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Meaning of the venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio.

Critical Care Medicine www.ccmjournal.org e489 Regarding vascular access, the guidelines highlight the importance of not delaying therapy by lack of central access, emphasizing the use of intraosseous access, and administration of antibiotics by alternative routes (i.e., orally or intramuscularly), as well as beginning peripheral inotropic support until central venous access can be attained. However, the authors do not position themselves about which central catheter insertion site is preferential, not taking into account the risks of infection and deep vein thrombosis associated with the catheter site (4). Thus, the “take-home message” about central catheter insertion sites is still not clear. In relation to the type of solution used for fluid resuscitation, albumin is considered as the first option in the industrialized world. The trials were performed with adult patients, and the conclusions drawn in adults cannot be extrapolated to children for several reasons, such as different physiological response, requirement of more aggressive volume resuscitation, and major volume component in septic shock. A systematic review about fluid resuscitation in children showed that there is insufficient evidence to support the preferential use of colloids in pediatric sepsis (5). These facts associated with lower side effects, cost, and wide availability (considering developing countries) make crystalloids the first choice in fluid resuscitation of children, and albumin should be reserved for specific cases or when there is no response to initial crystalloids use, even in a resourceful setting. Still regarding fluid resuscitation, the presence of pulmonary rates can be a poor marker of fluid overload, since the septic patient presents with generalized inflammation, including pulmonary capillaritis. The same consideration applies to hepatomegaly, especially in mechanically ventilated patients. These possible misinterpretations of the fluid status leading to using diuretics (especially on an early treatment stage) could be deleterious to the hemodynamic status. Other signs of hypervolemia (transthoracic echocardiographic assessment, for instance) should be evaluated, and the wariness front of diuretic use should be emphasized. In conclusion, we believe that applying the above considerations on the extensive work done by the pediatric subgroup will improve the odds of success on an early goal-directed therapy with septic pediatric patients worldwide. The authors have disclosed that they do not have any potential conflicts of interest.