RESUMEN
BACKGROUND AND AIMS: Children with asthma and respiratory failure comprise a small but significant subset of children with acute asthma. In addition to clinical and historical factors that have been associated with respiratory failure, there may also be genetic factors that predispose some asthmatic children to intubation and mechanical ventilation. However, this has not previously been assessed in this population. We hypothesized that genetic polymorphisms of the ß(2)-adrenergic receptor (ADRß(2)) are associated with intubation and mechanical ventilation in children with asthma. MATERIALS AND METHODS: We performed genotyping of the ADRß(2) in a pooled cohort of 104 children admitted to the intensive care unit (ICU) with a severe asthma exacerbation between 2002 and 2008. Genotype of the ADRß(2) was compared with intubation for respiratory failure. RESULTS: At amino acid position 16, 33% (n = 34) of children were homozygous for the glycine allele (Gly16Gly), 15% (n = 16) were homozygous for the arginine allele (Arg16Arg), and 52% (n = 54) were heterozygous (Arg16Gly). At amino acid position 27, 54% (n = 56) of children were homozygous for the glutamine allele (Gln27Gln), 8% (n = 8) were homozygous for the glutamic acid allele (Glu27Glu), and 38% (n = 40) were heterozygous (Gln27Glu). The haplotypes at these positions were Arg16Gly-Gln27Gln (29%, n = 30), Arg16Gly-Gln27Glu (22%, n = 23), Gly16Gly-Gln27Glu (16%, n = 17), Arg16Arg-Gln27Gln (16%, n = 17), Gly16Gly-Gln27Gln (9%, n = 9), and Gly16Gly-Glu27Glu (8%, n = 8). Twelve children in this cohort were intubated for respiratory failure. Intubation was not associated with age, obesity, race/ethnicity, or NHBLI asthma classification. However, children with the Arg16Gly-Gln27Gln haplotype were significantly more likely to be intubated and mechanical ventilated (OR = 4.2; 95% CI = 1.2-14.5; p = .036) than children with other haplotypes of the ADRß(2). When examining the subset of intubated children, those with the Arg16Gly-Gln27Gln haplotype trended towards longer ICU length of stay (329 ± 270 vs. 124 ± 57 hours; p = .09), but this was not statistically significant. CONCLUSIONS: Children with the Arg16Gly-Gln27Gln haplotype of the ADRß(2) were four times more likely to be intubated and mechanically ventilated during severe asthma exacerbations. Genetic factors may influence the development of a more severe asthma phenotype during acute exacerbations.
Asunto(s)
Asma/genética , Receptores Adrenérgicos beta 2/genética , Respiración Artificial , Adolescente , Asma/terapia , Niño , Preescolar , Femenino , Haplotipos , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Intubación Intratraqueal , Masculino , Polimorfismo Genético , Insuficiencia Respiratoria/genética , Insuficiencia Respiratoria/terapiaRESUMEN
BACKGROUND AND AIMS: Bronchiolitis is a common cause of critical illness in infants. Inhaled ß(2)-agonist bronchodilators are frequently used as part of treatment, despite unproven effectiveness. The purpose of this study was to describe the physiologic response to these medications in infants intubated and mechanically ventilated for bronchiolitis. MATERIALS AND METHODS: We conducted a prospective trial of albuterol treatment in infants intubated and mechanically ventilated for bronchiolitis. Before and for 30 minutes following inhaled albuterol treatment, sequential assessments of pulmonary mechanics were determined using the interrupter technique on repeated consecutive breaths. RESULTS: Fifty-four infants were enrolled. The median age was 44 days (25-75%; interquartile range (IQR) 29-74 days), mean hospital length of stay (LOS) was 18.3 ± 13.3 days, mean ICU LOS was 11.3 ± 6.4 days, and mean duration of mechanical ventilation was 8.5 ± 3.5 days. Fifty percent (n = 27) of the infants were male, 81% (n = 44) had public insurance, 80% (n = 41) were Caucasian, and 39% (n = 21) were Hispanic. Fourteen of the 54 (26%) had reduction in respiratory system resistance (Rrs) that was more than 30% below baseline, and were defined as responders to albuterol. Response to albuterol was not associated with demographic factors or hospitalization outcomes such as LOS or duration of mechanical ventilation. However, increased Rrs, prematurity, and non-Hispanic ethnicity were associated with increased LOS. CONCLUSIONS: In this population of mechanically ventilated infants with bronchiolitis, relatively few had a reduction in pulmonary resistance in response to inhaled albuterol therapy. This response was not associated with improvements in outcomes.
Asunto(s)
Albuterol/uso terapéutico , Bronquiolitis/tratamiento farmacológico , Broncodilatadores/uso terapéutico , Pulmón/fisiopatología , Respiración Artificial , Bronquiolitis/fisiopatología , Femenino , Humanos , Lactante , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Estudios ProspectivosRESUMEN
BACKGROUND: During severe exacerbations, asthmatic children vary significantly in their response to high-dose continuous ß(2) -adrenergic receptor (ADRß(2) ) agonist therapy. Genetic polymorphisms have been identified within the ADRß(2) that may be functionally relevant, but few studies have been performed in this population. Our hypothesis was that genotypic differences are associated with magnitude of response to ADRß(2) agonist treatment during severe asthma exacerbations in children. METHODS: Children aged 2-18 years admitted to the ICU (intensive care unit) with a severe asthma exacerbation between 2006 and 2008 were eligible. Genotyping of the ADRß(2) was performed. RESULTS: Eighty-nine children consented and were enrolled. Despite similar clinical asthma scores on admission, children with the Gly(16) Gly genotype at amino acid position 16 had significantly shorter ICU length of stay (LOS) and hospital LOS, compared to children with Arg(16) Arg and Arg(16) Gly genotypes. Children with either the Gln(27) Glu or Glu(27) Glu genotype at amino acid position 27 also had significantly shorter ICU LOS and hospital LOS compared to children with the Gln(27) Gln genotype. The Arg(16) Gly-Gln(27) Gln haplotype was associated with the longest ICU LOS, but this was not statistically different from other haplotypes. CONCLUSIONS: In this cohort of children with severe asthma exacerbations, ADRß(2) polymorphisms were associated with responses to therapy. Knowledge of the genetic profile of children with asthma may allow for targeted therapy during acute exacerbations.
Asunto(s)
Hospitalización/estadística & datos numéricos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Polimorfismo Genético , Receptores Adrenérgicos beta 2/genética , Estado Asmático/genética , Adolescente , Niño , Preescolar , Estudios de Cohortes , Femenino , Genotipo , Haplotipos , Humanos , Masculino , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Children are frequently admitted to hospitals for treatment of severe asthma exacerbations. Anecdotally, a cohort of these children are thought to have multiple readmissions to the intensive care unit (ICU), yet this group of children has not been characterized. The purpose of this study was to examine the factors related to recurrent ICU admissions in children with asthma. METHODS: The authors conducted a retrospective study of all children admitted to the pediatric ICU for asthma between April 1997 and December 2007. Children with more than one ICU admission were defined as having recurrent near-fatal asthma exacerbations. RESULTS: During this period, 306 children with asthma were admitted to the ICU on 350 occasions; 269 children had only one ICU admission and 33 children (11%) had two or more ICU admissions. To predict who might require readmission, the authors compared the first hospitalization of all children. When compared with children admitted to the ICU only once, children admitted to the ICU more than once were more likely to be overweight (odds ratio [OR] 2.3; 95% confidence interval [CI] 1.1, 4.9), to have public insurance (OR 3.6; 95% CI 1.5, 8.5), and less likely to be Caucasian (OR 0.34; 95% CI 0.14, 0.86). There was no difference in Nation Heart, Lung and Blood Institute (NHLBI) asthma classification, admission illness severity, durations of therapy, or length of stay (LOS) that might identify those who would require readmission. To determine the effect of readmission analysis on subsequent hospitalization, the authors used multiple logistic regression to identify factors associated with increased LOS in all hospitalizations of the subset of children with recurrent near-fatal asthma exacerbations. In this analysis, LOS was most closely associated with admission severity of illness (p = .002), but not with number of hospitalizations. CONCLUSIONS: In this single hospital cohort, there were identifiable factors in children admitted to the ICU that are associated with an increased risk of developing recurrent near-fatal asthma exacerbations. Specifically, overweight children with public insurance were more likely and Caucasian children less likely to be readmitted to the ICU for asthma. These children may represent a group to which specific interventions should be targeted prospectively to prevent readmission.
Asunto(s)
Asma/epidemiología , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Adolescente , Asma/etnología , Asma/fisiopatología , Niño , Preescolar , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Asistencia Médica/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: Emergent endotracheal intubations carry a high risk of morbidity and mortality in critically ill adults. Although children may be at higher risk during this procedure as a result of age-related differences in anatomy and physiology, this has not been previously examined. The purpose of this study was to delineate the risks of emergent endotracheal intubations in children. DESIGN: Retrospective cohort study. SETTING: A 122-bed free-standing children's hospital. PATIENTS: We conducted a retrospective review of all intubations occurring outside of the operating room setting between October 2005 and October 2007. Elective intubations were excluded. Intubations were classified as emergent after review of the child's vital signs, blood gas values, and written documentation by nurses, respiratory therapists, and physicians. Intubations occurring on weekends or between 5 pm and 8 am on weekdays were categorized as "off-hours." INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 137 intubations were performed, 77 of which (56%) were emergent. Emergent endotracheal intubations were significantly more likely to occur off-hours (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) and to be associated with a complication (odds ratio, 3.0; 95% confidence interval, 1.4-6.1). Complications occurred in 41% of all intubations. The most common complications were desaturations (29% of all intubations), hypotension (16%), and bradycardia (7%). In a multivariate logistic regression analysis, emergent intubation, off-hours intubation, three or more attempts at intubation, smaller endotracheal tube size, and admission for cardiovascular disease all increased the likelihood of experiencing a complication during intubation. Complications were not associated with an indication for intubation or baseline chronic disease of the child and were not associated with prolonged intensive care unit course or duration of mechanical ventilation. CONCLUSIONS: Emergent endotracheal intubations are commonly performed in children, are two times more likely to occur off-hours, and are associated with three times the risk of complications as nonemergent intubations.
Asunto(s)
Enfermedad Crítica , Intubación Intratraqueal/efectos adversos , Preescolar , Femenino , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico , Intubación Intratraqueal/estadística & datos numéricos , Modelos Logísticos , Masculino , Estudios Retrospectivos , Medición de RiesgoRESUMEN
BACKGROUND: beta(2)-adrenergic receptor (AR) agonists are the mainstay of treatment for severe asthma exacerbations, one of the most common causes of critical illness in children. Genotypic differences in the beta(2)-AR gene, particularly at amino acid positions 16 and 27, have been shown to affect the response to beta(2)-AR agonist therapy. Our hypothesis is that genotypic differences contribute to patient response to beta(2)-AR agonist treatment during severe asthma exacerbations in children. METHODS: Children admitted to the hospital ICU for a severe asthma exacerbation between 2002 and 2005 were located, and genetic samples were obtained from saliva. Children hospitalized during this period were treated with a protocol that titrated beta(2)-AR therapy (first nebulized, then IV) according to a validated clinical asthma score. RESULTS: Thirty-seven children hospitalized during the study period were enrolled into the study. At amino acid position 16 in the beta(2)-AR gene, 13 children were homozygous for the glycine (Gly) allele (Gly/Gly), 8 were homozygous for the arginine (Arg) allele (Arg/Arg), and 16 were heterozygous (Arg/Gly). Despite similar clinical asthma scores on hospital admission, the children with the Gly/Gly genotype had significantly shorter hospital ICU length of stay and duration of continuously nebulized albuterol therapy and were significantly less likely to require IV beta(2)-AR therapy than those with Arg/Arg or Arg/Gly genotypes. No association existed among polymorphisms at amino acid position 27 and response to beta(2)-AR therapy. CONCLUSIONS: In this cohort of children with severe asthma exacerbations, children whose genotypes were homozygous for Gly at amino acid position 16 of the beta(2)-AR gene had a more rapid response to beta(2)-AR agonist treatment. The beta(2)-AR genotype appears to influence the response to therapy in this population.
Asunto(s)
Agonistas Adrenérgicos beta/administración & dosificación , Albuterol/administración & dosificación , Asma/tratamiento farmacológico , Asma/genética , Polimorfismo de Nucleótido Simple , Receptores Adrenérgicos beta 2/genética , Adolescente , Asma/patología , Niño , Preescolar , Progresión de la Enfermedad , Femenino , Genotipo , Ácido Glutámico/genética , Glutamina/genética , Glicina/genética , Humanos , Tiempo de Internación , Masculino , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: NHLBI guidelines classify asthma in children as intermittent, mild persistent, moderate persistent, and severe persistent asthma based on baseline symptoms and pulmonary function. However, this may not capture the spectrum of asthma in children, since even mild baseline disease can have significant effects on quality of life. Our objective was to describe a population of children with mild asthma admitted to the ICU with severe exacerbations. METHODS: We examined data from all children with asthma who were admitted to the ICU with an acute exacerbation between April 1997, and December 2006. Children were defined as having mild asthma if their disease was classified as intermittent or mild persistent according to NHLBI criteria. RESULTS: Of the 298 children admitted to the ICU with asthma, 164 (55%) were classified as having mild baseline asthma. Compared with children with more severe baseline asthma, mild asthmatic children were younger and less likely to have been previously admitted to the hospital for asthma. Other demographics, including admission severity of illness, gender, and prevalence of overweight, were similar in the two groups. There were no differences between the groups in ICU length of stay, hospital length of stay or types of therapies received. Thirteen children with mild asthma were intubated, although less frequently than those with more severe disease. CONCLUSIONS: Children with mild asthma have severe exacerbations. This suggests that chronic asthma severity does not necessarily predict asthma phenotypes during acute exacerbations.
Asunto(s)
Asma/fisiopatología , Enfermedad Aguda , Adolescente , Asma/clasificación , Asma/terapia , Niño , Preescolar , Femenino , Humanos , Unidades de Cuidado Intensivo Pediátrico , Intubación Intratraqueal , Tiempo de Internación , Masculino , Fenotipo , Respiración ArtificialRESUMEN
BACKGROUND: Children with impending respiratory failure due to severe asthma may be treated with endotracheal intubation and mechanical ventilation. Barotrauma occurs in a significant number of these children. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy and potentially prevents intubation. However, the comparative risk of barotrauma associated with the use of NPPV has not been evaluated in this population. OBJECTIVE: To determine if the mode of positive pressure delivery per se affects the likelihood of development of barotrauma. METHODS: We retrospectively examined data from all children older than 2 years of age admitted to the Intensive Care Unit (ICU) with an asthma exacerbation between April 1997 and August 2006. RESULTS: Of the 293 children admitted to the ICU with asthma, 45 (17%) received treatment with positive pressure ventilation: 11 received only NPPV, 29 were intubated and mechanically ventilated, and 7 children received both of these therapies. Compared with those not requiring positive pressure, children receiving positive pressure were significantly more likely to develop barotrauma during hospitalization (OR 8.9; 95% CI 2.4-32.7). However, the incidence of barotrauma did not significantly differ according to the mode of positive pressure delivery: 9% in those who received only NPPV, 14% in those who were intubated, and 14% in those who received both therapies (p = 0.92). CONCLUSIONS: The use of positive pressure is associated with an increased risk of barotrauma in children with asthma, regardless of the mode of delivery.
Asunto(s)
Asma/complicaciones , Barotrauma/etiología , Respiración con Presión Positiva/métodos , Estado Asmático/terapia , Asma/diagnóstico , Asma/terapia , Barotrauma/epidemiología , Distribución de Chi-Cuadrado , Niño , Preescolar , Estudios de Cohortes , Intervalos de Confianza , Femenino , Estudios de Seguimiento , Humanos , Unidades de Cuidados Intensivos , Ventilación con Presión Positiva Intermitente/efectos adversos , Ventilación con Presión Positiva Intermitente/métodos , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/métodos , Masculino , Respiración con Presión Positiva/efectos adversos , Probabilidad , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapia , Estudios Retrospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Estado Asmático/etiología , Estado Asmático/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVES: While aerosolized administration of beta(2)-adrenergic receptor (beta(2)-AR) agonists is the mainstay of treatment for pediatric asthma exacerbations, the efficacy of intravenous (IV) delivery is controversial. Failure to demonstrate improved outcomes with IV beta(2)-AR agonists may be due to phenotypic differences within this patient population. Our hypothesis is that children who respond more slowly to IV beta(2)-AR agonist therapy comprise a distinct phenotype. METHODS: Retrospective chart review of all children admitted to the ICU for status asthmaticus who were treated with IV terbutaline between December 2002 and September 2006. RESULTS: Seventy-eight children were treated with IV terbutaline according to guidelines that adjusted the dose by clinical asthma score. After examining the histogram of duration of terbutaline infusions, a 48-hr cutoff was chosen to define responsiveness. Thirty-eight (49%) children were slow-responders by this definition. There were no significant differences in baseline asthma severity or severity on admission between the slow-responders and responders. Slow-responders required significantly higher total doses of IV terbutaline, higher maximum administration rates, and had longer ICU and hospital length of stay. CONCLUSION: There were significant differences in outcomes between the responders and slow-responders without differences in acute or chronic illness severity. Other factors may have lead to slower response to IV beta(2)-agonist therapy.
Asunto(s)
Agonistas Adrenérgicos beta/administración & dosificación , Fenotipo , Estado Asmático/tratamiento farmacológico , Estado Asmático/genética , Terbutalina/administración & dosificación , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: Dexmedetomidine is a potentially useful sedative for hospitalized children, but there is little published data regarding its safety, dosage, or efficacy. OBJECTIVE: To report our experience with dexmedetomidine for the sedation of hospitalized children. DESIGN: Retrospective case series. SETTING: Pediatric ICU of a university-affiliated children's hospital. PATIENTS: We retrospectively examined data from the medical records of all children who received dexmedetomidine for sedation between December 2003 and October 2005. INTERVENTION: None. RESULTS: Dexmedetomidine was administered 74 times to 60 children (median age 1.5 years, range 0.1-17.2 years). The most common indications for ICU admission were respiratory distress/failure (53%), status-postcorrective cardiac surgery (19%), and other postoperative patients (18%). In 53% of cases dexmedetomidine was used to supplement ongoing sedation judged inadequate and in 41% of cases it was used as a bridge to extubation while other sedatives were weaned or discontinued. Among all the children, the median dose to maintain adequate sedation was 0.7 microg/kg per hour (range 0.2-2.5 microg/kg per hour), with a median duration of therapy of 23 hours (range 3-451 hours). Most children (80%) experienced no adverse effects from the sedation, with hypotension (9%), hypertension (8%), and bradycardia (3%) the most common adverse events. For 93% of children who experienced a side effect, it resolved either without treatment or by withholding the infusion. CONCLUSIONS: In this cohort of children hospitalized in the ICU, dexmedetomidine appeared to be effective and to have few adverse effects. Dexmedetomidine may have a potentially useful role to play in sedating hospitalized children.
Asunto(s)
Sedación Consciente/métodos , Dexmedetomidina/administración & dosificación , Dexmedetomidina/farmacología , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/farmacología , Adolescente , Niño , Preescolar , Protocolos Clínicos , Esquema de Medicación , Femenino , Hospitales Pediátricos , Hospitales Universitarios , Humanos , Lactante , Recién Nacido , Unidades de Cuidado Intensivo Pediátrico , Masculino , Estudios RetrospectivosRESUMEN
OBJECTIVES: Although childhood overweight has been associated with increased hospital lengths of stay for patients with asthma, the possible relationship between overweight and hospital admission for asthma has not been well studied. We hypothesized that overweight children who presented to the emergency department with asthma exacerbations were more likely to be admitted to the hospital than nonoverweight children. METHODS: A retrospective chart review was conducted of all children who were older than 2 years and presented to the emergency department with an asthma exacerbation in calendar year 2005. Children with chronic medical conditions other than asthma were excluded. Children were classified as nonoverweight (< or = 95% weight-for-age percentile) or overweight (> 95% weight for age). RESULTS: During the study period, there were 884 visits to the emergency department for an asthma exacerbation by 813 children; 238 (27%) were admitted to the hospital, and 33 (4%) were admitted to the ICU. Overall, hospital admission was associated with higher clinical asthma score but not with age, gender, or poverty status (as quantified as home in zip-code areas designated as "impoverished"). Overweight children (n = 202 [23%]) were significantly older (8.5 +/- 4.4 vs 7.3 +/- 4.3 years) and more likely to live in an impoverished area (37% vs 28%). Presenting clinical asthma score and therapeutic interventions in the emergency department were similar for overweight and nonoverweight children; however, overweight children were significantly more likely to be admitted to the hospital. CONCLUSIONS: Overweight children who present to the emergency department with acute asthma exacerbations are significantly more likely to be admitted to the hospital than nonoverweight children. This identifies an important area in which childhood overweight has a significant impact on the health of children with asthma.
Asunto(s)
Asma/epidemiología , Sobrepeso , Admisión del Paciente/estadística & datos numéricos , Asma/terapia , Niño , Connecticut/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Modelos Logísticos , Masculino , Grupos Raciales/estadística & datos numéricos , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
Status asthmaticus is one of the most common causes of admission to a pediatric intensive care unit (PICU). There is little published data, however, examining the complications associated with the treatment of status asthmaticus in children in the PICU. Our hypothesis was that children experiencing a complication would have an increased duration of hospitalization for status asthmaticus. We performed a retrospective review of the complication profile and hospital course of all children admitted to a PICU with status asthmaticus over a 9 years period. Twenty-two (8%) of the 293 children admitted to the ICU with status asthmaticus experienced one or more complications during their treatment. The most common complications were aspiration pneumonia, ventilator-associated pneumonia, pneumomediastinum, pneumothorax, and rhabdomyolysis. Intubated children were significantly more likely than non-intubated children to experience a complication (RR 15.3; 95% CI 6.7-35). Fifteen (42%) of the 36 intubated children experienced a complication. Intubated children experiencing a complication had significantly longer duration of mechanical ventilation (163 +/- 169 hr vs. 66 +/- 65 hr, P = 0.03), ICU length of stay (237 +/- 180 hr vs. 124 +/- 86 hr, P = 0.02) and hospital charges (US dollars 117,184 +/- 111,191 vs. US dollars 38,788 +/- 27,784; P = 0.001) than intubated children not experiencing a complication. In this review, complications were associated with increased morbidity and duration of hospitalization in children with status asthmaticus, particularly in those intubated as part of their therapy. This suggests that intubation and mechanical ventilation itself may increase the risk of developing a complication in this population.
Asunto(s)
Unidades de Cuidado Intensivo Pediátrico/economía , Estado Asmático/complicaciones , Estado Asmático/economía , Adolescente , Niño , Preescolar , Costos y Análisis de Costo , Femenino , Humanos , Intubación Intratraqueal/efectos adversos , Tiempo de Internación/economía , Masculino , Respiración Artificial/efectos adversos , Estudios Retrospectivos , Estado Asmático/terapia , Estados UnidosRESUMEN
OBJECTIVES: Status asthmaticus is a common cause of admission to a pediatric intensive care unit (PICU). Children unresponsive to medical therapies may require endotracheal intubation; however, this treatment carries significant risk, and thresholds for intubation vary. Our hypothesis was that children who sought care at community hospitals received less aggressive treatment and more frequent intubation than children who sought care at a children's hospital. DESIGN: Retrospective cohort study. SETTING: A university-affiliated children's hospital PICU. PATIENTS: We retrospectively examined data from all children older than 2 yrs admitted to the PICU with status asthmaticus between April 1997 and July 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 251 children admitted to the PICU with status asthmaticus, 130 initially presented to the emergency department of a children's hospital and 116 presented to the emergency department of a community hospital. Despite similar illness severity, children presenting to a community hospital were significantly more likely to be intubated than those presenting to a children's hospital (17% vs. 5%; p = .004). In addition, those children intubated at community hospitals were intubated sooner after presentation (2.4 +/- 5.2 vs. 7.5 +/- 5.8 hrs; p = .009), had shorter durations of intubation (71 +/- 73 vs. 151 +/- 81 hrs; p = .02), and had shorter PICU length of stays (129 +/- 82 vs. 230 +/- 84 hrs; p = .01). CONCLUSIONS: Children with status asthmaticus are more likely to be intubated, and intubated sooner, at a community hospital. The shorter duration of intubation suggests that some children may not have been intubated had they presented to a children's hospital or received more aggressive therapy at their community hospital.
Asunto(s)
Hospitales Comunitarios/estadística & datos numéricos , Hospitales Pediátricos/estadística & datos numéricos , Unidades de Cuidado Intensivo Pediátrico , Intubación Intratraqueal/estadística & datos numéricos , Estado Asmático/terapia , Distribución de Chi-Cuadrado , Niño , Femenino , Humanos , Masculino , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Estado Asmático/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Chronic therapy with inhaled corticosteroids (ICS) suppresses airway inflammation and increases airway responsiveness to beta(2)-adrenergic receptor agonists. We hypothesized that the chronic use of ICS would be associated with shorter duration of hospitalization in severely ill children with status asthmaticus. An 8-year retrospective chart review was conducted of all children admitted to the ICU with status asthmaticus. During the study period, 241 children were admitted, and 44% reported the use of chronic ICS. ICS use was associated with increased baseline asthma severity, previous hospitalization for asthma, and public insurance status. However, ICS use had no effect on hospital or ICU length of stay, type, and duration of treatments received, or the rate of recovery determined by a standard severity of illness scoring system. In the subsets of patients including children with persistent asthma and those who received intravenous terbutaline, there was also no improvement in outcomes with the use of chronic ICS showing that the chronic use of ICS did not improve response to beta(2)-adrenergic receptor agonists in severely ill children with status asthmaticus. Although useful as a preventive therapy, the chronic use of ICS does not appear to affect the course of severe acute asthma exacerbations in pediatric patients once hospitalized.
Asunto(s)
Resistencia de las Vías Respiratorias/efectos de los fármacos , Glucocorticoides/administración & dosificación , Estado Asmático/tratamiento farmacológico , Administración por Inhalación , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Tiempo de Internación , Masculino , Recurrencia , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Estado Asmático/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Childhood obesity contributes to a wide array of medical conditions, including asthma. There is also increasing evidence in adult patients admitted to the intensive care unit (ICU) that obesity contributes to increased morbidity and to a prolonged length of stay. We hypothesized that obesity is associated with the need for increased duration of therapy in children admitted to the ICU with status asthmaticus. DESIGN: Retrospective cohort study. SETTING: A tertiary pediatric ICU in a university-affiliated children's hospital. PATIENTS: We retrospectively examined data from all children older than 2 yrs admitted to the ICU with status asthmaticus between April 1997 and June 2004. Children were classified as normal weight (<95% weight-for-age percentile) or obese (>95% weight-for-age). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 209 children admitted to the ICU with asthma, 45 (22%) were obese. Compared with children of normal weight, the obese children were older (9.7 +/- 4.4 vs. 8.0 +/- 4.3 yrs, p = .02), more likely to be female (60% vs. 37%, p < .01), and more likely to have been admitted to the ICU previously (40% vs. 20%, p = .01). The obese children also had a statistically significant difference in race (more likely to be Hispanic) and in baseline asthma classification (more likely to have persistent asthma). Despite similar severity of illness at ICU admission, obese children had a significantly longer ICU length of stay (116 +/- 125 hrs vs. 69 +/- 57 hrs, p = .02) and hospital length of stay (9.8 +/- 7.0 vs. 6.5 +/- 3.4 days, p < .01). Obese children also received longer courses of supplemental oxygen, continuous albuterol, and intravenous steroids. CONCLUSIONS: Childhood obesity significantly affects the health of children with asthma. Obese children with status asthmaticus recovered more slowly from an acute exacerbation, even after adjustment for baseline asthma severity and admission severity of illness.
Asunto(s)
Unidades de Cuidado Intensivo Pediátrico , Obesidad/complicaciones , Estado Asmático/complicaciones , Estado Asmático/terapia , Adolescente , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Tiempo de Internación , Masculino , Estudios RetrospectivosRESUMEN
The demand for pediatric solid organs for transplantation exceeds the available supply. Transplant surgeons may elect to use organs from a donor whose cause of death is uncertain, especially when the recipient is deteriorating. In such circumstances, it is possible that organs from a patient with a systemic metabolic disorder may be transplanted into the recipient, leading to an adverse outcome. We report the first case in which liver and small bowel were procured from a donor with an unsuspected mitochondrial respiratory transport chain defect (succinate cytochrome C reductase deficiency). We describe the subsequent course of the recipient, who died 10 weeks later of multiorgan failure, and unusual findings at autopsy. In the absence of a clear cause of death in a potential pediatric organ donor, factors such as parental consanguinity should prompt physicians to acknowledge the increased possibility of an inherited metabolic disorder and to take this into consideration before proceeding with the transplant procedure.