ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis

PURPOSE Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. METHODS A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. RESULTS 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations. CONCLUSIONS Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Płynoterapia śródoperacyjna w praktyce pediatrycznej — porównanie wybranych płynów infuzyjnych

Background: Fluid therapy is essential for safe perioperative management. Numerous reports of serious complications, including brain damage and death of children, as a result of inappropriate fluid management, have been published. The aim of this study was to assess the effects of intraoperative fluids on serum glucose and electrolytes concentrations as well as serum osmolality. Methods: 91children, ASA I and II, undergoing elective ENT surgery were enrolled to this prospective, randomized, open-label study. They were randomly assigned to receive: group G5W: 5% glucose in water solution, group GNaCl: 3.33% glucose in 0.3% NaCl, and group RA: Ringer’s acetate. Serum glucose, sodium, potassium, phosphate concentrations and serum osmolality were analysed before induction of anaesthesia, immediately after completion of surgery and 60 min later. Results: Postoperative hyperglycaemia was observed in 94% of children in group G5W and in 37% of group GNaCl. In all the groups glucose concentration increased significantly after surgery. Postoperative hyponatraemia occurred in 36% of patients in the group G5W, and in 3.7% in the group GNaCl. Neither hyperglycaemia nor hyponatremia occurred in the group RA. Postoperative osmolality decreased significantly in groups G5W and GNaCl and remained unchanged in the group RA. Conclusions: Ringer’s acetate did not cause significant changes in glucose and electrolyte concentrations, so it seems to be the safest for intraoperative use in children undergoing elective surgery. Hypotonic fluids may cause hyperglycaemia and hyponatraemia so they should be avoided intraoperatively.Background: Fluid therapy is essential for safe perioperative management. Numerous reports of serious complications, including brain damage and death of children, as a result of inappropriate fluid management, have been published. The aim of this study was to assess the effects of intraoperative fluids on serum glucose and electrolytes concentrations as well as serum osmolality. Methods: 91children, ASA I and II, undergoing elective ENT surgery were enrolled to this prospective, randomized, open-label study. They were randomly assigned to receive: group G5W: 5% glucose in water solution, group GNaCl: 3.33% glucose in 0.3% NaCl, and group RA: Ringer’s acetate. Serum glucose, sodium, potassium, phosphate concentrations and serum osmolality were analysed before induction of anaesthesia, immediately after completion of surgery and 60 min later. Results. Postoperative hyperglycaemia was observed in 94% of children in group G5W and in 37% of group GNaCl. In all the groups glucose concentration increased significantly after surgery. Postoperative hyponatraemia occurred in 36% of patients in the group G5W, and in 3.7% in the group GNaCl. Neither hyperglycaemia nor hyponatremia occurred in the group RA. Postoperative osmolality decreased significantly in groups G5W and GNaCl and remained unchanged in the group RA. Conclusions: Ringer’s acetate did not cause significant changes in glucose and electrolyte concentrations, so it seems to be the safest for intraoperative use in children undergoing elective surgery. Hypotonic fluids may cause hyperglycaemia and hyponatraemia so they should be avoided intraoperatively

Przedoperacyjna doustna podaż roztworu węglowodanów u dzieci — ocena tolerancji i odpowiedzi metabolicznej — doniesienie wstępne

Background: The need for long preoperative fasting has been questioned. Recent data shows that intake of oral carbohydrate-containing clear fluid prior to anaesthesia is safe and may have positive impact on recovery, metabolic status and improve glucose tolerance. Such solutions are routinely used in adults but not children. The aim of this study was to evaluate safety, tolerance and influence of oral carbohydrate on selected metabolic parameters in children.Methods: With the ethics committee approval and parental informed consent 20 children, aged 4–17 years, ASA status I or II, scheduled for abdominal or thoracic surgery were randomized to group 1 — receiving a 12.6% carbohydrate-containing drink (10 mL kg-1 the evening before surgery and 2 hours before anaesthesia) or control group 2 — fasting. Serum glucose and insulin concentration were measured four times: before and after anaesthesia, in the evening after surgery and the following morning. IGF-1 concentration was measured once, before surgery. Insulin resistance was assessed by the HOMA-IR equation.Results: Oral carbohydrate solution was well tolerated and no adverse events were noted. Glucose concentrations were within the normal range in both groups. Insulin concentration did not show significant differences between groups, however before surgery it tended to be lower in group 1. Insulin resistance after surgery was significantly higher in group 2 (2.0 vs. 0.62, P = 0.03), also the increase in insulin resistance after operation was significant only in control group (P = 0.03).Conclusion: Oral carbohydrates were safe, well tolerated and did not cause any perioperative adverse events. They seem to improve postoperative metabolism by decreasing insulin resistance.Background: The need for long preoperative fasting has been questioned. Recent data shows that intake of oral carbohydrate-containing clear fluid prior to anaesthesia is safe and may have positive impact on recovery, metabolic status and improve glucose tolerance. Such solutions are routinely used in adults but not children. The aim of this study was to evaluate safety, tolerance and influence of oral carbohydrate on selected metabolic parameters in children.Methods: With the ethics committee approval and parental informed consent 20 children, aged 4–17 years, ASA status I or II, scheduled for abdominal or thoracic surgery were randomized to group 1 — receiving a 12.6% carbohydrate-containing drink (10 mL kg-1 the evening before surgery and 2 hours before anaesthesia) or control group 2 — fasting. Serum glucose and insulin concentration were measured four times: before and after anaesthesia, in the evening after surgery and the following morning. IGF-1 concentration was measured once, before surgery. Insulin resistance was assessed by the HOMA-IR equation.Results: Oral carbohydrate solution was well tolerated and no adverse events were noted. Glucose concentrations were within the normal range in both groups. Insulin concentration did not show significant differences between groups, however before surgery it tended to be lower in group 1. Insulin resistance after surgery was significantly higher in group 2 (2.0 vs. 0.62, P = 0.03), also the increase in insulin resistance after operation was significant only in control group (P = 0.03).Conclusion: Oral carbohydrates were safe, well tolerated and did not cause any perioperative adverse events. They seem to improve postoperative metabolism by decreasing insulin resistance

Alexander disease - astrogliopathy considered as leukodystrophy - experience of an institution

Alexander Disease (ALXDRD) is an autosomal dominant leukodystrophy caused by mutation in one allele of GFAP gene, encoding glial fibrillary acidic protein (GFAP). Most cases occur due to de novo. There are three clinical subtypes of ALXDRD: infantile, juvenile and adult form, but congenital form is also outlined. The disease's spectrum comprises of macrocephaly, progressive pyramidal signs, and seizures in congenital and infantile subtypes. Neuropathologically are enormous number of Rosenthal fibers (RF) mainly around vessels, in subependymal and subpial regions are found. The diagnosis is based on the typical findings on MRI: diffuse white mater lesions with frontal regions preponderance and possibly on the detection of the gene mutation. Here we present six Polish children affected of Alexander disease with congenital (1), infantile (4) and juvenile (1) form. Five of them were previously misdiagnosed as cerebral palsy or unspecific developmental delay; two patients had MRI because of another suspicion, before specific diagnosis was established. Molecular analysis performed in four cases confirmed mutations of GFAP gene; all mutation were de novo. The role of astroglia in brain is shortly reviewed

Neurogenic stunned myocardium — do we consider this diagnosis in patients with acute central nervous system injury and acute heart failure?

Neurogenic stunned myocardium (NSM) is defined as myocardial injury and dysfunction of a sudden onset, occurring after various types of acute brain injury as a result of an imbalance in the autonomic nervous system. The typical spectrum of clinically observed abnormalities includes acute left ventricular failure, not uncommonly progressing to cardiogenic shock with hypotension that requires inotropic agents, pulmonary oedema and various arrhythmias. Commonly-seen electrocardiographic changes include: prolonged QT interval, ST segment changes, T-wave inversion, a new Q-wave or U-wave. Echocardiography shows an impaired both systolic and diastolic function of the left ventricle. Biochemical markers of NSM comprise metabolic acidosis and increased cardiac enzymes and markers: creatine kinase (CK), and CK-MB, troponin I and B-type natriuretic peptide. The main cause of NSM is myocardial injury induced by local catecholamine release from nerve endings within the myocardium. Recently, a theory has been proposed to classify NSM as one of the stress-related cardiomyopathies, together with Takotsubo cardiomyopathy, acute left ventricular failure in the critically ill, cardiomyopathy associated with pheochromacytoma and exogenous catecholamine administration. The occurrence of NSM increases the risk of life-threatening complications, death, and worsens neurologic outcome. As far as we know, treatment should generally focus on the underlying neurologic process in order to maximize neurologic recovery. Improvement in neurologic pathology leads to rapid improvement in cardiac function and its full recovery, as NSM is a fully reversible condition if the patient survives. Awareness of the existence of NSM and a deeper knowledge of its etiopathology may reduce diagnostic errors, optimise its treatment.Neurogenic stunned myocardium (NSM) is defined as myocardial injury and dysfunction of a sudden onset, occurring after various types of acute brain injury as a result of an imbalance in the autonomic nervous system. The typical spectrum of clinically observed abnormalities includes acute left ventricular failure, not uncommonly progressing to cardiogenic shock with hypotension that requires inotropic agents, pulmonary oedema and various arrhythmias. Commonly-seen electrocardiographic changes include: prolonged QT interval, ST segment changes, T-wave inversion, a new Q-wave or U-wave. Echocardiography shows both an impaired both systolic and diastolic function of the left ventricle. Biochemical markers of NSM comprise metabolic acidosis and increased cardiac enzymes and markers: creatine kinase (CK), and CK-MB, troponin I and B-type natriuretic peptide. The main cause of NSM is myocardial injury induced by local catecholamine release from nerve endings within the myocardium. Recently, a theory has been proposed to classify NSM as one of the stress-related cardiomyopathies, together with Takotsubo cardiomyopathy, acute left ventricular failure in the critically ill, cardiomyopathy associated with pheochromacytoma and exogenous catecholamine administration. The occurrence of NSM increases the risk of life-threatening complications, death, and worsens neurologic outcome. As far as we know, treatment should generally focus on the underlying neurologic process in order to maximize neurologic recovery. Improvement in neurologic pathology leads to rapid improvement in cardiac function and its full recovery, as NSM is a fully reversible condition if the patient survives. Awareness of the existence of NSM and a deeper knowledge of its etiopathology may reduce diagnostic errors, optimise its treatment