Pediatr Crit Care Me
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Pediatr Crit Care Me · Apr 2002
Randomized clinical trials in pediatric critical care: Rarely done but desperately needed.
To review the benefits and challenges of using the randomized, controlled trial (RCT) study design to evaluate preventive and therapeutic interventions in pediatric critical care medicine. ⋯ The RCT design is able to control for many sources of potential bias that other types of study designs cannot. The findings of RCTs often contradict the findings of less rigorous study designs. Before performing an RCT, there must exist a state of clinical equipoise, a sufficient number of eligible patients must be available, and the epidemiology of the disorder in question must be well studied. There are many challenges to performing high-quality RCTs. Studying multiple element support strategies in the critically ill patient population is more complex than studying a single drug therapy. High patient and practice variability and hazy diagnostic definitions can dilute the signal-to-noise ratio. Most interventions in critical care are expected to have a modest or small effect. This markedly increases the requisite sample size. There is a paucity of accepted clinically important measurements of the outcome of critical care, making mortality a common outcome to evaluate with a not-so-common incidence. Developmental issues, the inability to give informed consent, and the failure to perform the appropriate pharmacokinetic and safety studies are additional challenges facing pediatric investigators. Despite these limitations, a good RCT remains the best way to prove that an intervention is working or not. Indeed, RCTs are and will remain the "gold standard" method to estimate the efficacy of a therapeutic or prophylactic intervention.
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Pediatr Crit Care Me · Apr 2002
Failed extubation after cardiac surgery in young children: Prevalence, pathogenesis, and risk factors.
A total of 212 children
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Pediatr Crit Care Me · Apr 2002
National survey on the use of sedatives and neuromuscular blocking agents in the pediatric intensive care unit.
To describe the sedative and neuromuscular blocking agents (NMBA) that are currently used in pediatric intensive care units across the country and to assess the use of written protocols for their use, criteria used for selecting these agents, monitoring practices, and clinicians responsible for making therapeutic decisions in the pediatric intensive care units. DESIGN: A questionnaire was mailed to pediatric attending physician members of the Society of Critical Care Medicine practicing in the United States in January 1997. A cover letter was also enclosed that explained the purpose of the survey and asked the respondent to forward the questionnaire to a colleague if unable to complete. ⋯ Clinicians continue to use the opioids and benzodiazepines most often for sedation in the pediatric intensive care units, but newer agents are being used more often and warrant further investigation. The use of written protocols is very low, possibly because of the lack of guidelines in the literature on pediatric intensive care unit sedation and neuromuscular blockade. Development and implementation of protocols for the selection, use, and monitoring of sedatives and NMBA through a multidisciplinary team approach may be a beneficial way to provide safe and cost-effective therapy to critically ill pediatric patients.
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Pediatr Crit Care Me · Apr 2002
Noninvasive positive-pressure ventilation in pediatric status asthmaticus.
To describe the use of noninvasive positive-pressure ventilation in children with status asthmaticus. DESIGN: Brief report. SETTING: Pediatric intensive care unit in two tertiary institutions. SUBJECTS: Children with severe acute asthma and hypercarbic respiratory failure. INTERVENTIONS: Noninvasive positive-pressure ventilation using a bilevel positive-pressure (BIPAP) device. MEASUREMENTS AND MAIN ⋯ In three children with status asthmaticus, BIPAP seemed to improve ventilation and gas exchange, culminating in resolution of hypercarbic respiratory failure. A prospective, randomized, and controlled study is required to determine its role in pediatric status asthmaticus.
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Pediatr Crit Care Me · Apr 2002
Pediatric fiberoptic bronchoscopy: Clinical experience with 2,836 bronchoscopies.
To report 21 yrs of experience with pediatric flexible fiberoptic bronchoscopy in infants and children, explore newer applications, delineate potential complications, and make recommendations for its future application. DESIGN: Retrospective review. SETTING: A 20-bed pediatric critical care unit in a tertiary care, university-based children's hospital. PATIENTS: A total of 2,836 pediatric and infant fiberoptic bronchoscopies, performed over a course of 21 yrs, were reviewed. Measurement and MAIN ⋯ Pediatric flexible fiberoptic bronchoscopy is a safe diagnostic and interventional tool, even in young or extremely premature infants. Although the rate of serious complications in this report is low, general anesthetic agents and incorporation of laryngeal mask airway is advocated for severe mucoid impaction, transbronchial biopsy, and chronic pulmonary infiltrates, which may necessitate extensive bronchoalveolar lavage.