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Endothelial and Glycocalyx Biomarkers in Children With Sepsis After One Bolus of Unbalanced or Balanced Crystalloids
Jaime Fernández-Sarmiento1,2, Lina María Salazar-Peláez2, Lorena Acevedo1
1Department of Pediatrics and Intensive Care, Fundación Cardioinfantil-Instituto de Cardiología, Universidad de La Sabana, Bogotá, Colombia.
Insights
Unbalanced crystalloids worsen endothelial glycocalyx damage in children with sepsis, increasing risks of metabolic acidosis and acute kidney injury. This disruption peaks six hours post-resuscitation.
Area of Science:
- Pediatric Critical Care Medicine
- Resuscitation Science
- Endothelial Biology
Background:
- Sepsis in children can lead to endothelial glycocalyx disruption.
- Fluid resuscitation is critical but may impact glycocalyx integrity.
- Understanding crystalloid effects is vital for pediatric sepsis management.
Purpose of the Study:
- To evaluate endothelial glycocalyx integrity in pediatric sepsis patients receiving balanced versus unbalanced crystalloid fluid resuscitation.
- To determine the association between crystalloid type and markers of endothelial damage, vascular permeability, and apoptosis.
Main Methods:
- Prospective cohort study in a pediatric intensive care unit (PICU).
- Assessed endothelial glycocalyx disruption using perfused boundary region (PBR) and syndecan-1 levels.
- Measured angiopoietin-2 and annexin A5 levels to assess vascular permeability and apoptosis.
Main Results:
- Children receiving unbalanced crystalloids showed significantly higher rates of endothelial glycocalyx degradation (84.5% vs. 60.4%) six hours post-resuscitation.
- This degradation correlated with increased angiopoietin-2 and annexin A5 levels.
- Unbalanced crystalloid use was associated with higher odds of metabolic acidosis and acute kidney injury.
Conclusions:
- Fluid resuscitation with unbalanced crystalloids in pediatric sepsis exacerbates endothelial glycocalyx damage.
- This disruption is linked to adverse clinical outcomes including metabolic acidosis and acute kidney injury.
- The findings highlight the importance of crystalloid choice in pediatric sepsis management.
Objectives:
To assess the disruption of endothelial glycocalyx integrity in children with sepsis receiving fluid resuscitation with either balanced or unbalanced crystalloids. The primary outcome was endothelial glycocalyx disruption (using perfused boundary region >2 µm on sublingual video microscopy and syndecan-1 greater than 80 mg/dL) according to the type of crystalloid. The secondary outcomes were increased vascular permeability (using angiopoietin-2 level), apoptosis (using annexin A5 level), and associated clinical changes.
Design:
A single-center prospective cohort study from January to December 2021.
Setting:
Twelve medical-surgical PICU beds at a university hospital.
Patients:
Children with sepsis/septic shock before and after receiving fluid resuscitation with crystalloids for hemodynamic instability.
Interventions:
None.
Measurements And Main Results:
We included 106 patients (3.9 yr [interquartile range, 0.60-13.10 yr]); 58 of 106 (55%) received boluses of unbalanced crystalloid. This group had greater odds of endothelial glycocalyx degradation (84.5% vs 60.4%; adjusted odds ratio, 3.78; 95% CI, 1.49-9.58; p < 0.01) 6 hours after fluid administration, which correlated with increased angiopoietin-2 (rho = 0.4; p < 0.05) and elevated annexin A5 ( p = 0.04). This group also had greater odds of metabolic acidosis associated with elevated syndecan-1 (odds ratio [OR], 4.88; 95% CI, 1.23-28.08) and acute kidney injury (OR, 1.7; 95% CI, 1.12-3.18) associated with endothelial glycocalyx damage. The perfused boundary region returned to baseline 24 hours after receiving the crystalloid boluses.
Conclusions:
Children with sepsis, particularly those who receive unbalanced crystalloid solutions during resuscitation, show loss and worsening of endothelial glycocalyx. The abnormality peaks at around 6 hours after fluid administration and is associated with greater odds of metabolic acidosis and acute kidney injury.
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