Pediatr Crit Care Me
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Pediatr Crit Care Me · Apr 2001
The costs associated with nosocomial bloodstream infections in the pediatric intensive care unit.
To assess the operational and subsidiary costs and length of stay (LOS) attributable to nosocomial bloodstream infections (BSI) in a pediatric intensive care unit (PICU). DESIGN: Matched case-control study. SETTING: Sixteen bed PICU in a 250-bed tertiary-care pediatric hospital. PATIENTS: Cases with BSI were prospectively identified from PICU patients who developed a nosocomial BSI from August 1996 to July 1998. Controls were PICU patients who were matched for age, severity of illness, diagnosis, and admission date who did not develop a nosocomial BSI. ⋯ The costs and LOS associated with nosocomial BSI in patients admitted to the PICU were significantly higher than controls.
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To review the clinical use of noninvasive positive pressure ventilation (NPPV) in both acute hypoxic and hypercarbic forms of pediatric respiratory failure, including its mechanism of action and implementation. DATA SOURCES: Studies were identified through a MEDLINE search using respiratory failure, pediatrics, noninvasive ventilation, and mechanical ventilation as key words. STUDY SELECTION: All original studies, including case reports, relating to the use of noninvasive positive pressure in pediatric respiratory failure were included. Because of the paucity of published literature on pediatric NPPV, no study was excluded. DATA EXTRACTION: Study design, numbers and diagnoses of patients, types of noninvasive ventilator, ventilator modes, outcome measures, and complications were extracted and compiled. DATA SYNTHESIS: For acute hypoxic respiratory failure, all the studies reported improvement in oxygenation indices and avoidance of endotracheal intubation. The average duration of NPPV therapy before noticeable clinical improvement was 3 hrs in most studies, and NPPV was applied continuously for 72 hrs before resolution of acute respiratory distress. In patients with acute hypercarbic respiratory failure, application of NPPV resulted in reduction of work of breathing, reduction in CO(2) tension, and increased serum bicarbonate and pH. These patients are older than patients in the acute hypoxic respiratory failure group and, in addition to improved blood gas indices, they reported improvement in subjective symptoms of dyspnea. Improvement in gas exchange abnormalities and subjective symptoms occurred within the same time span (the first 3 hrs) as in the acute hypoxic respiratory failure group. However, use of noninvasive techniques in patients with acute hypercarbic respiratory failure continued after resolution of acute symptoms. Complications related to protracted use of NPPV were common in this group. ⋯ NPPV has limited benefits in a group of carefully selected pediatric patients with acute hypoxic and hypercarbic forms of respiratory failure. The routine use of this technique in pediatric respiratory failure needs to be studied in randomized controlled trials and better-defined patient subsets.
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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.
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Pediatr Crit Care Me · Jan 2001
A comparison of propofol and ketamine/midazolam for intravenous sedation of children.
To compare ketamine and propofol sedation in children undergoing diagnostic and therapeutic procedures. DESIGN: Retrospective study. SETTING: A six-bed pediatric intensive care unit and a pediatric hematology oncology clinic. PATIENTS: From 1996 to 1998, 405 procedures were performed on patients between 1 month and 22 yrs of age. INTERVENTIONS: All patients but one were sedated intravenously with either propofol or ketamine; those who received ketamine also received midazolam and either atropine or glycopyrrolate. Vital signs were monitored continuously. Procedures included bone marrow biopsies, lumbar punctures, esophagoduodenoscopies, colonoscopies, and other miscellaneous procedures. A pediatric intensivist performed all sedations. MEASUREMENTS AND MAIN ⋯ Both propofol and ketamine provided safe and effective sedation for the short, painful procedures performed. Because the patients who received propofol awakened almost twice as quickly as the patients who received ketamine, the sedation service operated more efficiently when propofol was used. The major complication rates for propofol and ketamine were small, and the differences between the two groups were not statistically significant. We conclude that with proper monitoring, intravenous propofol can be used safely and effectively for short procedures in the pediatric setting.
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To determine the incidence of pulmonary fat embolism after the intraosseous (IO) infusion of normal saline and drugs and to determine whether pulmonary capillary blood is a predictor of lung fat embolism. DESIGN: A randomized, prospective, animal study. SETTING: Animal research laboratory of a university hospital. SUBJECTS: Twenty-eight mixed breed piglets (average weight 30.9 kg). Interventions and Methods: Animals were anesthetized, intubated, mechanically ventilated, and instrumented. IO needles were placed in the tibial bone. Animals were assigned to one of four groups: Group 1 received fluid (20 mL/kg) under 300 mm Hg pressure (n = 6); group 2 received fluid (20 mL/kg) at free flow under gravity (n = 6); group 3 received 100 mL of fluid over 20 mins (n = 8); and group 4 received 100 mL of fluid over 7 mins (n = 8). MEASUREMENTS AND MAIN ⋯ Fat embolism is common; however, the method of IO fluid administration does not influence the number of emboli. Our study therefore implies that the risk of fat embolization is of concern, but its clinical relevance is unclear. Until the clinical significance of pulmonary fat emboli and the prevalence of fat emboli syndrome are delineated more precisely, the IO route is an effective but not necessarily safe route for delivery of fluids and drugs.