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RÉSUMÉ Pour traiter l’acidocétose diabétique pédiatrique, il faut porter une attention particulière aux liquides et aux électrolytes pour limiter le risque de complications, telles qu’une lésion cérébrale, associée à une morbidité et une mortalité élevées. L’incidence d’œdème cérébral en cas d’acidocétose diabétique n’a pas diminué malgré les protocoles visant la limitation des liquides qui s’appuient sur la restriction de la réanimation liquidienne initiale. Selon de nouvelles données probantes, l’administration précoce de liquides isotoniques n’entraîne pas de risque supplémentaire et peut améliorer les résultats cliniques chez certains patients. Les protocoles et les directives cliniques sont adaptés et axés particulièrement sur la surveillance et le remplacement initiaux et continus des liquides et des électrolytes. Il est maintenant recommandé de commencer par une réanimation à l’aide de liquides isotoniques chez tous les patients dans les 20 à 30 minutes suivant leur arrivée à l’hôpital, suivie par la réplétion du déficit volumique sur une période de 36 heures, en association avec une perfusion d’insuline et des suppléments d’électrolytes, ainsi qu’avec la surveillance et la prise en charge attentives d’une éventuelle lésion cérébrale.

Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients. Protocols and clinical practice guidelines are being adjusted, with a particular focus on recommendations for initial and ongoing fluids and electrolyte monitoring and replacement. Initial isotonic fluid resuscitation is now recommended for all patients in the first 20 to 30 minutes after presentation, followed by repletion of volume deficit over 36 hours in association with an insulin infusion, electrolyte supplementation, and careful monitoring for and management of potential CI.

This ISTH “State of the Art” review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion‐related considerations, age‐ and size‐related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.

BACKGROUND: Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. METHODS: MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I(2) 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I(2) 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I(2) 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I(2) 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62–1.70), I(2) 28%, n = 7), length of stay (MD − 0.18 (95% − 1.42, 1.05), I(2) 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I(2) 74%, n = 9). The quality of evidence was rated very low. DISCUSSION: Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05236-8) contains supplementary material, which is available to authorized users.