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Permissive Hypotension/ Low-Volume Resus In Peds

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#41 JLP


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Posted 29 May 2011 - 01:28 AM

Mortality after Fluid Bolus in African Children with Severe Infection: http://www.nejm.org/...101549?query=OF

Fluid Resuscitation in Acute Illness Time to Reappraise the Basics: http://www.nejm.org/...105490?query=OF

Have you seen some of the data that suggests that in children with malnutrition and/or gastrointestinal disease and borderline shock, enteral fluid resuscitation using NG or OG tubes may be better? Apparently 2 reasons - first, IV fluid resusc seems to often be too rapid and causes electrolyte derangement and fluid overload, and second, enteral fluids seem to help protect against gut breakdown (and thus reduce sepsis caused by translocation across damaged gut wall). Seems to me that the studies you attached point back to the old adage that things that occur fast should be treated fast, things that took time to develop (DKA is a good example) should be treated more gradually. When the disease state has taken a long time already, longer-onset compensatory mechanisms may have taken place that can cause severe derangement if we "normalize" things too fast.
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#42 SerendepitySaki


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Posted 29 May 2011 - 03:05 AM

FAN-FREAKING-TASTIC post! as always, Sir!

and yeppers....think i actually referred to the TPN/HAL vs. Enteral Feed debate elsewhere... sidebar, but germane to some of your points.....

did YOU search on the incidence of pedi trauma bleeds missed by FAST?

you're too far away, brother.... lifting a glass of cab your way....
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Sean G. Smith, RN-Alphabet Soup

#43 TexRNmedic


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Posted 08 June 2011 - 09:07 PM

After weeks of busy-ness, I have grabbed a Shiner Blonde ( not what you are thinking! It's a very nice Texas beer), and am going to attempt to write what I picked up at the pedi trauma symposium. I had a chance to visit with Dr Paul Sirbaugh, an emergency medicine attending at Texas Children's Hospital, professor at Baylor College of Medicine and is the pediatric medical director for the City of Houston EMS as well as with Dr Charles Cox, pediatric trauma surgeon extraordinaire at Children's Memorial Hermann and the University of Texas Health Science Center about this very topic.

To begin, they generally divide pediatric trauma into the categories of burn, blunt and penetrating. As we all know, fluid resuscitation in burns has been well documented and formulas are available to help calculate fluid volumes over time. As an aside, we should know that surface area distribution is different in the pediatric population when compared to the adult. Also, fluid resuscitation must also include maintenance fluid volumes in addition to the burn resuscitation volume.

The remaining two categories of blunt and penetrating trauma have their own unique quirks of resuscitation and injury pattern. Penetrating trauma has an injury pattern that lies in the size of the object and energy transfer to the body, varying the amount of primary and secondary injury as well as the amount of cavitation that has occurred. The above physicians agree that low volume resuscitation may have a place in penetrating trauma, but the overriding concern is the avoidance of hypoxia and hypotension in the pediatric patient. The challenge is what to use as the guide for this kind of resuscitation as blood pressure changes occur late and is an indicator of poor outcomes. Heart rate may be relatively unreliable due to size/age variations and the inherent tachycardia of a frightened child.

Where these physicians feel that low volume resuscitation has no place is in the blunt trauma pediatric patient. They emphasized the importance of cerebral resuscitation in these patients and the high probability of neurological injury in the blunt traumatized patient. For example the pedi auto-ped injury pattern of Waddell's triad (femur, thoracoabdominal and cerebral injuries). The physicians emphasize the importance of cerebral perfusion pressure maintenance and the focus of the avoidance of hypoxia and hypotension in these patients. Citing Dr Pigula et al in a 1994 Journal of Pediatric Surgery article (Single documented episode of hypoxia and/or hypotension increases mortality for any given GCS) they state that resuscitation should be guided by the premise of avoiding these events. This should focus on the utilization of good airway management techniques and oxygenation that avoid hypoxia as well as hemorrhage control, fluid resuscitation and cautious administration of medications to avoid any episode of hypotension. They discuss the differences in pediatric neuro anatomy put them at greater risk for head injury (edema or bleeding), subsequent loss of cerebral autoregulation, and elevated ICP, making the need for aggressive cerebral resuscitation be the focus of the management of any pediatric trauma with any possibility of associated head injury.

Another supporting article can be found here- http://pediatrics.aa...t/124/1/56.full

As always, if I am unclear on something (blame it on the Shiner Blonde) or you would like me to follow up on something on this subject, just let me know. Regards- Wes
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Wes Seale
Houston , TX