Just like Adults? Evaluating the Impact of Fluid Resuscitation in Pediatric Trauma
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1 Just like Adults? Evaluating the Impact of Fluid Resuscitation in Pediatric Trauma Abbas PI 1,2, Carpenter K 2, Sheikh F 1,2, Peterson ML 1,2, Kljajic M 1, Naik-Mathuria B 1,2 1 Texas Children s Hospital and 2 The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX No Disclosures
2 ATLS fluid algorithm
3 Background Adult literature o Focuses on resuscitation with blood products o Some literature on crystalloid fluid resuscitation Aggressive crystalloid resuscitation was associated with: o Higher rate of mortality o Longer ICU hospital stays o Coagulopathy o Mechanical ventilation o Multisystem organ failure
4 Background Pediatric trauma patients o More blunt trauma o Less severe injuries o Less need for blood transfusions o Different physiology o Higher threshold for multisystem organ failure
5 Hypothesis Higher volume of crystalloid fluid resuscitation is associated with worse clinical outcomes in pediatric trauma patients
6 Methods IRB approval (H-29836) Prospective cohort study Level 1 pediatric trauma center Data collected from 9/2011 7/2014 Detailed chart review
7 Clinical Variables Patient demographics Admission vital signs Crystalloid fluid intake (cc/kg/hr) o Pre-hospital (scene) o Emergency Department (ED) o Inpatient up to 24 hours after arrival to ED
8 Outcomes of interest Ileus (NPO >3 days) Coagulopathy (INR >1.5) within 24 hours Need for intubation within 24 hours
9 Statistical Analyses Univariate analyses for association between clinical variables with outcomes Multivariate regression to determine predictors of outcomes Receiver Operator Curve (ROC) analysis to identify a fluid threshold for outcomes
10 Results 603 patients o Median age of 8.1 years (range ) o 63% males o 94% blunt trauma MVC (21%), Falls (19%), Autoped (15%) o Only 7% required blood transfusions Median of 14.5 cc/kg PRBCs (IQR ) o Median ISS 9 (IQR 5-14) o Median 24-hr fluid volume: 1.5 cc/kg/hr (IQR )
11 Results 10% (n=58) developed ileus 3% (n=18) developed coagulopathy 11% (n=64) required mechanical ventilation within 24 hours
12 Higher median fluid volumes associated with worse clinical outcomes Fluid volumes (cckg/hr) * * * *p< Ileus No ileus Coagulopathy No Coagulopathy Mechanical ventilation No Mechanical ventilation
13 Predictors of ileus Variables Age, years Mean±SD Male gender N (%) Weight, kg Admission HR Admission RR Admission SBP Admission temp, o C Lowest SBP in first 24 hours ISS Fluid resuscitation volume, cc/kg/hr Blunt trauma N (%) Surgical intervention N (%) Ileus (n=58) No ileus (n=545) p-value 7.4± ± (48) 350 (65) ( ) ( ) 28 (20-34) 111 ( ) 36.8 ( ) 90 ( ) 17 ( ) 3.0 ( ) 29.6 ( ) 107 (89-130) 24 (20-32) 117 ( ) 36.7 ( ) 95 (88-102) 9 (4-10) 1.5 ( ) <0.001 < (97) 507 (94) (50) 148 (27) <0.001
14 Predictors of mechanical ventilation Variables Age, years Mean±SD Male gender N (%) Weight, kg Admission HR, bpm Admission RR, bpm Admission SBP, mm Hg Admission temp, o C Lowest SBP in first 24 hours, mm Hg ISS Fluid resuscitation volume, cc/kg/hr Blunt trauma N (%) Surgical intervention N (%) Need for intubation (n=67) No intubation (n=536) p-value 6.1± ±5.2 < (61) 340 (64) ( ) 120 ( ) 29.5 ( ) 117 ( ) 36.6 ( ) 83 ( ) 17 (10-27) 3.0 ( ) 30 ( ) 107 ( ) 24 (20-32) 117 ( ) 36.7 ( ) 95 (89-102) 9 (4-10) 1.5 ( ) < <0.001 <0.001 < (97) 500 (93) (34) 153 (29) 0.336
15 Predictors of coagulopathy Variables Age, years Mean±SD Male gender N (%) Weight, kg Admission HR Admission RR Admission SBP Admission temp, o C Mean±SD Lowest SBP in first 24 hours ISS Fluid resuscitation volume, cc/kg/hr Blunt trauma N (%) Surgical intervention N (%) Coagulopathy (n=18) xxx00.#####.ppt 11/12/ :46:34 PM No coagulopathy (n=585) p-value 6.2± ± (61) 343 (64) ( ) 30 ( ) ( ) (89-131) ( ) (20-32) ( ) ( ) 36.4± ± (75-93) 23.5 ( ) 4.0 ( ) 95 (87-102) 9 (5-12.8) 1.6 ( ) <0.001 < (94) 499 (94) (50) 151 (28) 0.046
16 Fluid threshold to minimize poor outcomes AUC 0.79, p< cc/kg/hr sensitivity 71%, specificity 75% NPV 96%, PPV 23% AUC 0.82, p< cc/kg/hr sensitivity 75%, specificity 73% NPV 96%, PPV 25% Ileus xxx00.#####.ppt 11/12/ :46:34 PM Mechanical Ventilation Fluid resuscitation threshold 2.2 cc/kg/hr (53 cc/kg/day)
17 Conclusions In pediatric trauma patients, limited crystalloid resuscitation within the initial resuscitation period leads to better outcomes Administering less than 50 cc/kg/day (or 2 cc/kg/hr) of fluid correlates with lower incidence of ileus and mechanical ventilation Larger, prospective studies are needed to validate this study and determine the optimal resuscitation algorithm for pediatric trauma xxx00.#####.ppt 11/12/ :46:34 PM
18 Correlates Acker SN, Ross JT, Partrick DA, et al: Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation. Journal of Pediatric Surgery 49: xxx00.#####.ppt 11/12/ :46:34 PM
19 Clinical Implications xxx00.#####.ppt 11/12/ :46:34 PM
20 References Cotton BA, Guy JS, Morris Jr JA, et al: The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 26: , 2006 Kasotakis G, Sideris A, Yang Y, et al: Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: an analysis of the Glue Grant database. The journal of trauma and acute care surgery 74:1215, 2013 Ley EJ, Clond MA, Srour MK, et al: Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. Journal of Trauma and Acute Care Surgery 70: , 2011 Owens TM, Watson WC, Prough DS, et al: Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements. Journal of Trauma and Acute Care Surgery 39: , 1995 Watters JM, Jackson T, Muller PJ, et al: Fluid resuscitation increases inflammatory response to traumatic injury. Journal of Trauma and Acute Care Surgery 57:1378, 2004 Acker SN, Ross JT, Partrick DA, et al: Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation. Journal of Pediatric Surgery 49: xxx00.#####.ppt 11/12/ :46:34 PM
21 Thank you! Questions?
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