gastroesophageal varices. They are present in 50 percent of patients with cirrhosis at the diagnosis. The risk of bleeding depends on the degree of portal hypertension and the severity of liver disease. Variceal hemorrhage is the most common lethal complication of cirrhosis. In the last decades there had been numerous clinical trials involving different treatment options for variceal bleeding (pharmacological, endoscopic and surgery) trying to establish the best treatment strategy. Since the rise in portal pressure is the cause of variceal rupture, therapies that can decrease portal pressure have a theoretical rationale for their use. Endoscopic treatment, although effective, has no effect on portal pressure. Vasoactive agents (vasopressin and its analogue terlipressin, somatostatin and its analogue octreotide) cause splanchnic vasoconstriction and decrease portal pressure. Pharmacological treatments have the advantage that they can be easily administered, and started as soon as the diagnosis of variceal bleeding is suspected. This makes pharmacological treatment especially attractive for centers that have no chance of emergency endoscopy. At this moment there is sufficient evidence to recommend combined treatment with vasoactive drugs and endoscopy for the control of variceal hemorrhage.

Una de las principales complicaciones de los pacientes cirróticos con hipertensión portal es el desarrollo de várices gastroesofágicas. Éstas están presentes al momento del diagnóstico en alrededor de 50 por ciento de los pacientes con cirrosis. La hemorragia variceal es la complicación letal más frecuente en los pacientes cirróticos. En las últimas décadas se han realizado múltiples esfuerzos para lograr definir la mejor combinación de técnicas (endoscópicas, farmacológicas y quirúrgicas) para disminuir la morbimortalidad asociada a la hemorragia variceal. Dado que la causa de la ruptura de las várices es un aumento de la presión portal, todas las medidas que logren disminuirla son medidas racionales para lograr detener la hemorragia. El tratamiento endoscópico, si bien efectivo, no afecta la fisiopatología de la hemorragia variceal. Las drogas vasoconstrictoras (vasopresina y su derivado terlipresina o somatostatina y su derivado octreotide) actúan a nivel de la circulación esplácnica, disminuyendo el flujo sanguíneo. El tratamiento farmacológico tiene la ventaja de ser fácilmente administrado, incluso antes de realizar una endoscopia, toda vez que se sospecha una hemorragia variceal, lo que hace particularmente atractivo su uso en centros en que no se cuenta con endoscopia de urgencia. Actualmente, existe suficiente evidencia para recomendar el uso de estos fármacos como terapia adicional a la endoscopia ante la sospecha de una hemorragia variceal.

Frequência de insuficiência adrenal em crianças com sepse / Adrenal insufficiency in children with sepsis

OBJETIVO: Determinar a frequência de insuficiência adrenal em crianças com diagnóstico de sepse internadas em unidades de terapia intensiva pediátrica e estabelecer a associação entre a função adrenal e a necessidade e tempo de utilização de drogas vasoativas, tempo de ventilação mecânica e mortalidade. MÉTODOS: Estudo de coorte destinado a avaliar a incidência de insuficiência adrenal em crianças com idade de 29 dias a 12 anos e diagnóstico de sepse por meio do teste de estímulo com ACTH. RESULTADOS: Foram incluídas 39 crianças no estudo. A freqüência de insuficiência adrenal foi de 30,7 por cento, totalizando 12 pacientes. Observou-se maior necessidade de drogas vasoativas, bem como no tempo de ventilação mecânica em crianças com insuficiência adrenal, porém sem significância estatística. A curva de Kaplan-Meyer mostrou menor sobrevivência no grupo de crianças com insuficiência adrenal, sem significância estatística (p = 0,1263). Não houve diferenças entre os grupos com e sem insuficiência adrenal quando avaliados tempo de ventilação mecânica, necessidade de drogas vasoativas, tipo de infecção e presença de doenças crônicas. CONCLUSÃO: O estudo determinou a frequência de insuficiência adrenal em crianças com sepse e sua relação com maior mortalidade nos primeiros 28 dias de internação. Não se encontrou significância na associação entre insuficiência adrenal e tempo de ventilação mecânica ou necessidade de drogas vasoativas.

OBJECTIVE: To determine the frequency of adrenal insufficiency in children diagnosed with sepsis that were staying in pediatric intensive care units and to establish the association between adrenal function and the use of vasoactive drugs, mechanical ventilation time and mortality. METHODS: A cohort-designed study was conducted to assess the incidence of adrenal insufficiency in children aged 29 days to 12 years who were diagnosed with sepsis using the adrenocorticotropic hormone (ACTH) stimulation test. RESULTS: Thirty-nine children were included in the study. The frequency of adrenal insufficiency was 30.7 percent (12 patients). Children with adrenal insufficiency had an increased need for vasoactive drugs as well as longer mechanical ventilation times; however, the differences were not statistically significant. A Kaplan-Meier curve indicated lower survival rates among the adrenal insufficiency children, but the differences were not statistically significant (p = 0.1263). No differences were identified between the adrenal sufficiency and adrenal insufficiency groups in regards to mechanical ventilation time, use of vasoactive drugs, infection type and chronic disease. CONCLUSION: This study determined the frequency of adrenal insufficiency in children with sepsis and its relationship to increased mortality within the first 28 post-admission days. No statistically significant association was found between adrenal insufficiency and mechanical ventilation time or the use of vasoactive drugs.

Balance hídrico y uso de drogas vasoactivas como predictores de mortalidad en pacientes con lesión pulmonar aguda y síndrome de distress respiratorio agudo: Estudio multicéntrico / Water balance and drug use vasoactive as predictors of mortality in patients with acute lung injury and respiratory distress syndrome acute: Multicentric study

Introducción. Desde la década de 1990, la mortalidad por el síndrome de distress respiratorio agudo ha disminuido. Sin embargo, no hay datos concluyentes acerca de que una nueva estrategia sea responsable de esta evolución (p. ej., el manejo de los fluidos). Aún no se ha dilucidado cuál es la cantidad óptima de fluidos para tratar a estos pacientes. Clásicamente la discusión se basa en estrategias liberales o conservadoras. Objetivo. El objetivo principal fue conocer cómo impacta el balance de fluidos asociado con el uso de noradrenalina en la evolución. Materiales y métodos. Se llevó a cabo un estudio observacional en 87 pacientes con síndrome de distress respiratorio agudo entre agosto y diciembre de 2007, en tres hospitales universitarios. Se utilizó el protocolo de tratamiento estándar de las Unidades de Cuidados Intensivos permitiendo la expansión en forma liberal cuando se sospechaba hipovolemia no resuelta. Resultados. Se detectaron tres situaciones de mayor riesgo y mala evolución: a) la asociación de noradrenalina y balance positivo de fluidos <2500 ml en las primeras 24 h (OR: 5,4; IC95%: 2,1-13,9; p = 0,0004), b) la asociación de noradrenalina y balance acumulativo >5500 ml en las primeras 72 h (OR: 2,7; IC95%: 1,1-6,5; p = 0,032) y c) pacientes con puntaje APACHE II >21, noradrenalina y balance positivo <2500 ml en las primeras 24 h (OR: 8,4; IC95%: 1,8-39; p = 0,008). Conclusión. La utilización de noradrenalina y escaso fluido en estrategias de reanimación que intentan "proteger" al pulmón con lesión parece no ser adecuada, según este estudio observacional(AU)

Introduction. Recent studies have shown an important decline in mortality due to acute respiratory distress syndrome since 1990. However, to date, there is no definitive evidence to demonstrate that any mode of specific therapeutic approach (i.e., fluid management) make a difference in survival or other outcome measures. The optimal fluid management of acute lung injury is not established. Classically there are two arguments: the wet or dry strategy. Objective. The main goal was to know the impact on outcome of fluid balance and the use of noradrenaline as a vasoactive drug. Materials and methods. In this observational study, 87 ventilated patients with acute respiratory distress syndrome were included from August to December 2007 in three University Critical Care Units. A standard protocol of resuscitation was used, fluid intake was liberal only in hypovolemic patients. Results. Three categories of risk and poor outcome were detected: a) noradrenaline plus positive fluid balance <2500 mL in first day (OR: 5.4; IC95%: 2.1-13.9; p = 0.0004), b) noradrenaline plus a cumulative positive balance >550 mL in first 72 hours (OR: 2.7; IC95%: 1.1-6.5; p = 0.032), c) APACHE II >21 and noradrenaline plus positive fluid balance <2500 mL in the first day (OR: 8.4; IC95%: 1.8-39; p = 0.008). Conclusion. The use of noradrenaline and conservative resuscitation with fluid in critically ill patients with acute respiratory distress syndrome in order to minimize the risk of excessive fluid therapy was associated with poor outcome and higher mortality(AU)