Background

Fluid resuscitation in sepsis is controversial. The only large randomised controlled trial (RCT) of different volume fluid bolus resuscitation in severe infection is the Fluid Expansion as Supportive Therapy (FEAST) study. FEAST was conducted in Africa, in a low resource setting, without access to intensive care; it demonstrated a lower mortality rate in children receiving restrictive fluid therapy (no bolus) compared to those given more liberal fluid therapy (20 ml/kg in the first hour). Despite these findings, the current ACCM guidance continues to recommend a liberal fluid strategy, with up to 60 ml/kg bolus fluid in the first hour of treatment.

Objectives

Review of current evidence relating to fluid resuscitation strategies in sepsis.

Methods

Literature review.

Results

Numerous observational studies support the current ACCM guidance. However, these are all before/after studies in which liberal fluid bolus therapy has formed part of a bundle of care. There have been no large scale RCTs. There have been three small RCTs of different volume resuscitation strategies in settings in which intensive care is available. These studies between them included 316 children and showed no difference in mortality between the restrictive and liberal fluid resuscitation groups. There is also emerging evidence from observational studies that fluid overload in a PICU setting is associated with poor outcomes, both in relation to length of organ support and mortality.

Conclusion

Possible strategies to limit fluid bolus resuscitation will be discussed. Non invasive haemodynamic markers of volume status and evidence based resuscitation targets should be developed to help guide treatment.

Background

Major Congenital Heart Disease (CHD) occurs in about 35/10,000 births.Despite advances in screening programme,up to 50% of major congenital heart diseases were still missed on fetal anomaly scans in UK.

Objectives

To identify missed cases of major congenital heart disease¹ which require immediate cardiac assessment and/or treatment within the first two weeks of a child’s life.

Methods

Babies born from 1^st January 2014- 31^st Dec 2018 who were diagnosed with CHD were identified from local neonatal database. Cases with confirmed post-natal echocardiogram CHD were included and cases identified antenatally were excluded. Isolated cases of ASD and VSD were also excluded from analysis.

Results

48 babies with CHD were identified. 30 were missed on antenatal screening. Of them, 17 had major CHD needing surgical intervention. Out of 17, 11 had major cyanotic heart disease and 6 had major acyanotic heart disease.

Conclusion

Up to 35% of major congenital heart diseases were still missed on foetal anomaly scans in UK. This highlights importance of implementing newborn pulse oximetry screening in conjunction with Foetal Cardiac Screening Protocol to improve detection of major CHD.

References:

NHS Fetal Anomaly Screening Programme - Congenital Heart Disease. Version 2. Apr 2013.

Background

Decelerations are the most common change seen in heart rate during labor. The role of autonomic nervous system (ANS) is well-establish for regulating heart rate (HR) and mean arterial pressure (MAP). Nevertheless, evolution of cholinergic and ß-adrenergic activity remains unclear.

Objectives

To evaluate the effect of sympathetic or/and parasympathetic blockade during 1-min cord occlusion on fetal hemodynamic response.

Methods

Fifteen chronically instrumented fetal sheep received atropine 2.5 mg (n=8), or propranolol 5 mg (n=7), or atropine and propranolol (n=7), or vehicle (n=9), followed by 3 * 1 min of occlusions every 5 minutes.

Results

For control group, HR decrease was immediately observed during 30 seconds with a rising of MAP. Then, a slightly rising of HR and a stable MAP appeared until the end of the occlusion. Blood gases did not change. Cholinergic blockage with atropine attenuated the bradycardia, demonstrated the key role of parasympathetic tone. Atropine exaggerated the initial hypertensive response during the few first seconds with two stages. In contrast, ß-blockade was associated with a greater reduction in HR from the onset of the occlusion and impaired the increase in MAP, confirming the role of parasympathetic activity at the early stage of occlusion and the key role of sympathetic activity after 30 seconds of occlusion. Both injection of atropine and propranolol have showed a gradually HR decline from the second period to the end of occlusion duration, demonstrating a possible role of an unknow mechanism, likely direct myocardium hypoxia.

Conclusion

These data provided a better understanding of fetal regulation during labor.

Background

We have shown that using age-adjusted admission systolic blood pressure (SBP) values (z-scores) may offer advantages in determining the associated mortality risk in a large unselected PICU population.

Objectives

We hypothesized that the SBP z-score risk profile would differ in children admitted with a primary cardiac diagnosis from the rest of the cohort.

Methods

This is a retrospective cohort study using data from 2 cardiac and 2 general PICUs from 2004-2018. We derived SBP z-scores according to the NIH Task Force definitions of normal SBP (1,2). We defined the relationship between mortality and SBP z-scores using logistic regression, adjusted for PIM-2 with the blood pressure component removed.

Results

Data from 34,745 patients were analysed (19,649 cardiac and 15,096 non-cardiac admissions). The relationship between mortality and SBP z-scores are shown in Figure 1. The relationship is U-shaped for general ICU admission, but inverse for cardiac ICU.

Conclusion

Our data show an inverse relationship between SBP z-scores and mortality in the cardiac population. The decreased risk of mortality with hypertension is potentially representative of the favourable outcome in children with good post-operative recovery of heart function. Whether manipulating blood pressure modifies the risk of death needs to be assessed in an interventional trial.

References:

(1) National Institutes of Health. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Available from:https://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf [Accessed 18/6/2018].

(2) National Institutes of Health-Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children-1987.Pediatrics. 1987. 79;1:1-25.