Critical Illness, Pediatrics, General Surgery, Fluid Therapy, Wounds and Injuries
Conditions
Keywords
Fluid Therapy, Intensive Care Units, Pediatric, Critical Care, Wounds and Injuries, Multiple Trauma, Treatment Outcome, Postoperative Complications, Resuscitation, Hemodynamics, Infusions, Intravenous, Isotonic Solutions, Crystalloid Solutions, Diuretics, Organism Hydration Status, Body Water
Brief summary
This study is designed to help decide how much intravenous (IV) fluid should be given to pediatric trauma patients. No standard currently exists for managing fluids in critically ill pediatric trauma patients, and many fluid strategies are now in practice. For decades, trauma patients got high volumes of IV fluid. Recent studies in adults show that patients actually do better by giving less fluid. The investigators do not know if this is true in children and this study is designed to answer that question and provide guidelines for IV fluid management in children after trauma.
Detailed description
Aggressive fluid resuscitation has been the cornerstone of early post-operative and trauma management for decades. However, recent prospective adult studies have challenged this practice, linking high volume crystalloid resuscitation to increased mortality, cardiopulmonary, gastrointestinal and hematologic complications. A retrospective study the investigators recently performed at their quaternary-care children's hospital echoed these results. High quality prospective data is necessary to determine best practice guidelines in our pediatric surgery and trauma patients. Currently, no standard exists to guide management of crystalloid fluid administration in trauma patients. Both liberal and restricted strategies are in use, dependent on physician discretion. The investigators propose the first randomized controlled trial (RCT) comparing a liberal to a restricted fluid management strategy in critically ill pediatric trauma patients. The objective of this comparative effectiveness study is to conduct a multicenter (around 10 sites) randomized controlled trial (RCT) to determine whether liberal or restricted fluid administration leads to better outcomes in these patients.
Interventions
OTHERBalanced crystalloid solution volume administration
Maintenance and bolus fluid volumes of balanced isotonic crystalloid solution administered based on arm.
OTHERPacked Erythrocytes Units, Blood Product Unit volume
For patients designated as Bleeding, where hemoglobin \<7 then patient will be transfused 10 mL/kg up to 250 mL/transfusion. If patient is hypovolemic with clinician discretion transfuse 20 mL/kg.
OTHERPlasma volume
For patients designated as Bleeding, where International Normalized Ratio (INR) \> 1.5 then patient will be transfused 10 mL/kg up to 250 mL/transfusion. If patient is hypovolemic with clinician discretion transfuse 20 mL/kg.
OTHERPlatelets volume
For patients designated as Bleeding, where platelets \< 50,000 then patient will be transfused 10 mL/kg up to 250 mL/transfusion. If patient is hypovolemic with clinician discretion transfuse 20 mL/kg.
Sponsors
Northwell Health
Johns Hopkins University
Cornell University
Childress Institute for Pediatric Trauma
Columbia University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
6 Months to 15 Years
Healthy volunteers
No
Inclusion criteria
* Trauma patients older than 6 months and younger than 15 years admitted to the pediatric intensive care unit (PICU) * Patients admitted to the PICU directly from the Emergency Department (ED) * Patients admitted to the PICU from the operating room (OR) * Patients transferred to PICU from outside facility ED (need to have been in ED 12 hours or less)
Exclusion criteria
* Patients transferred to PICU from outside PICU or inpatient floor * Patients transferred to PICU from outside facility ED if \>12 hours * Patients expected to be discharged from the PICU within 24 hours * Patient with congenital heart disease as defined by a congenital cardiac defect requiring surgery or medication * Patient with diagnosis of chronic cardiac condition (e.g. hypertension, cardiac arrhythmia) * Patients with chronic kidney disease as defined by an abnormality of kidney structure or function, present for more than 3 months, with implications to health * Post-operative transplant, cardiac, and neurosurgical patients * Patients with traumatic brain injury * Patients with any disease that may affect baseline blood pressure and heart rate (endocrine disorders, certain genetic disorders, mitochondrial diseases) * Hypotension requiring vasopressor therapy * If massive transfusion protocol initiated
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Overall complications | Up to time of discharge (up to approximately 1 month) | Total number of complications defined as pulmonary edema, hemorrhage, deep cavity infection, anastomotic dehiscence, thrombosis, death, superficial wound infection, ileus, and pneumonia. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Hours of Hospital Length of Stay | Up to time of discharge (up to approximately 1 month) | length of time in hospital to inpatient discharge in hours |
| Number of Hours of ICU Length of Stay | Up to time of discharge (up to approximately 1 month) | length of time in pediatric intensive care unit in hours |
| Number of hours on Supplemental Oxygen | Up to time of discharge (up to approximately 1 month) | length of time patient requires non-invasive supplemental O2 in hours |
| Number of Hours on Ventilator | Up to time of discharge (up to approximately 1 month) | length of time patient requires invasive ventilation in hours |
Countries
United States
Contacts
Primary ContactVincent P Duron, MD
Outcome results
None listed