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1.
Crit Care Med ; 37(2): 666-88, 2009 Feb.
Article in English | MEDLINE | ID: mdl-19325359

ABSTRACT

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.


Subject(s)
Hemodynamics , Pediatrics , Shock, Septic/therapy , Child , Child, Preschool , Extracorporeal Circulation , Humans , Infant , Infant, Newborn
2.
Brain Dev ; 30(1): 86-90, 2008 Jan.
Article in English | MEDLINE | ID: mdl-17614229

ABSTRACT

A 20-year-old female with hemiplegic migraine was treated during an acute attack with intravenous verapamil, which reproducibly resolved the headache within 20 min but did not affect her hemiplegia. Magnetic resonance (MR) and computed tomographic (CT) angiography and perfusion performed during the attack showed vasodilation and hyperperfusion. Cerebral hyperperfusion concurrent with hemiplegia suggests a dissociation between cerebral perfusion and neuronal function in hemiplegic migraine. The beneficial effect of verapamil on headache but not hemiplegia suggests a distinct mechanism for pain and neuronal dysfunction in hemiplegic migraine, with the beneficial effect on pain not due to vasodilation.


Subject(s)
Cerebrovascular Circulation/drug effects , Cerebrovascular Disorders/physiopathology , Hyperemia/physiopathology , Migraine with Aura/drug therapy , Migraine with Aura/physiopathology , Verapamil/administration & dosage , Adult , Brain/blood supply , Brain/drug effects , Brain/physiopathology , Cerebral Angiography , Cerebral Arteries/diagnostic imaging , Cerebral Arteries/drug effects , Cerebral Arteries/physiopathology , Cerebrovascular Circulation/physiology , Cerebrovascular Disorders/diagnostic imaging , Female , Gadolinium , Hemiplegia/diagnostic imaging , Hemiplegia/etiology , Hemiplegia/physiopathology , Humans , Hyperemia/diagnostic imaging , Injections, Intravenous , Magnetic Resonance Imaging , Migraine with Aura/diagnostic imaging , Pain/drug therapy , Pain/etiology , Pain/physiopathology , Tomography, X-Ray Computed , Treatment Outcome , Vasodilation/drug effects , Vasodilation/physiology , Vasodilator Agents/administration & dosage
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