Pediatr Crit Care Me
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The purpose of this study was to determine the effectiveness of airway pressure release ventilation in children. DESIGN: Prospective, randomized, crossover clinical trial. SETTING: This study was conducted in our 33-bed pediatric intensive care unit at The Children's Hospital of Philadelphia. PATIENTS: Patients requiring mechanical ventilatory support and weighing >8 kg were considered for enrollment. Patients were excluded if they required mechanical ventilatory support for >7 days or required >.50 Fio(2) for >7 days before enrollment. Patients with documented obstructive airway disease and congenital or acquired heart disease were excluded as well. INTERVENTIONS: Each patient received both volume-controlled synchronized intermittent mechanical ventilation (SIMV) and airway pressure release ventilation (APRV) via the Drager Evita ventilator (Drager, Lubeck, Germany). Measurements were obtained after the patient was stabilized on each ventilation mode. Stabilization was defined as oxygenation, ventilation, hemodynamic variables, and patient comfort within the acceptable range for each patient as determined by the bedside physician. After measurements were obtained on the initial mode of ventilation, the subjects crossed over to the alternative study mode. Stabilization was again achieved, and measurements were repeated. After completion of the second study measurements, patients were placed on the ventilation modality preferred by the bedside clinician and were followed through weaning and extubation. Measurements: Vital signs, airway pressures, minute ventilation, Spo(2), and E(T)CO(2) were recorded at enrollment and at each study condition. MAIN ⋯ Using APRV in children with mild to moderate lung disease resulted in comparable levels of ventilation and oxygenation at significantly lower inspiratory peak and plateau pressures. Based on these findings, we plan to evaluate APRV in children with significant lung disease.
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Pediatr Crit Care Me · Jul 2001
Prospective documentation of sedative, analgesic, and neuromuscular blocking agent use in infants and children in the intensive care unit: A multicenter perspective.
To describe the use of neuromuscular blocking agents (NMBA) in critically ill children. DESIGN: Prospective cohort study. SETTING: Two pediatric intensive care units (ICUs). PATIENTS: All children who received NMBA in the ICUs during the study year. INTERVENTIONS: None Measurements: Data on use of NMBA agents and concurrent use of narcotic and sedative agents were collected. Demographic and outcome information was also obtained. MAIN ⋯ Use of NMBA is more common in critically ill children than in reported studies of critically ill adults. Use of NMBA in critically ill children is associated with high severity of illness and mortality rates. Choice of NMBA and method of administration varies among providers. Concurrent use of narcotic and sedative agents with NMBA is frequent, but medication choice also varies among medical providers.
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Conventional wisdom and recently published reports suggest that children <48 months of age have a higher mortality rate after burns than older children and adolescents with similar injuries and that young age is a predictor of mortality. This study was done to validate or refute this impression. DESIGN: Retrospective review. SETTING: Regional pediatric burn center. PATIENTS: All children (n = 1223) managed over a recent 8-yr interval (1991-1998) for acute thermal burns. INTERVENTIONS: The survival rate of children <48 months of age was compared with the survival rate of children >/=48 months of age. MEASUREMENTS AND MAIN ⋯ Young age is not a predictor of mortality in burns.
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Pediatr Crit Care Me · Jul 2001
Hemodynamic changes during opening of the bridge in venoarterial extracorporeal membrane oxygenation.
To investigate the cause of the hemodynamic changes occurring during opening of the bridge in venoarterial (VA) extracorporeal membrane oxygenation (ECMO). DESIGN: Prospective intervention study in animals. SETTING: Animal research laboratory of a university medical center. SUBJECTS: Eight anesthetized lambs installed on VA-ECMO. INTERVENTIONS: During VA-ECMO the bridge was randomly opened during 1, 2.5, 5, 7.5, 10, and 15 secs at ECMO flow rates of 500, 400, 300, 200, 100, and 50 mL/min. Flows in the ECMO circuit between venous cannula and bridge and bridge and arterial cannula, mean arterial blood pressure, mean left carotid artery blood flow, central venous pressure, superior sagittal sinus pressure, inline mixed venous oxygen saturation, heart rate, and arterial oxygen saturation were measured continuously. Using near infrared spectrophotometry, changes in concentrations of cerebral oxygenated and deoxygenated hemoglobin and cerebral blood volume were also measured. Values during bridge opening were compared with values before opening. The same variables were determined with a roller pump on the bridge with a flow over the bridge at various flow rates. MEASUREMENTS AND MAIN ⋯ Bridge opening in VA-ECMO resulted in significant cerebral hemodynamic changes caused by an arteriovenous shunt over the bridge. The decreased cerebral perfusion pressure may contribute to the occurrence of cerebral ischemia, and the venous congestion may result in intracranial hemorrhages. These could be prevented by installing a roller pump on the bridge.
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Pediatr Crit Care Me · Apr 2001
Frequency of change of ventilator circuit in premature infants: Impact on ventilator-associated pneumonia.
Ventilator-associated pneumonia (VAP) is associated with substantial mortality. The frequency of changing the ventilator circuit (VC) might influence the occurrence rate of VAP. In premature infants receiving ventilatory support, the question regarding the frequency of changing VC is as yet unsettled. DESIGN: A prospective, randomized, and controlled trial in 60 premature neonates receiving ventilatory support. INTERVENTIONS: We investigated the impact of two VC change regimens on VAP in premature infants, either every 24 hrs or every 72 hrs. In each patient, the humidifier, inspiratory tube, and expiratory tube were changed and cultured at the assigned intervals along with cultures of tracheal aspirates. Blood cultures were obtained whenever there was clinical evidence of pneumonia or sepsis. MEASUREMENTS AND MAIN ⋯ Extending the VC-change interval in premature infants from 24 hrs to 72 hrs is safe and cost-effective.