Neutrophil to lymphocyte ratio, monocyte to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume as a predictor of sepsis mortality in children at Dr. Soetomo General Hospital


Objective: The purpose of this study was to analyze the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV) as a predictor for mortality in children with sepsis.

Design: This was a prospective cohort study.

Setting: In Pediatric Intensive Care Unit (PICU), Emergency Room, and pediatric ward at Dr. Soetomo General Hospital, Surabaya on March 1, 2020 to August 2020.

Patients and participants: A total of 80 children consisted of 40 septic and 40 non-septic patients were included.

Measurement and results: The leukocyte count in septic patients was not significantly higher than in non-septic patients with a p value>0.05. The number of neutrophils (12.99±7.35x103/mm3 versus 9.12±6.67x103/mm3) had a relevant and significantly higher increase in septic patients (p=0.014). The NLR value (8.99±6.73 versus 4.80±5.30; p=0.001) was higher in septic patients. The cut-off of NLR as a diagnostic marker for sepsis was 3.52 with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) of 82.50%, 47.50%, 61.11%, 73.08%, and 4.26 (p=0.004), respectively. The MLR, PLR, and MPV did not differ significantly between septic and non-septic patients. NLR values (11.61±7.39 versus 5.77±4.05; p=0.014) between survive and dead septic patients. The NLR cut-off 8.98 has sensitivity, specificity, PPV, NPV, and OR of 77.78%, 54.55%, 58.3%, 75%, and 4.20 (p=0.038), respectively, as a predictor for mortality. Patient with NLR more than 8.98 has a risk for mortality 4.20 times higher than those with a low or equal NLR value.

Conclusion: NLR can be used as a predictor of mortality in children with sepsis.

Authors: Frans M. Pasaribu, Arina Setyaningtyas, Mia Ratwita Andarsini

The correlation between vasoactive-inotropic score with mortality and the use of mechanical ventilation in pediatric shock admitted to the PICU in Dr. Soetomo General Hospital, Surabaya


Objective: To evaluate and to assess the correlation between the vasoactive-inotropic score (VIS) with mortality and the used of mechanical ventilation in pediatric shock.

Design: A retrospective cross-sectional study.

Setting: The study was conducted in the Pediatric Intensive Care Unit (PICU) at Dr. Soetomo General Hospital, Surabaya from November 1st, 2017 until April 30th, 2018.

Patients and participants: All children <18-year-old with shock who were admitted to the PICU.

Interventions: None.

Measurement and results: Eighty children with shock were admitted in PICU using minimal one vasoactive-inotropic treatment in the first 48 hours were included. Fifty-nine patients were eligible and met the inclusion criteria such as age <18-year-old, has one or more types of shock (hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock), and received at least one vasoactive-inotropic drug £48 hours. We used Chi-square and Fisher’s Exact test and Receiver Operating Characteristic (ROC) curve analysis. The children consisted of 31 males (52.5%) and 28 females (47.5%). The median age was 36 ranging from 2-216 months. Fifty-four used mechanical ventilation. The mean of VIS was 10±6 and the mortality rate was 47.5%. The cut-off value of the ROC curve of VIS in relation to mortality was 6 with sensitivity 82.1% and specificity 64.5%. We divided our subjects into two groups based on the cut-off value of 6 as High VIS (>6) and Low VIS (≤6). The High VIS group consisted of 34 subjects, in which 68% of them died and 59% of them needed mechanical ventilation. VIS had a correlation with mortality (r=-0.472, p<0.001).

Conclusion: VIS had a moderately correlation with mortality, but had no correlation with the used of mechanical ventilation. Nevertheless, VIS may be a better screening tool for pediatric shock in our setting.

Authors: Iin Fatimah, Arina Setyaningtyas, Ira Dharmawati, Abdul Latief Azis, Neurinda Permata Kusumastuti, Dwi Putri Lestari

Effect of zinc supplementation in PELOD-2 score and zinc serum level in children with sepsis


Background: Sepsis in children still shows a high mortality rate. Nutritional factors are important in the treatment of sepsis. Zinc is one of the key elements that can limit mitochondrial dysfunction due to an imbalance between reactive oxygen species and antioxidants that occur in sepsis. We aim to determine the effect of Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score and zinc serum level before and after zinc supplementation in septic children.

Methods: This is an experimental study with one group pretest-posttest design in patients aged 1 month to 18 years with sepsis treated at the PICU H. Adam Malik General Hospital from March 2018-February 2019. Oral zinc supplementation was given for 5 days. The PELOD-2 score and zinc serum level measurement were performed by using inductively coupled plasma-mass spectrometry (ICP-MS) on the first and fifth days. Bivariate analysis was performed by paired T test.

Results: A total of 17 patients were analyzed. The paired T test showed significant difference in serum zinc levels before and after supplementation (p<0.001) even though the zinc levels were both still below normal values (28.7±11.7 µg/dl and 40.5±18.3 µg/dl, respectively). PELOD-2 score still showed increasing values with significant differences (p<0.001) before and after zinc supplementation (7.76±2.4 and 11.7±3.3, respectively).

Conclusion: This was the first report that evaluated effect of zinc supplementation on PELOD-2 score. Zinc supplementation did not decrease PELOD-2 score but could give significant improvement in zinc serum level.

Authors: Winny, Munar Lubis, Erna Mutiara

Lower target temperature management in patients with post-cardiac arrest syndrome could not show advantage, with or without resuscitation interval ≤30 minutes. Retrospective analysis of nationwide multicenter observational study in Japan


Introduction: Target temperature management (TTM) is one of the effective therapies for patients with post-cardiac arrest syndrome (PCAS). A low target temperature is traditionally believed to be more effective, but this has not been confirmed in recent studies, even in any patient subgroup. Our previous study suggested the possible effectiveness of low TTM for patients with PCAS when the period from collapse to the return of spontaneous circulation (ROSC) is ≤30 minutes. Therefore, we tested this hypothesis in a nationwide Japanese registry.

Methods: This was a retrospective subanalysis based on a registry of patients who experienced out-of-hospital cardiac arrest (OHCA), which was established by the Japanese Association for Acute Medicine. Witnessed cases of adult OHCA were selected. Univariate and multivariate analyses were used to compare the neurological outcomes of patients treated with low (32-33 °C) or mild (34-36 °C) TTM or no temperature management. The analysis was performed in both the total patients and in patients in whom the interval from collapse to ROSC was ≤30 minutes.

Results: We analyzed 1763 cases of PCAS. There was no significant difference in the neurological outcomes of patients treated with low or mild TTM, with or without an interval from collapse to ROSC of 30 minutes. However, neurological outcomes of patients treated with low or mild TTM differed significantly from no temperature management, with or without an interval from collapse to ROSC of ≤30 minutes.

Conclusions: Even in the subgroup in which the interval from collapse to ROSC was ≤30 minutes, neurological outcomes in the low TTM group did not differ significantly from those in the mild TTM group.

Authors: Kazuya Odawara, Tadashi Kaneko, Shunji Kasaoka

The validity of urinary neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker of acute kidney injury in pediatric patients with sepsis


Background: Septic patients with acute kidney injury (AKI) are associated with increased morbidity and mortality compared to septic patients without AKI. These usually occur within 24 hours of admission into ICU. The measurement of serum creatinine is usually used to diagnose AKI. However, the concentrations do not change until a decline in kidney function has reached 50% or less within a few days. Many studies have shown urinary neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of AKI with different cut-off points.

Objective: This study aimed to determine the cut-off point of urinary NGAL in predicting the occurrence of AKI in pediatric septic patients within 48 to 72 hours after being admitted into ICU.

Methods: This was an observational analytic study with prospective longitudinal design, carried out on patients who met the inclusion and exclusion criteria at the resuscitation room in the Emergency Room (ER) at Dr. Soetomo Hospital Surabaya. The urine was taken at the 0th, 6th, 12th, and 24th hours for urinary NGAL examination. Every procedure taken on each patient was recorded and followed until the third day to determine factors correlated with AKI.

Result: Of the total 41 pediatric septic patients, 30 met the inclusion and exclusion criteria and about 56.7% had AKI. The urinary NGAL at 0th hour had significant value. A cut-off point of 1242 ng/ml was a better determinant of the incidence of AKI with a sensitivity of 76.5%, specificity of 61.5%, area under the curve (AUC) of 0.715, and relative risk of 2.2. Furthermore, the urinary NGAL at 0th hour was able to differentiate each level of AKI. Yet, the urine values of NGAL at 6th, 12th, and 24th hours were invalid as predictor of AKI.

Conclusion: Urinary NGAL at 0th hour is a valid predictor of occurrence of AKI grades 1, 2, and 3 in pediatric septic patients 48-72 hours after being admitted into the hospital.

Authors: Nugroho Setia Budi, Arie Utariani, Elizeus Hanindito, Bambang Pujo Semedi, Ninik Asmaningsih

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension


Introduction: The World Society for the Abdominal Compartment Syndrome (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) £15 mmHg. The role of point-of-care ultrasound (POCUS) as a bedside modality in critical care patients, is not well studied in the intra-abdominal hypertension (IAH) management algorithm.

Aim: To test POCUS in the medical management of patients with IAH.

Method: We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management.

Result: A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65±22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (5 cases). Ultrasound and abdominal X-rays were comparable in confirming nasogastric tube (NGT)'s correct position, but the ultrasound was superior in determining the gastric content (fluid vs solid) and diagnoses of gastric paresis in 2 cases. Small bowel obstruction was present in four patients and confirmed with computerized tomography (CT) abdomen, and 2 of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely in 72%, 56%, and 42% of the times on days 1, 2, and 3. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites and ultrasound (US)-guided paracentesis performed.

Conclusion: POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH.

Authors: Zouheir Ibrahim Bitar, Ossama Sajeh Maadarani, Tamer Mohamed Zaalouk, Mohammed Jaber Mohsen, Ragab Desouky Elshabasy, Mahmoud Mostafa Elzoueiry

Correlation between elevated TNF-α, syndecan 1, and urine IL 18 levels in acute kidney injury following on pump cardiac surgery


Objective: This study aims to determine the correlation between elevated tumor necrosis factor alpha (TNF-α) and syndecan-1 with urine interleukin (IL)-18 levels as post-cardiac surgery-related acute kidney injury (AKI) marker.

Design: This study was an analytical observational study with a cross sectional design.

Setting: This study was conducted at Dr. Wahidin Sudirohusodo Central General Hospital. The period of study was from October 2019 to February 2020.

Patients and participants: Population of study was all patients who underwent adult on pump cardiac surgery. Study samples were patients who were included in inclusion criteria. Patient’s characteristics were presented as frequency and percentage.

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Spearman correlation test was performed to determine the correlation between TNF-α, syndecan-1, and IL-18 levels toward AKI incidence. The data was presented with odds ratio (OR) 95% confidence interval (CI). There were 33 subjects who underwent adult cardiac surgeries including coronary artery bypass grafting (CABG), valve, and congenital disorder surgeries. Twenty-one people (63.6%) had AKI and 12 people (36.4%) did not. In AKI patients there was an increased syndecan-1 level of 61.94±36.58 ng/ml with relative risk (RR)=1.11 (95% CI 1.02-1.21), TNF-α level of 6.85±4.05 pg/ml, RR=2.61 (95% CI 1.19-5.71), and IL-18 level of 205.5±121.35 pg/ml, RR=1.38 (95% CI 1.06-1.79). There was a significant correlation between syndecan-1, TNF-α, and IL-18 levels. AKI incidence in post-cardiac surgery patients had a significant elevated IL-18 level (p=0.016), with RR=1.38 (95% CI 1.06-1.79).Conclusion: Elevated syndecan-1, TNF-α, and IL-18 levels were correlated with AKI incidence in post-cardiac surgery patients.

Authors: Andi Adil, Setiawan P, Yan Efrata Sembiring, Budiono

Clinical characteristics and outcomes of critically ill COVID-19 patients admitted to an Infectious Diseases Intensive Care Unit in Portugal


Objective: We aimed to describe the characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to an intensive care unit (ICU) in Portugal.

Design: This is an observational retrospective study. Demographic and clinical data were collected. Respiratory failure treated with invasive mechanical ventilation (IMV) and death during ICU stay were the main outcomes evaluated.

Setting: This study was conducted in the Infectious Diseases ICU of Centro Hospitalar e Universitário de São João, in Porto, Portugal, between March 11 and August 17, 2020.

Patients and participants: All consecutive patients with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, admitted to the ICU during the study period were enrolled, and 62 patients were included.

Measurements and results: The median age was 71 years (IQR, 54-78) and 39 (62.9%) were male. Thirty-four (54.8%) patients received IMV in contrast to 28 (45.2%) who were not intubated and the median lowest PaO2/FiO2 was 86 (IQR, 70-113) in IMV and 150 (94-257) in non-IMV patients. Several patients with severe hypoxemic COVID-19 were treated without IMV, especially with high flow nasal cannula (HFNC). Overall mortality was 21.8% and older age, male sex, active cancer, lower lymphocyte count, higher aspartate aminotransferase (AST) level, and higher creatinine level at admission, hematologic dysfunction, and renal dysfunction during ICU stay were all associated with fatal outcome. Mortality was lower than observed in other series of critically ill patients, although comparisons are limited by different ICU admission criteria, management practices, and duration of follow-up.Conclusions: This study provides data regarding the characteristics and outcomes of COVID-19 critically ill patients that can be used to optimize ICU preparedness in the future.

Authors: António Martins, Margarida Mouro, João Caldas, André Silva-Pinto, Ana Sofia Santos, Sandra Xerinda, Alcina Ferreira, Paulo Figueiredo, António Sarmento, Lurdes Santos

Age factor and COVID-19: Are there limits to be admitted in the ICU? An ethical issue


Objective: The aim of this article is to clarify different aspects including ethics about the elderly patients during coronavirus disease 2019 (COVID-19) scenario in Spain.

Design: Retrospective, observational.

Methods: Description and comparison of all age groups by confirmed cases and hospitalizations, with special emphasis on those elderly admitted to the intensive care unit (ICU) and mortality. Study of the ethical recommendations of different Spanish scientific societies with treatment proposals for the elderly group. Patients were divided into 6 different age groups. Group I (0-14 years), Group 2 (15-29 years), Group 3 (30-49 years), Group 4 (50-69 years), Group 5 (70-79 years), and Group 6 (>80 years).

Results: The number of confirmed cases during the study was 250,273 and 20,534 deaths. The global mortality was 8.2%. Number of hospitalized patients was 37.1% and 18.25% died. Three point one percent were admitted to the ICU with a mortality of 30.4%. ICU admission ratio: Group 4 51.7%, Group 5 28.4%, and Group 6 4.95%. Average age survivors were 58 (44-76 years), 83 (75-89 years) corresponding to Group 5-6. Non-ICU mortality increased to 14.6% in Group 5, while Group 6 achieved the highest mortality (21.7%).

Conclusion: The number of elderly patients admitted to the ICU was exceptionally low.

Authors: Santiago Herrero

Ultrasound cardiac output monitor inter-rater agreement in Pediatric Intensive Care Unit


Objective: Although Ultrasound Cardiac Output Measurement (USCOM) is relatively simple to operate, its reliability for novice user needs to be assessed. This study aims to determine inter-rater agreement of USCOM between pediatric residents as novices and pediatric intensivist as experienced operator.

Design: An observational study.

Setting: A single-center study in Pediatric Intensive Care Unit.

Patients and participants: Pediatric residents underwent in-house training and 20 practice scans, followed by blinded trans-aortic USCOM cardiac index (CI) measurements made by one of two randomly selected pediatric residents paired with one pediatric intensivist. CI, its categorization and image quality, were noted.

Measurements and results: Paired measurements were performed on 48 subjects. Median of subjects age were 2 years (1 month to less than 18-year-old). Spearman’s rank showed strong positive correlation of CI (rs=0.77; 95% CI=0.62-0.86). Inter-rater agreement by Cohen’s kappa showed substantial agreement on CI (ĸ=0.78).

Conclusion: Following training, pediatric residents were able to measure CI using USCOM with substantial inter-rater agreement.

Authors: Putu Aditya Wiguna, Indah Kartika Murni, Desy Rusmawatiningtyas

Comparison of the resuscitative effects between lactated ringer and lactated ringer/hydroxyethyl starch 6% (200/0.5) combination to serum lactate level in hemorrhagic shock in Lepus nigricollis rabbits


Objective: The ideal resuscitative strategy in hemorrhagic shock remains a matter of debate. The standard resuscitation fluid comprises of crystalloid and colloid, such as lactated Ringer’s (LR) and hydroxyethyl starch (HES), respectively. Whether the administration of LR/HES combination can provide better microcirculatory improvements than LR alone is still unknown.

Design: Experimental analytic study comparing the effect between LR and LR/HES (200/0.5) 2:1 combination to serum lactate level in hemorrhagic shock in rabbit (Lepus nigricollis).

Setting: This study was conducted at Hasanuddin University Medical Research Center (HUMRC), Makassar, Indonesia, from July to October 2019.

Patients and participants: A total of 30 Lepus nigricollis rabbits were included in this study. Fifteen animals were allocated in each group.

Interventions: After the initiation of induced hemorrhagic shock, a hypotension period was maintained for 30 minutes using infusion of LR/HES 6% (200/0.5) 1:2 combination if mean arterial pressure (MAP) decreased more than 30% from baseline, or if there was continuous bleeding if MAP was decreased less than 20% from baseline. The animals in LR group were then resuscitated with LR, while the animals in combination group were resuscitated with LR/HES 6% (200/0.5) 2:1 30 ml/kg/hour, then continued with 3 ml/kg/hour.

Measurements and results: Serum lactate level was measured at baseline, after the initiation of hemorrhagic shock, and after resuscitation. After hemorrhage was initiated, 19 animals had a <20% decrease in MAP and 11 animals had a ≥20% decrease in MAP. There was a significant decrease in serum lactate level in both LR and combination group with <20% decrease in MAP. LR group had a significant difference in serum lactate level from before and after resuscitation, whereas in combination group, only those with <20% decrease in MAP had a significant difference. There were no significant differences in the changes of serum lactate level between both groups.

Conclusions: Resuscitation in both groups may decrease serum lactate level in hemorrhagic shock, and resuscitation with LR/HES 6% (200/0.5) 2:1 combination provided better improvement than LR alone.

Authors: Faisal Muchtar, Syafri Kamsul Arif, Andi Husni Tanra, Arif Santoso, Made Wiryana, Agussalim Bukhari, Nurpudji Astuti Daud, Hisbullah, Warsinggih, Ilhamjaya Patellongi

Are preinjury anticoagulant and antiplatelet medications a pitfall in the bleeding tendencies of elderly trauma patients in intensive care?


Purpose: The elderly are more likely to be on anticoagulant or antiplatelet medications, which increase bleeding. We aimed to determine the effect of preinjury anticoagulant or antiplatelet medications on required blood transfusions and the trauma outcomes of elderly patients.

Methods: We retrospectively reviewed the medical records of all elderly trauma patients admitted to Chungbuk National University Hospital from January 2016 to June 2019. We compared the required number of blood transfusion units, complications, and mortality rate between those on anticoagulant or antiplatelet medications and those that were not, using the chi-squared test, independent t-test, linear regression analysis, and logistic regression analysis.

Results: Out of 466 patients, 142 were on anticoagulant or antiplatelet medications while 324 were not. There was a significant statistical difference in the unit amount of red blood cells transfused within 4 hours of arriving at the hospital between the medicated and non-medicated groups (0.89 vs 1.43 units, respectively, p=0.02); however, multivariate analysis showed no statistical difference (p=0.28). The medication group showed a higher rate of complications compared to the non-medicated group (47.9% vs 29.6%, respectively, p=0.001), bleeding (17.6% vs 2.8%, respectively, p=0.001), and pneumonia (24.4% vs 14.2%, respectively, p=0.01). There was no statistical difference in the mortality rate (16.9% vs 22.2%, respectively, p=0.21).

Conclusion: Preinjury anticoagulant or antiplatelet medications in elderly trauma patients increased bleeding and complications such as pneumonia but did not affect transfusion requirement, or mortality rate.

Authors: Se Heon Kim, Young Hoon Sul, Jin Young Lee, Joong Suck Kim

Does preinjury anticoagulant or antiplatelet medication increase the need for blood transfusions in patients aged older than 65 years with traumatic brain injury?


Background: Anticoagulant or antiplatelet medications are commonly prescribed in older adults, increasing bleeding tendency and affecting traumatic brain injury (TBI)-related morbidity and mortality.

Objectives: This study aimed to determine the effects of preinjury anticoagulant or antiplatelet medication on blood transfusions and outcomes in patients aged >65 years with TBI.

Methods: We retrospectively reviewed records of patients with TBI without other injuries admitted to our hospital between January 2016 and June 2019. We compared the number of blood transfusions administered and outcomes between patients who were receiving anticoagulant/antiplatelet medication and those who were not.

Results: Overall, 82 patients (66% male) with an average±standard deviation age of 76.6±7.29 years were enrolled. Thirty-one patients were receiving anticoagulants or antiplatelets and 51 were not. There were no differences in age, medical history, Injury Severity Score, and Glasgow Coma Scale score between the groups. International normalized ratios of patients who were on warfarin were significantly higher than those of patients who were not (p<0.05). Analysis of covariance demonstrated that patients who were receiving medications needed more plasma transfusions than did those who were not (p<0.05). The incidence of complications was 64.5% and 37.3% in patients who were and were not receiving medication, respectively (p<0.05). Multivariate regression analysis showed that patients who were receiving medications bled 5.62 times more than did those who were not (95% confidence interval: 1.52~20.70).

Conclusions: Bleeding incidence and plasma transfusion requirements are increased by preinjury anticoagulant or antiplatelet medication in patients aged >65 years with TBI.

Authors: Se Heon Kim, Young Hoon Sul, Jin Young Lee, Jin Bong Ye, Jin Suk Lee, Hong Rye Kim, Soo Young Yoon, Joong Suck Kim, Moon Sang Ahn

Renal angina index in pediatric septic patients as a predictor of acute kidney injury in remote area


Background: One of the most common sepsis comorbidities is severe acute kidney injury (AKI), which occurs in about 20% of pediatric patients with severe sepsis and is independently associated with poor outcomes. Many studies have shown the ability of renal angina index (RAI) with a cut-off point of 8 to predict the risk of AKI grade 2 and 3, but with varying sensitivity and specificity. Therefore, this study aims to identify a RAI cut-off point to predict the incidence of AKI in pediatric septic patients in the setting of a regional hospital in Indonesia.

Methods: An observational analytic study with a prospective longitudinal design was conducted on 30 pediatric patients in the Resuscitation Room of Dr. Soetomo General Hospital Surabaya. Patients who met the inclusion criteria were given 1-hour standardized resuscitation, then were observed. Every action taken to the patient was recorded, fluid input and output were measured, and mechanical ventilation and vasopressor administration were documented until the third day to determine factors influencing the incidence of AKI.

Results: In this study, 56.7% of pediatric septic patients had AKI. The Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in this study had a median of 11, in accordance with the pediatric sepsis guideline. RAI, with a cut-off point of 8 as a predictor for AKI grade 2-3, had a sensitivity of 100% and a specificity of 68% (area under the curve [AUC]=0.912). In terms of AKI risk tranche, the majority of patients (93.1%) had mechanical ventilation, while in terms of AKI injury tranche, the majority met the fluid overload criteria (79.3%).

Conclusion: RAI, with a cut-off point of 8, can be used as a predictor for severe AKI in pediatric septic patients.

Authors: Nugroho Setia Budi, Bambang Pujo Semedi, Arie Utariani, Ninik Asmaningsih

Balanced salt solution versus normal saline solution as initial fluid resuscitation in pediatric septic shock: A randomized, double-blind controlled trial


Objective: Initial fluid resuscitation is mandatory in treatment of septic shock. Current sepsis guidelines do not have the recommendation for either balanced salt or normal saline solution for initial fluid resuscitation. The objective of this study was to determine the impact of balanced salt solution (BS) versus normal saline solution (NS) in pediatric septic shock as initial fluid resuscitation.

Design: A double-blind randomized controlled trial study.

Setting: A single tertiary care center in Bangkok, Thailand.

Patients and participants: Children aged 1 month to 18 years who were diagnosed with septic shock. We excluded patients who received fluid resuscitation in the 24 hours prior to septic shock, end-stage disease, and refusal of informed consent.

Interventions: Patients were randomly assigned into 2 groups after being diagnosed with septic shock and required fluid resuscitation (NS or BS).

Measurements and results: Demographic data, vasoactive-inotropic scores, and outcomes were evaluated. The primary outcome was incidence of hyperchloremic metabolic acidosis. Sixty-one septic shock children were enrolled into this study (NS=31 patients, and BS=30 patients). Baseline characteristics between two groups were not different. The incidence of hyperchlor-emic metabolic acidosis was 17 (54.8%) and 10 (33.3%) in NS and BS groups, respectively (p=0.091). The hospital mortality and prevalence of acute kidney injury were not different between groups.

Conclusion: In pediatric septic shock, the initial fluid resuscitation with balanced salt solution and normal saline was associated with similar clinical outcomes. However, normal saline solution had a trend toward more frequent hyperchloremic metabolic acidosis in children with septic shock when compared to balanced salt solution.

Authors: Nattachai Anantasit, Sriwanna Thasanthiah, Rojjanee Lertbunrian