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Objectives: The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.", Design: Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups., Measurements and Main Results: The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations., Conclusions: The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Objective: To evaluate Co(2) clearance in oleic acid-induced lung injury in rabbits receiving high-frequency oscillatory ventilation with helium-oxygen mixtures through a low bias flow oscillation system designed to conserve expensive gases., Design: A prospective, controlled, interventional, in vivo animal laboratory study., Setting: Research laboratory of a health sciences university., Subjects: Eight New Zealand White Rabbits., Interventions: Lung injury (Pao(2)/Fio(2) of <250) was induced by intravenous infusion of oleic acid. Low bias flow oscillation was performed with a modified high-frequency oscillatory ventilation circuit that uses low bias flow (100 mL/kg/min) and a soda lime canister to clear CO(2). Low bias flow oscillation-heliox trials were performed with 40%, 50%, 60%, and 70% helium (balanced with oxygen) for 20 mins. Each heliox trial was preceded by a 20-min paired control trial with 40% oxygen/60% nitrogen., Measurements and Main Results: Helium concentrations of 40%, 50%, 60%, and 70% decreased Paco(2) by 13% (47 +/- 7 to 41 +/- 8 torr), 17% (50 +/- 7 to 41 +/- 6 torr), 22% (49 +/- 5 to 38 +/- 7 torr), and 26% (48 +/- 7 to 35 +/- 9 torr), respectively. The gradient between partial pressure of alveolar oxygen and Pao(2) was not affected by 60% helium; however, absolute Pao(2) increased by 15%. Fluid and inotropic requirements were similar in both control and heliox low bias flow oscillation trials., Conclusion: Helium concentrations greater than 40% increase Co(2) clearance from oleic acid-injured lungs of rabbits during low bias flow oscillation. The low bias flow oscillation system makes this possible using 1% of the gas volume required during high-frequency oscillatory ventilation.

Objective: To examine whether perfluorooctyl bromide (perflubron) is capable of protecting biological and nonbiological systems against oxidative damage through a mechanism independent of its known anti-inflammatory property., Design: A controlled, in vitro laboratory study., Setting: Research laboratory of a health sciences university., Subjects: Rat pulmonary artery endothelial cell cultures (biological system) and linoleic acid in sodium dodecyl sulfate micelles (nonbiological system)., Interventions: Rat pulmonary artery endothelial cells labeled with dichlorofluorescein diacetate and incubated with perflubron or culture media (control) were exposed to H2O2. H2O2-induced fluorescence of dichlorofluorescein diacetate was measured as an index of intracellular oxidative stress. In another experiment, linoleic acid in sodium dodecyl sulfate micelles was exposed to various concentrations of the azo initiator 2,2'-diazo-bis-(2-amidinopropane) dihydrochloride (2, 4, 20, and 50 mM) in the presence or absence of perflubron. Malondialdehyde measurements were obtained as a marker of oxidative damage to linoleic acid., Measurements and Main Results: Cell monolayers incubated with perflubron exhibited 66.6% attenuation in intracellular fluorescence compared with controls (p < .05). Linoleic acid in sodium dodecyl sulfate micelles incubated with perflubron and exposed to 2, 4, 20, or 50 mM of 2,2'-diazo-bis-(2-amidinopropane) dihydrochloride showed less evidence of lipid peroxidation as indicated by lower malondialdehyde measurements at 240 mins (10.6%, 16%, 41%, and 14.2%, respectively) compared with controls., Conclusions: Perflubron attenuates oxidative damage to both biological and nonbiological systems. This newly recognized property of perflubron is independent of its anti-inflammatory properties.