American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

OBJECTIVES: The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine “Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.” DESIGN: Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006–2014). The PubMed/Medline/Embase literature (2006–14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS: The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS: The major new recommendation in the 2014 update is consideration of institution—specific use of 1) a “recognition bundle” containing a trigger tool for rapid identification of patients with septic shock, 2) a “resuscitation and stabilization bundle” to help adherence to best practice principles, and 3) a “performance bundle” to identify and overcome perceived barriers to the pursuit of best practice principles

Can we see enough? A comparative study of film-screen vs digital radiographs in small lesions in rheumatoid arthritis

The aim of this study was to evaluate the performance of digital radiography in the detection of early very small erosions and joint space narrowing; in the hands and feet in rheumatoid arthritis. Fifty-three sets of film-screen and digital radiographs of the same hands and feet with very small and some-times questionable lesions (possible erosions and cysts) were scored independently two times by four investigators. The percentage of lesions found in exactly the same position for each investigator was calculated. Intra-observer agreement between first and reading in film-screen radiography was (mean 67%), and in digital radiographs 60-71% (mean 64%), Agreement between film-screen and digital radiographs ranged fi om 54 to 64% (mean 58%) in the first reading and from 56 to, 66% (mean 62%) in the second reading. Overall agreement between both techniques between first and second reading ranged between 62 and 73% (mean 65%). Digital radiography of the hands and feet can be used in patients suspected of rheumatoid arthritis and in follow-up of those patients, because small and early erosions call be seen equally well with the digital technique as compared with the conventional film-screen technique