RESUMEN
OBJECTIVES: Tracheal suctioning is a routine procedure in mechanically ventilated children, however, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning. DESIGN: Prospective randomized controlled crossover study. SETTING: PICU of a tertiary hospital. PATIENTS: Eleven patients with severe head trauma (Glasgow Coma Scale score 4-8) INTERVENTIONS:: Lidocaine (1.5 mg/kg) or saline solution was endotracheally instilled before a standardized tracheal suctioning maneuver. Each patient received both treatments in a crossover design. Cerebral hemodynamic and systemic and ventilatory effects were assessed at four time points: in baseline (T0), within 2 minutes (T1), 5 minutes (T2), and 15 minutes after tracheal instillation (T3). The 2-minute time interval around tracheal suctioning was used to assess each treatment efficacy MEASUREMENTS AND MAIN RESULTS:: The time course of intracranial pressure was different throughout the study in both treatment groups, with a significant increase of intracranial pressure from 14.82 ± 3.48 to 23.27 ± 9.06 with lidocaine (p = 0.003) and from 14.73 ± 2.41 to 30.45 ± 13.14 with saline (p = 0.02). The mean variation in intracranial pressure immediately after tracheal suctioning was smaller with lidocaine instillation than saline (8.45 vs 15.72 mm Hg; p = 0.006). Patients treated with lidocaine returned to baseline intracranial pressure value at 5 minutes after tracheal suctioning whereas those receiving saline solution returned to baseline intracranial pressure value at 15 minutes. Although patients treated with lidocaine had no significant hemodynamic changes, patients receiving saline solution experienced a higher mean value of mean arterial pressure (99.36 vs 81.73 mm Hg; p = 0.004) at T1. CONCLUSIONS: This preliminary study showed that tracheal lidocaine instillation can attenuate increase in intracranial pressure induced by tracheal suctioning and favor a faster return to the intracranial pressure baseline levels without significant hemodynamic and ventilatory changes.
Asunto(s)
Traumatismos Craneocerebrales/terapia , Presión Intracraneal/efectos de los fármacos , Lidocaína/administración & dosificación , Respiración Artificial/métodos , Succión/métodos , Adolescente , Circulación Cerebrovascular/efectos de los fármacos , Niño , Preescolar , Estudios Cruzados , Método Doble Ciego , Femenino , Escala de Coma de Glasgow , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico/organización & administración , Intubación Intratraqueal/métodos , Lidocaína/farmacología , Masculino , Estudios Prospectivos , Centros de Atención TerciariaRESUMEN
BACKGROUND AND OBJECTIVE: Benzodiazepines and opioids are commonly used in pediatric intensive care unit. However, there is no previous study assessing the use of administering these drugs combined (single solution) or separately. We sought to evaluate the impact of these 2 different methods of providing sedation/analgesia in pediatric intensive care unit. METHODS: One hundred twelve patients mechanically ventilated for more than 48 hours were randomized to receive a protocolized sedation regime comprising midazolam and fentanyl either separately (group 1, 57 patients) or combined as a single solution (group 2, 55 patients). Primary end point variable was the cumulated dose of midazolam and fentanyl. RESULTS: The median cumulated doses of both fentanyl (0.19 vs 0.37 mg/kg, P < .05) and midazolam (28.8 vs 45.6 mg/kg, P < .05) required in group 2 were higher when compared with those of group 1. Moreover, group 2 patients had a significantly longer time of vasopressor drugs requirement and a higher number of patients developing tolerance. CONCLUSION: Patients who received a single solution of midazolam and fentanyl had a higher cumulated dose of compared with those patients who did not. The potential risk for long-term neurologic effects on developing brains associated with this finding should be considered.
Asunto(s)
Analgésicos Opioides/administración & dosificación , Fentanilo/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Midazolam/administración & dosificación , Adolescente , Benzodiazepinas/administración & dosificación , Niño , Preescolar , Cuidados Críticos/métodos , Combinación de Medicamentos , Quimioterapia Combinada , Femenino , Humanos , Infusiones Intravenosas , Unidades de Cuidado Intensivo Pediátrico , Masculino , Respiración Artificial/métodos , Factores de Tiempo , Resultado del Tratamiento , Ventiladores MecánicosRESUMEN
OBJECTIVES: Determine prevalence, risk factors and outcomes of iatrogenic pneumothoraces (IPs) in a pediatric intensive care unit (PICU). METHODS: Patients with IP (cases) and patients without IP (controls) were retrieved from a 5-year prospective cohort of 645 PICU patients who received mechanical ventilation (MV). RESULTS: Twenty cases and eighty controls were assessed. The overall prevalence of IP was 3%. Eleven IPs were procedure-related IP and 9 MV related. Performance of thoracic invasive procedures (odds ratio 11) was the significant IP predictor in the logistic regression analysis. IP incidence was higher within 12 hours. There were no differences between the groups concerning duration of MV, length of PICU and hospital stays. IP patients had a significantly higher mortality rate (p = 0.005). CONCLUSIONS: Performance of thoracic invasive procedures was strongly associated with IPs events in mechanically ventilated children. Many of these events may potentially be preventable with the implementation of quality improvement programs.
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Enfermedad Iatrogénica/epidemiología , Neumotórax/epidemiología , Respiración Artificial/efectos adversos , Estudios de Casos y Controles , Preescolar , Estudios de Cohortes , Femenino , Humanos , Incidencia , Lactante , Unidades de Cuidado Intensivo Pediátrico , Tiempo de Internación , Masculino , Neumotórax/etiología , Prevalencia , Estudios Prospectivos , Factores de RiesgoRESUMEN
AIM: Although the modified Clinical Pulmonary Infection Score (CPIS) has been used to guide treatment decisions in adults with ventilator-associated pneumonia (VAP), paediatric studies are lacking. We assessed a modified CPIS tool to define VAP resolution and identify treatment failure at an early stage. METHODS: We identified 70 mechanically ventilated children with VAP according to the Center for Disease Control criteria. Modified CPIS was initially measured at VAP onset and then three and five days afterwards. Children were defined as low risk or high risk based on a cut-off score of six. RESULTS: There were 50 high-risk and 20 low-risk patients. Culture results were positive in 64% of the high-risk patients and just 10% of the low-risk patients. Patients on adequate therapy significantly improved their CPIS scores by day three, regardless of the likelihood of VAP. A lack of score improvement demonstrated sensitivity of 100% and specificity of 83% when it came to detecting treatment failure. The area under the receiver operating curve was 0.92. CONCLUSION: Serial modified CPIS measurements showed that low-risk patients with negative cultures at day three should be considered for a short course of antibiotics. In contrast, high-risk patients with no score improvement were potentially failing their treatment.
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Antibacterianos/uso terapéutico , Utilización de Medicamentos/estadística & datos numéricos , Neumonía Asociada al Ventilador/tratamiento farmacológico , Femenino , Humanos , Lactante , Masculino , Neumonía Asociada al Ventilador/diagnóstico , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Insuficiencia del TratamientoRESUMEN
RATIONALE: Although the modified clinical pulmonary infection score (mCPIS) has been endorsed by national organizations, only a very few pediatric studies have assessed it for the diagnosis of ventilator-associated pneumonia (VAP). METHODS: Seventy children were prospectively included if they fulfilled the diagnosis criteria for VAP referenced by the Centers for Disease Control and Prevention. The primary outcome was performance of mCPIS calculated on day 1 to accurately identify VAP as defined by microbiological data. RESULTS: The data showed that an mCPIS of 6 or higher had a sensitivity of 94%, specificity of 50%, positive predictive value of 64%, negative predictive value of 90%, a positive likelihood ratio of 1.88, and a negative likelihood ratio of 0.11. The area under the receiver operating characteristic curve was 0.70. A positive posttest result increased the disease probability by 15.4%, whereas a negative test result reduced the probability by 38.6%. Patients with an mCPIS of 6 or higher had longer length of mechanical ventilation and pediatric intensive care unit stay compared with patients with an mCPIS lower than 6. CONCLUSION: The mCPIS had a clinically acceptable performance, and it can be a helpful screening tool for VAP diagnosis. An mCPIS lower than 6 was highly able in distinguishing patients without VAP. Despite its high sensitivity and negative predictive value of this score, further studies are required to assess the use of mCPIS in guiding therapeutic decisions.
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Neumonía Asociada al Ventilador/diagnóstico , Área Bajo la Curva , Preescolar , Enfermedad Crítica , Técnicas de Diagnóstico del Sistema Respiratorio , Femenino , Fiebre , Humanos , Lactante , Masculino , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Respiración Artificial/estadística & datos numéricos , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
BACKGROUND: The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS). METHODS: This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days. RESULTS: A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018). CONCLUSIONS: Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS.
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Apendicectomía , Apendicitis/cirugía , Pediatría , Especialidades Quirúrgicas , Apendicectomía/educación , Niño , Preescolar , Femenino , Cirugía General , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Although unplanned postoperative admission to PICUs (unplanned intensive care admission [UIA]) is uncommon, it might be associated with increased costs, morbidity, and mortality. However, detailed knowledge of risk factors and outcomes after UIA in children is still lacking. OBJECTIVES: To determine prevalence, risk factors, and outcomes of UIA patients compared with non-UIA patients. DESIGN: Case-control study. SETTING: A tertiary university-affiliated hospital. PATIENTS: All postoperative children admitted to the PICU were monitored for UIA. About 28 cases and 88 controls were included. INTERVENTIONS: none. MEASUREMENTS AND MAIN RESULTS: The overall prevalence of UIA was 2.6%. About 28 patients (24.1%) of 116 had unplanned admission. Multiple logistic regression revealed that factors predicting UIA were airway abnormality (odds ratio 16.2, 95% confidence interval 2.65-99.6), anesthetic factors (odds ratio 5.8, 95% confidence interval 1.06-32.2), and hypoxia intraoperative (odds ratio 7.4, 95% confidence interval 1.21-46.24). Procedures on abdomen, emergency surgery, combined anesthesia, and occurrence of intraoperative adverse events were also risk factors for an UIA. Patients with UIA had longer duration of mechanical ventilation than non-UIA patients (4.5 vs. 2 days, p = 0.01), but there were no differences in length of PICU and hospital stays. Preventable adverse events were detected in 25% of UIA children. CONCLUSIONS: Airway abnormality, anesthetic factors, and hypoxia intraoperative were risk factors associated with UIA. Although preventable events contribute significantly to unplanned PICU admissions, they constitute a room of opportunity in quality improvement programs.
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Cuidados Críticos/estadística & datos numéricos , Complicaciones Intraoperatorias/epidemiología , Admisión del Paciente/estadística & datos numéricos , Cuidados Posoperatorios/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Anestesia General/efectos adversos , Estudios de Casos y Controles , Niño , Preescolar , Urgencias Médicas , Femenino , Humanos , Hipoxia/complicaciones , Lactante , Recién Nacido , Unidades de Cuidado Intensivo Pediátrico , Masculino , Prevalencia , Anomalías del Sistema Respiratorio/complicaciones , Factores de Riesgo , Centros de Atención Terciaria , Resultado del TratamientoRESUMEN
Aminophylline exerts a renovascular effect, acting by adenosine receptor blockade or type IV phosphodiesterase inhibition. Clinically, these drugs have been used with furosemide to induce diuresis in adults and neonates. However, reports on use of aminophylline in diuretic-dependent children are limited to a few studies. We report a case series of four critically ill children unresponsive to furosemide continuous infusion who were subsequently given aminophylline as an adjunct diuretic in the treatment of fluid overload. No side effects were evident. Administration of aminophylline at low doses (3 mg/kg) successfully promoted increased urine output over the 6-h study period in all four children.
Asunto(s)
Aminofilina/farmacología , Diuréticos/farmacología , Furosemida/farmacología , Preescolar , Sinergismo Farmacológico , Femenino , Humanos , Lactante , MasculinoRESUMEN
PURPOSE: Nebulized L-epinephrine has been recommended for the treatment of viral croup. However, the few studies assessing its effect on post-extubation stridor (PES) have shown conflicting results. We compared the efficacy and safety of nebulized L-epinephrine at three different doses for the treatment of PES. PATIENTS AND METHODS: We conducted a prospective, randomized, double-blind trial including all consecutive children with a PES score of ≥4 (Westley score). The primary efficacy outcome was change in PES score at 40 min. A reduction of ≥2 points in stridor score was defined as clinically significant. A total of 96 patients were randomly assigned to receive one of three doses of nebulized L-epinephrine upon achieving a PES score of 4 or more following extubation. Stridor score and vital signs were recorded before treatment, and at 20, 40, 60 and 180 min after nebulization. RESULTS: Baseline characteristics were similar among all study groups. No significant difference was detected among the treatments based on change in Westley score by intent-to-treat analysis. In addition, the difference in the number of patients who clinically improved among the treatment groups was not significant (p = 0.54). Patients receiving 5 ml nebulized epinephrine had a significant increase of systolic and diastolic blood pressure at 40 and 180 min. CONCLUSION: Nebulized L-epinephrine at doses of 0.5, 2.5 and 5 ml demonstrated a lack of dose response in effect on PES and a modestly clinically significant increase in undesired side effects (heart rate and blood pressure) at higher doses.
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Extubación Traqueal , Epinefrina/administración & dosificación , Ruidos Respiratorios/efectos de los fármacos , Niño , Preescolar , Método Doble Ciego , Femenino , Humanos , Lactante , Masculino , Nebulizadores y Vaporizadores , Estudios ProspectivosRESUMEN
BACKGROUND: The aim of this study was to evaluate the effectiveness and safety of intravenous ketamine-propofol admixture ("ketofol") in the same syringe for procedural sedation and analgesia in children undergoing bone marrow aspiration. METHODS: This was a prospective, observational pilot study. Patients aged between 4 and 12 years requiring sedation for bone marrow aspiration were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was given intravenously in 0.5 mg/kg aliquots each with a 1-min interval and titrated to reach sedation levels of 3 or 4 (Ramsay score). The primary outcome was patient satisfaction with the degree of sedation. Secondary outcomes included injection pain, total sedation time, recovery time, hemodynamic and respiratory parameters, and adverse events. RESULTS: A total of 20 patients were enrolled in the study. The median total dose of ketofol administered was 1.25 mg/kg each of propofol and ketamine (95%CI 0.77-2 mg/kg). The median score on the visual analog scale was 0 (extremely comfortable) (0-1.5; 95%CI 0.2-2.2). Median recovery time was 23 min (20.5-28 min; 95%CI 17.1-51.2). The incidence of injection pain was 2/20. Two patients had transient diplopia and one child reported dreams. No patients had hypotension, vomiting or required airway intervention. CONCLUSION: Ketofol provided effective sedation, which was reflected in the high degree of satisfaction recorded by children requiring procedural sedation and analgesia for bone marrow aspiration. We also observed rapid recovery and no clinically significant complications. A large number of patients is required to evaluate and validate these findings.