© Med Sci Monit, 2007; 13(4): CR182-186 PMID: 17392648
WWW. M ED S CI M ONIT.COM
Clinical Research
Received: 2006.08.10 Accepted: 2006.08.25 Published: 2007.03.30
Safety and usefulness of invasive arterial blood pressure monitoring in purpura fulminans resuscitation
Authors’ Contribution: A Study Design B Data Collection C Statistical Analysis D Data Interpretation E Manuscript Preparation F Literature Search G Funds Collection
Taher Khalil1 BCDEF, Stéphane Leteurtre2 BCDE, Christine Fonteyne1 BC, Ahmed Sadik2 BC, Dominique Biarent1 ADE, Francis Leclerc2 ADEF 1 2
PICU, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium PICU, Hôpital Jeanne de Flandre, Lille, France
Source of support: Departmental sources
Summary Background:
Material/Methods:
Invasive blood pressure (BP) monitoring (IBPM) is recommended in the treatment of fluid-refractory septic shock, but has been suspected of inducing distal ischemia in children with purpura fulminans (PF). The aim of the study was to determine if IBPM increases the risk of limb and skin necrosis and alters outcome of children with PF. Children admitted with PF and suspected meningococcal sepsis to two PICUs were retrospectively studied. BP was invasively monitored in one unit (arterial catheter: AC group), but not in the second (controls). Treatment was otherwise in accordance with recent guidelines. Children from the two units were matched according to age and PRISM score value. Mortality and limb or skin necrosis rates were compared and catheter-related complications were analyzed.
Results:
Among 156 children (1996–2004), 46 from each unit (median age: 25 months, median PRISM value: 19) could be matched. The mortality rate was 19.5% in the AC group and 21.7% in the control group (p=0.8). Nine children (6 survivors) in the AC group and 9 (8 survivors) of the controls had distal necroses (p=1). Fifty-three ACs were inserted in the AC-group children. Catheter-related complications were three hemorrhages or hematomas, one local thrombosis, and six transient distal ischemia; there were no major catheter-related complications. Distal necrosis incidence was not increased on limbs where catheters were inserted.
Conclusions:
In this series of children with PF and suspected meningococcal sepsis, BP was monitored by arterial catheter in one unit; this did not affect limb and skin necrosis and mortality rates.
key words: Full-text PDF: Word count: Tables: Figures: References:
Author’s address:
CR182
meningococcal sepsis • arterial catheter • monitoring • limb necrosis
http://www.medscimonit.com/fulltxt.php?IDMAN=9678 1704 3 — 17
Professor Francis Leclerc, Service de Réanimation Pédiatrique, Hôpital Jeanne de Flandre, 59037 Lille Cedex, France, e-mail: fl
[email protected]
Current Contents/Clinical Medicine • SCI Expanded • ISI Alerting System • Index Medicus/MEDLINE • EMBASE/Excerpta Medica • Chemical Abstracts • Index Copernicus
Med Sci Monit, 2007; 13(4): CR182-186
BACKGROUND Purpura fulminans (PF) is a life-threatening illness mainly caused by Neisseria meningitidis [1] and characterized, like septic shock of other origin [2], by multiple organ dysfunction and disseminated intravascular coagulation. It is sometimes associated with limb and cutaneous necroses that may lead to amputations or skin grafts. Invasive blood pressure (BP) monitoring (IBPM) has been recommended in children with septic shock who remain hypotensive despite adequate fluid resuscitation [3], but arterial catheters (ACs) could increase the risk of distal ischemia among patients with PF [4]. The objective of the study was to determine if AC use increased the risk of limb and cutaneous necrosis and/or altered outcome of children with PF.
MATERIAL AND METHODS The study was carried out in two tertiary pediatric intensive care units (PICUs): one in France (PICU 1) and one in Belgium (PICU 2) (Table 1). This retrospective study included all children admitted between January 1996 and October 2004. The inclusion criterion was the association of purpura and severe sepsis as defined by the ACCP/SCCM criteria [5] adapted to children by Hayden [6]. The files came from the computerized data bases of the two units. In PICU 2, an AC was systematically inserted on admission or before the transfer from the referring hospital (AC group). In PICU 1 (non-invasive group: NI group), blood pressure monitoring (BPM) was performed only non-invasively (NIBPM) by the oscillometric method (Spacelabs Medical, Issaquah, WA USA). For each patient, the following data were collected: age and sex, clinical data of sepsis and organ dysfunction, bacteria, serotype, and admission laboratory data, i.e. C-reactive protein (CRP), platelets, activated thromboplastin time (APTT), prothrombin time (PTT), and lactate. The Pediatric index of Mortality (PIM) [7] score was calculated one hour after admission; Pediatric Risk of Mortality (PRISM) [8] and Pediatric Logistic Organ Dysfunction (PELOD) [9] scores were calculated within 24 hours after admission. Mechanical ventilation, 24th hour fluid resuscitation volume, and inotropic and vasopressor therapies were noted. Other treatments recorded were corticoids, local and systemic vasodilators, hemofiltration, anticoagulants, thrombolytic agents, protein C, antithrombin, sympathetic blockade, and extracorporeal membrane oxygenation (ECMO). In the AC group, the following data regarding the ACs were collected: location, cannulation attempts, duration, indications for catheter removal and complications such as hemorrhage, hematoma, distal ischemia, thrombosis, and malfunction. Children with and without ACs were matched by age and PRISM score [8], known to accurately predict outcome of severe meningococcal sepsis [10]. An AC group child was matched with a control group child of the same range of age (±6 months for children less than one year, ±8 months for children between one and three years, and ±12 months for children older than three years) and of the same range of PRISM score value (±20%). The primary outcome was the development of ischemic sequels: limb necroses leading to amputations or functional orthopedic sequels, and extensive cutaneous necroses requiring skin grafts. In case of death after amputation, or withholding/withdrawing treatments due to extensive limb
Khalil T et al – Safety and usefulness of invasive arterial blood pressure monitoring…
Table 1. Study sites and patient characteristics of the whole population admitted during the period 1996–2004. PICU 1 (France) PICU 2 (Belgium) Beds in PICU (n)
16
15
476 (445–549)
717 (648–802)
Age (months)
50 (48–65)
53 (49–79)
Surgical patients (%)
24 (16–32)
39 (35–44)
Ventilated patients* (%)
38 (36–47)
40 (35–50)
Length of stay (days)
10
(5–12)
8
(7–9)
8
(7–10)
3
(2–4)
Annual admissions (n)
Deaths (%)
Data are given as median and annual range. * Invasive mechanical ventilation. necroses, children were also considered as having ischemic sequels. Secondary outcome was death whatever the cause. In the AC group, we searched for an increase in amputation and skin graft rate on limbs where catheters were inserted. Statistical analyses were performed with SPSS software (SPSS Inc, Chicago, IL, USA). For the comparison of continuous biological variables, the Mann-Whitney test was used. For the comparison of categorical variables, the chisquare or Fisher’s exact tests were used. A p-value 0.05); only age was different in the catheter group children (p=0.044). Hypotension is not an early indicator of septic shock; however, adequate organ perfusion depends on maintenance of a mean arterial BP beyond a critical value; therefore BPM is essential when managing children with septic shock [3,12]. IBPM gives reliable values, even when BP is low [12], and it gives, interestingly, a continuous measurement. Correlation between IBPM and NIBPM is good, but individual differences between the two methods are greater than 10 mmHg in more than 30% of measurements [13]. In addition, for NIBPM, if the cuff size is inappropriate, the measured BP
1. Hazelzet JA: Diagnosing meningococcemia as a cause of sepsis. Pediatr Crit Care Med, 2005; 6(Suppl.): S50–S54 2. Tsiotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J: Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit, 2005 11(3): RA76–85 3. Carcillo JA, Fields AI, Task force committee members: Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med, 2002; 30: 1365–78 4. Arul GS, Sacks L, Wolf A et al: Protein-C concentrate for meningococcal purpura fulminans. Lancet, 1998; 351: 988–89 5. Bone RC, Balk RA, Cerra FB et al: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee. Chest, 1992; 101: 1644–55 6. Hayden WR: Sepsis terminology in pediatrics. J Pediatr, 1994; 124: 657–58 7. Shann F, Pearson G, Slater A, Wilkinson K: Paediatric index of mortality: a mortality prediction model for children in intensive care. Intensive Care Med, 1997; 23: 201–7 8. Pollack MM, Ruttimann UE, Getson PR: Pediatric risk of mortality (PRISM) score. Crit Care Med, 1988; 16: 1110–16 9. Leteurtre S, Martinot A, Duhamel A et al: Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet, 2003; 362: 192–97
CR185
CR
Clinical Research 10. Leteurtre S, Leclerc F, Martinot A et al: Can generic scores (PRISM and PIM) replace specific scores in predicting the outcome of presumed meningococcal septic shock in children? Crit Care Med, 2001; 29: 1239–46 11. Leclerc F, Leteurtre S, Cremer R et al: Do new strategies in meningococcemia produce better outcomes? Crit Care Med, 2000; 28(Suppl.): S60–S63 12. Hollenberg SM, Ahrens TS, Annane D et al: Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med, 2004; 32: 1928–48 13. Bur A, Herkner H, Vlcek M et al: Factors influencing the accuracy of oscillometric blood pressure measurement in critically ill patients. Crit Care Med, 2003; 31: 793–99
CR186
Med Sci Monit, 2007; 13(4): CR182-186 14. Graves PW, Davis AL, Maggi JC, Nussbaum E: Femoral artery cannulation for monitoring in critically ill children: prospective study. Crit Care Med, 1990; 18: 1363–66 15. Sellden H, Nilsson K, Larsson LE, Ekström-Jodal B: Radial arterial catheters in children and neonates: A prospective study. Crit Care Med, 1987; 15: 1106–9 16. Schindler E, Kowald B, Suess H et al: Catheterization of the radial or brachial artery in neonates and infants. Pediatr Anaesth, 2005; 15: 677–82 17. Scheer B, Perel A, Pfeiffer UJ: Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Critical Care, 2002; 6: 198–204
Index Copernicus Global Scientific Information Systems for Scientists by Scientists
IndexCopernicus.com
www.
EVALUATION & BENCHMARKING PROFILED INFORMATION NETWORKING & COOPERATION VIRTUAL RESEARCH GROUPS GRANTS PATENTS CLINICAL TRIALS JOBS STRATEGIC & FINANCIAL DECISIONS
Index Copernicus integrates
IC Scientists
IC Virtual Research Groups [VRG]
Effective search tool for collaborators worldwide. Provides easy global networking for scientists. C.V.'s and dossiers on selected scientists available. Increase your professional visibility.
Web-based complete research environment which enables researchers to work on one project from distant locations. VRG provides:
IC Journal Master List
IC Patents
Scientific literature database, including abstracts, full text, and journal ranking. Instructions for authors available from selected journals.
Provides information on patent registration process, patent offices and other legal issues. Provides links to companies that may want to license or purchase a patent. IC Grant Awareness
IC Conferences Effective search tool for worldwide medical conferences and local meetings.
Need grant assistance? Step-by-step information on how to apply for a grant. Provides a list of grant institutions and their requirements.
customizable and individually self-tailored electronic research protocols and data capture tools, statistical analysis and report creation tools,
profiled information on literature, publications, grants and patents related to the research project, administration tools.
IC Lab & Clinical Trial Register Provides list of on-going laboratory or clinical trials, including research summaries and calls for co-investigators.
