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A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: a systematic
Nienke N Hagedoorn1, Joany M Zachariasse1, Henriette A Moll2
1Department of Paediatrics, Room Sp 1540, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, PO Box 2060, 3000 CB, Rotterdam, The Netherlands.
Insights
Existing definitions for pediatric hypotension vary significantly. This study found that current clinical guidelines for low blood pressure in children show poor agreement with evidence-based reference values, necessitating updated guidelines for accurate diagnosis.
Area of Science:
- Pediatric Cardiology
- Clinical Pediatrics
- Evidence-Based Medicine
Background:
- Existing definitions for hypotension in children lack standardization, leading to diagnostic challenges.
- There is a need for evidence-based reference values for low blood pressure in pediatric populations.
- This study addresses the variability in current systolic hypotension definitions for children.
Purpose of the Study:
- To identify evidence-based, age-related centiles for systolic blood pressure in healthy children.
- To compare these reference values with existing clinical definitions of hypotension.
- To evaluate the agreement between population-based centiles and current hypotension cut-offs.
Main Methods:
- Conducted a systematic literature search of online databases (MEDLINE, EMBASE, Web of Science) up to February 2019.
- Identified studies reporting age-related centiles (1st-5th) for non-invasive systolic blood pressure in children (<18 years).
- Extracted and compared clinical hypotension cut-offs from international guidelines and textbooks with identified centiles.
Main Results:
- Fourteen studies provided population-based centiles; values for the 5th centile showed 8-17 mmHg variability by age.
- Thirteen clinical cut-offs were identified, with only 5 reporting accurate references; significant variability (15-30 mmHg) was observed.
- The Paediatric Advanced Life Support (PALS) definition aligned well for children <12 years but underestimated hypotension in older children.
Conclusions:
- Current clinical guidelines for pediatric hypotension exhibit substantial variability and moderate agreement with population-based centiles.
- The PALS definition is suitable for younger children (<12 years) but not older ones, where Parshuram's early warning score cut-off is more appropriate.
- Future research should focus on establishing reference values for hypotension in acutely ill children.
Background:
Different definitions exist for hypotension in children. In this study, we aim to identify evidence-based reference values for low blood pressure and to compare these with existing definitions for systolic hypotension.
Methods:
We searched online databases until February 2019 (including MEDLINE, EMBASE, Web of Science) using a comprehensive search strategy to identify studies that defined age-related centiles (first to fifth centile) for non-invasive systolic blood pressure in healthy children < 18 years. Existing cut-offs for hypotension were identified in international guidelines and textbooks. The age-related centiles and clinical cut-offs were compared and visualized using step charts.
Results:
Fourteen studies with population-based centiles were selected, of which 2 addressed children < 1 year. Values for the fifth centile differed 8 to 17 mmHg for age. We identified 13 clinical cut-offs of which only 5 reported accurate references. Age-related cut-offs for hypotension showed large variability (ranging from 15 to 30 mmHg). The clinical cut-offs varied in agreement with the low centiles. The definition from Paediatric Advanced Life Support agreed well for children < 12 years but was below the fifth centiles for children > 12 years. For children > 12 years, the definition of Parshuram's early warning score agreed well, but the Advanced Paediatric Life Support definition was above the fifth centiles.
Conclusions:
The different clinical guidelines for low blood pressure show large variability and low to moderate agreement with population-based lower centiles. For children < 12 years, the Paediatric Advanced Life Support definition fits best but it underestimates hypotension in older children. For children > 12 years, the Advanced Paediatric Life Support overestimates hypotension but Parshuram's cut-off for hypotension in the early warning score agrees well. Future studies should focus on developing reference values for hypotension for acutely ill children.
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