Notes From the Community – Pediatric Sepsis - Part 2

JS -

How about this article about Peds loading of APAP:

Antipyretic Efficacy of an Initial 30-mg/kg Loading Dose of Acetaminophen Versus a 15-mg/kg Maintenance Dose
Jean Marc Tréluyer, MD, PhD*, Sylvie Tonnelier, PharmD*, Philippe d'Athis‡, Beatrice Leclerc§, Isabelle Jolivet-Landreau, MD§, Gérard Pons, MD, PhD*

from Pediatrics. I believe that Rick and Jerry did this once on EMabstracts. I do this occasionally.

Graham J. -

I'm surprised to hear about dextrose being used for the acute resuscitation in hypovolaemia. Would giving the boluses IV of 0.9% Saline (or indeed Hartmann's) be better and get the sugar in PO/NG?

Andrew S. -

I'm not using dextrose to routinely resus; that would still be LR (Hartmann's) or NS. I do pay attention to the acidosis and give credence to using LR over NS for the severely acidotic patient as I don't want them to have to breath any faster than they already are doing from all the extra chloride. That being said...if a patient has bad gastro and has burned through their glycogen stores than I'm all about giving them the D5 after the initial resus in near bolus format to replete and stop the generation of keytones.. Here's the study that shows everything I just said doesn't work: http://www.ncbi.nlm.nih.gov/pubmed/22959318. My opinion: wrong endpoints and a lot of bias has to who got admitted. In my mind it's a matter of combining US / clinical exam to decide who's severely dehydrated and then actually giving them the time to try and po after the bolus...

Andrew S. -

Antipyretics are fine in 30mg/kg loading dose as the real toxic dose in kids would be 140-150mg/kg. The real question is why do we need to crush the fever? Fever is killing the virus most of the time. So..I like the 30/kg load if they won't drink and stay hydrated, but otherwise I tell the family to let the fever ride and it will kill all those little commie viri!!!

Xander Merboo -

Didn't I just hear recently that IBU is actually better than APAP for peds fever?

Andrew S. -

First I'd have to ask why we're so intent on treating fever...it's what's killing the virus and not the abx the pediatrician gave to kill the "ear infection" in the kid with cough/congestion/rhinorrhea and obvious URI that additionally has a slightly red ear.

That being said, my wife (who is a pediatrician) and is sitting right next to me (and currently offended) thinks ibuprofen is better. I'd have to say that I know of one meta-analysis (http://goo.gl/lp4C96g) that would agree with her, but I have also read a bunch of studies that say APAP is just as effective.

I would also offer up that alternating APAP and IBU may be the most effective treatment (http://goo.gl/oknozE), but there are plenty of articles that say this is bunk too. My personal opinion is I feel pretty good alternating IBU and APAP when I have the flu, but I have no hard evidence to say it works. I can also say it probably doesn't prevent the second febrile seizure (after you've sent them home with their first one) and it most likely prolongs the length of illness = time missed from work and school. You pick, but I say....let the fever ride as long as they're drinking and keeping up with their hydration...

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