One of my favorite parts about being in PEM is the constant sharing of good content – studies, FOAM posts, conferences, podcasts, interesting cases, practice-changing papers, and the occasional “you need to read this before your next shift” text message.
A lot of the best educational pearls I come across don’t start with a formal journal alert. They start in a group chat.
So I thought I’d start sharing some of those things here periodically with the broader HipPEMcrates community: quick-hitting PEM resources, studies, conferences, and educational content that are making the rounds among friends and colleagues in pediatric emergency medicine.
A few things that came across the HipPEMcrates group chat this week:
Fellow PEM FOAM physician Yaron Ivan – who runs the PEM Rules podcast – recently wrote a great piece through the American College of Emergency Physicians on the approach to the ill-appearing newborn in the pediatric emergency department.
The article walks through:
- Initial triage considerations
- Five critical diagnoses to keep on your radar
- Early stabilization priorities
- Suggested initial diagnostic workup
Check it out: Approach to the Ill-Appearing Newborn in the Pediatric Emergency Department
If you’re looking for a solid virtual PEM conference this month, the 15th Annual Cohen Children’s Medical Center Pediatric Emergency Medicine Symposium is coming up on Wednesday, May 27th. I may be biased because I did my residency at Cohen’s, but I’ve attended the conference in the past, and Dr. Josh Rocker and his team always puts together a great set of speakers.
The lineup covers a broad range of PEM topics including toxicology, cardiology, pain management, infectious diseases, trauma, burns, best PEM articles of the year, and the always entertaining PEM Fellow PICO Competition. It’s also free for all learners and only $25 for everyone else.
Worried you won’t be able to make it on the day of? If you register, you get access to the entire content whenever you want for over a year.
Last year they had nearly 700 registrants representing more than 13 countries and 27 U.S. states – a pretty good reflection of how widely respected this conference has become in the PEM community.
You can register here:
https://www.eventbrite.com/e/15th-annual-pediatric-emergency-medicine-symposium-tickets-1983620153276?aff=oddtdtcreator
One of the biggest PEM studies making the rounds recently was the PRoMPT trial, published in NEJM, comparing balanced crystalloids with 0.9% saline for children with suspected septic shock.
This was an enormous international pragmatic RCT conducted across 47 EDs in 5 countries and included more than 8,000 pediatric patients – making it the largest acute care interventional trial ever conducted in pediatrics.
The question was one many of us have debated for years: do balanced fluids actually improve meaningful clinical outcomes compared with saline in pediatric septic shock?
The short answer: probably not for most patients.
I recently wrote up the study for JournalFeed and thought it was worth sharing here as well because I suspect this will end up being one of those “practice-settling” trials for PEM. Read the full JournalFeed write-up below:
Spoon Feed
In children with suspected septic shock, balanced crystalloids did not reduce the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction compared with 0.9% saline, suggesting either fluid is reasonable for initial ED resuscitation.
A landmark trial with a surprisingly practical answer
Fluid choice in pediatric sepsis has often generated strong opinions, mostly because 0.9% saline can cause hyperchloremia and metabolic acidosis, while balanced fluids more closely resemble plasma composition. The PRoMPT BOLUS trial was designed to answer whether those biochemical differences actually matter clinically. This pragmatic, international randomized trial enrolled children 2 months to <18 years old with suspected septic shock and abnormal perfusion across 47 EDs in 5 countries, comparing balanced fluids with 0.9% saline for resuscitation and maintenance fluids for up to 48 hours.
Among 8,482 analyzed patients, a primary outcome event—a composite of death, new renal-replacement therapy, or persistent kidney dysfunction, all at 30 days—occurred in 3.4% of the balanced-fluid group vs. 3.0% of the saline group, with no significant difference (RR 1.10; 95%CI 0.88–1.40, p=0.85). Mortality, hospital length of stay, and hospital-free days were also similar. Balanced fluids reduced hyperchloremia (31% vs. 49%) and hypernatremia (1.8% vs. 3.1%), though hyperlactatemia was slightly more common (20% vs. 17%), but these lab differences did not translate into patient-centered benefit.
The major limitation is that the event rate was lower than expected, reducing power to detect small differences. The authors also note that the study may not fully exclude benefit in the sickest children, where point estimates favored balanced fluids in some analyses.
How will this change my practice?
There was a lot of anticipation for the results of this study, which was the largest acute care interventional trial ever conducted in pediatrics. Personally, as someone who helped to enroll during fellowship and as an attending, I was very curious what the study would reveal. I think a good way to frame the results is that it is practice-settling, not necessarily practice-changing. For most children with suspected septic shock in the ED, I would not delay resuscitation or overthink the fluid bag. Use what is immediately available, compatible, and appropriate for the patient. If LR or Plasma-Lyte is ready, great. If saline is what’s hanging, also fine. The priority remains early recognition, timely antibiotics, appropriate fluid resuscitation, reassessment, and vasoactive drugs when needed. Balanced fluids still make physiologic sense in some scenarios, especially when giving large volumes or trying to avoid hyperchloremia, but this trial makes it hard to argue that balanced fluids should be mandatory for all pediatric septic shock resuscitations. The bag probably matters less than the bedside care around it.
HipPEMcrates is proud to partner with JournalFeed to bring you concise, high-impact summaries of the latest pediatric emergency medicine literature. Through this collaboration, we’ll regularly feature JournalFeed synopses to keep you sharp, evidence-based, and up-to-date. Sign up for JournalFeed here.
As always, if you come across great PEM FOAM resources, interesting studies, conference announcements, or things worth sharing with the broader PEM community, send them my way. And if you’ve ever thought about contributing to HipPEMcrates, we’re always looking for clinicians interested in writing a post – even if you only have a rough idea or a PowerPoint you’ve used in the past.
Dr. Joshua Belfer, MD, is a Pediatric Emergency Medicine physician at the Children’s Hospital of Philadelphia, and is the Founder and Editor-in-Chief of HipPEMcrates. He can be reached at HipPEMcrates@gmail.com.
