ROGERS TEXTBOOK OF PEDIATRIC INTENSIVE CARE 5TH EDITION PDF
Rogers' Textbook of Pediatric Intensive Care View PDF. Rogers' Textbook of Pediatric Intensive Care. Publication Year: Edition: 5th Ed. Authors/Editor. Now in vibrant full color throughout, Rogersâ€™ Textbook of Pediatric Intensive Care, 5th Edition, continues its tradition of excellence as the. Rogers' textbook of pediatric intensive care. by David G Nichols; Donald H Shaffner; Mark C Rogers;. eBook: Document. English. 5th edition. Philadelphia.
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This is a comprehensive resource for clear explanations of both the principles underlying pediatric critical care disease and trauma as well as how these. Now in vibrant full color throughout, Rogers' Textbook of Pediatric Intensive Care, 5th Edition, continues its tradition of excellence as the gold standard in the. Free download links to Rogers' Textbook of Pediatric Intensive Care, Fourth Edition continues the tradition of this classic text–detailed discussions of the.
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Donald H. Shaffner MD, David G. Nichols MD. Request eReview Copy. String "". download from another retailer. There were no extravasation injuries observed in either group. While this study is limited by being performed at a single center and using a dose titration of vasoactive infusions that my not be equivalent across groups, the results are still compelling and warrant further study.
The dose titration period was also aggressive and patients unresponsive to escalating therapy after 60 minutes on the protocol were moved to open label therapy. Interestingly, for those who required vasoactive medications in addition to the study drug, no additional dopamine was used.
The Vasoactive Inotrope Score VIS is a score that attempts to normalize dosages of different vasoactive infusions to enable comparison of degree of hemodynamic support between patients receiving different or multiple vasoactive medications.
This score has been shown to be a predictor of morbidity and mortality after cardiopulmonary bypass surgery in children. Haque et al. The authors suggest that VIS is a simple tool that can be used as an outcome predictor, especially in resource-limited settings. Extracorporeal Therapies In , the American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric septic shock were updated. The update included continued recommendation for consideration of extracorporeal membrane oxygenation ECMO support for refractory shock and a new recommendation for fluid removal through diuretics, peritoneal dialysis, or continuous renal replacement therapy for those with signs of fluid overload once adequately fluid resuscitated.
Overall hospital mortality was The authors found that patients with severe sepsis were more likely to receive ECMO support between and compared to through OR 1. A similar improvement in mortality was seen for the subset of patients with severe sepsis and malignancy treated with extracorporeal therapies. These data are supportive of the idea that while the mortality remains high for patients with severe sepsis requiring extracorporeal support, steady improvement in outcomes is evident.
Mortality Prediction and Risk Stratification Early risk stratification using biomarkers is a promising method to identify patients at higher risk for morbidity and mortality who would be candidates for more aggressive interventions or for clinical trial enrollment. Acute kidney injury AKI is common in severe sepsis and associated with poor outcome.
Wong et al. The model predicts septic AKI at day 3 of septic shock, and the authors postulate that identification of these at risk patients could inform clinical decision making.
The risk stratification final model included the presence of AKI on day 1, and biomarkers elastase 2, matrix metalloproteinase 8, and proteinase 3.
The model had excellent performance in the derivation cohort area under the curve AUC of 0.
In both cohorts, the model added to predictive ability of the presence of septic AKI on day 1. Early prediction of morbidity and mortality is important for risk stratification in patients with severe sepsis.
It is well recognized that patients have not returned fully to baseline health at hospital discharge, and are at risk for subsequent re-hospitalization and mortality. Determining factors that impact post-discharge mortality may help providers identify patients that would most benefit from close follow-up while recovering from sepsis.
Wiens et al. The final model for post-discharge mortality prediction included mid-upper arm circumference, time since last hospitalization, oxygen saturation, abnormal Blantyre Coma Scale score, and HIV-positive status. The AUC for mortality prediction was 0. Although the predictive model may not generalizable to more developed regions with different infectious disease patterns, this study exemplifies how region-specific predictors of post-discharge mortality may help to identify a vulnerable population for close follow-up to decrease long-term morbidity and mortality.
Bundled Approaches to Shock Recognition and Management Recognition and management bundles are increasingly being used to enhance resuscitation of pediatric septic shock. Although a bundled approach has been emphasized for adult septic shock through the Surviving Sepsis Campaign for several decades, the application of these bundles to pediatric patients has been less pervasive.
In the last five years, several studies have demonstrated that a bundled approach to shock recognition and management can increase adherence to guidelines, decrease time to therapy, and improve outcomes in pediatric septic shock 10 , 31 , For example, Paul and colleagues showed that improved adherence to a 5-component sepsis bundle that included timely 1 recognition of septic shock, 2 vascular access, 3 administration of intravenous bolus fluid, 4 antibiotics, and 5 vasoactive agents when necessary within 60 minutes was associated with a decrease in mortality from 5 to 2 percent The electronic alert was based on vital signs, high-risk comorbid conditions, altered mentation, and abnormal perfusion.
The electronic algorithmic alert was more sensitive The authors concluded that a routine alert embedded within the electronic health record may be best used to trigger a rapid bedside clinician assessment for sepsis in order to maximize sepsis recognition without overextending available resources.
Along these lines, Tuuri et al. This may be a more feasible approach at smaller institutions with fewer information technology resources.
Two recent studies highlight the role that simulation can play in improving recognition and resuscitation of pediatric shock. Notably, teams with greater composite experience achieved the highest guideline adherence, highlighting the importance of reiterative experience in shock management. Given the relatively low frequency of shock amongst pediatric acute illness, simulation may help to optimize bedside implementation of management bundles.
Qian et al. Corticosteroid Use Corticosteroid use is currently recommended in refractory septic shock, however, the benefit remains unproven and controversial. Notably, gene expression related to the adaptive immune response was down-regulated in both groups compared to normal controls, but to a greater extent in patients who received corticosteroids.
While cause-and-effect cannot be determined from study, the authors raised concern that treatment with corticosteroids may repress adaptive immunity in patients with septic shock. This group has also used gene expression to identify subclasses of patients with septic shock with different morbidity and mortality, but have now moved this technology closer to the bedside using a messenger RNA technology that can provide results on expression of the subclass-defining genes in 8—12 hours Using test and validation cohorts of children with septic shock, the authors were able to reliably assign patients to subclasses with different morbidity and mortality rates based on their gene expression profile using samples collected within the first 24 hours of PICU presentation with septic shock.
Interestingly, Wong et al. The authors conclude that this technology has the potential to identify a subset of patients who may not respond favorably to adjunctive corticosteroid therapy.
Moreover, thoughtful commentaries on the research that is needed for neonates in resource poor areas as well as for the poorest in the world are exciting new developments that may change our understanding and approaches to sepsis in the next few years 41 , The authors emphasize the disappointing reality that, despite numerous promising drugs, there remain no specific anti-sepsis treatments and management relies mainly on recognition and aggressive organ support.
In resource rich countries, unraveling the pathobiology of sepsis and ensuring earlier recognition will take precedence, while in resource poor countries, creative solutions to implement basic life-saving resuscitative therapies and antibiotics is the priority.
Innovation in sepsis care as well as in adaptive clinical trial design will be increasingly important. The notable breadth of international contributions in this field is particularly enlightening given the global public health impact of sepsis and shock on children.
While there has been significant progress in the understanding of sepsis epidemiology and use of extracorporeal therapies in critically ill children with sepsis, the role of hyperlactatemia and risk stratification in pediatric septic shock, and the optimal timing of antibiotic administration, more work is clearly needed. Importantly, the consistent theme of a beneficial role for a bundled approach to septic shock recognition and management to improve both care and outcomes should drive their inclusion into future updates of pediatric shock guidelines.
A roadmap to relevant research offers possibilities to improve knowledge and outcomes. References 1. Sepsis: a roadmap for future research. Lancet Infect Dis. Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, — a multicentre retrospective cohort study.
Rogers' Handbook of Pediatric Intensive Care
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Rogers' Textbook of Pediatric Intensive Care
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All Ophthalmology. All Optometry. All General Surgery. All Neurology. All Radiology and All Cardiology.Shaffner MD, David G. In resource rich countries, unraveling the pathobiology of sepsis and ensuring earlier recognition will take precedence, while in resource poor countries, creative solutions to implement basic life-saving resuscitative therapies and antibiotics is the priority.
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