Paediatric Intensive Research Articles

The safety of propofol sedation for elective nonintubated esophagogastroduodenoscopy in pediatric patients.

To evaluate the safety of deep sedation provided by pediatric intensivists for elective nonintubated esophagogastroduodenoscopy. Retrospective observational study. The sedation program at the Helen DeVos Children's Hospital. A 4-year retrospective analysis was done on all outpatient elective pediatric esophagogastroduodenoscopy procedures performed in an intensivist run sedation program. Safety was examined by reviewing the occurrence of minor and major adverse effects during esophagogastroduodenoscopy sedation. Interventions were studied and reported. None. During the study period, 12,447 sedations were performed by the pediatric sedation program for various procedures. Two thousand one hundred forty-seven patients received 2,325 sedations (18.6%) for esophagogastroduodenoscopies performed for various indications. During the same time period, 53 (one for every 40 esophagogastroduodenoscopy sedations) were screened, found unsuitable for nonintubated sedation, and referred for general anesthesia. There were 2,254 sedations with propofol, 65 methohexital, five ketamine, and one fentanyl/midazolam sedation. Propofol sedation proved safe with a 2.1% prevalence of minor adverse events and no major events. Methohexital, on the other hand, had higher rate (p < 0.001) of minor events and one patient developed an anaphylactic reaction to its use. Regression analysis showed that other sedative agents were 8.6 times more likely to be associated with complications than propofol (odds ratio, 8.6; 95% CI, 4.1-18.2; p < 0.001). This study demonstrates that deep sedation for elective esophagogastroduodenoscopies can be provided safely in the appropriately screened patient by nonanesthesiologist physicians in a sedation program. These data suggest that propofol is a safe and effective agent for esophagogastroduodenoscopy sedation.

Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children

To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children. An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment. Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013. Pediatric critical care providers. Survey. The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in PICUs with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%) and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent's PICUs, and only 2% reported routine screening at least twice a day. The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.

Joint Paediatric and Psychiatric Follow-Up for Families following Paediatric Intensive Care Unit Admission: An Exploratory Study

Psychopathology in parents and children is increased after Paediatric Intensive Care Unit (PICU) admission; few studies have evaluated interventions to reduce this. Objective. Evaluation of the feasibility of setting up a joint paediatric and psychiatric follow-up clinic for families after PICU discharge. Design. Feasibility study offering joint follow-up with a consultant paediatric intensivist and child and adolescent psychiatrist. Setting. Paediatric outpatient clinic in a university teaching hospital with a PICU. Patients. Children and their families discharged from PICU. Interventions. Outpatient appointment focussing on physical and psychological health; psychoeducation about emotional and behavioural difficulties occurring after PICU discharge, advice for parents about supporting their child’s psychological recovery, screening for more severe psychiatric disorders, and provision of a leaflet outlining possible difficulties and management strategies. Measurements. Attendance, content of discussion, psychiatric questionnaires, and family feedback. Main Results. It proved feasible to set up follow-up appointments to address physical and psychological health concerns; 4/12(33%) eligible families attended. Children and mothers who attended all reported child difficulties including sleep disturbance, increased anxiety, and PTSD symptoms in children and parents. Conclusions. Follow-up clinics after PICU discharge are feasible to set up; take-up is poor but families attending report psychopathology which may be addressed through the intervention.

Citrate anticoagulation during continuous renal replacement therapy in pediatric critical care.

To provide the pediatric intensivist an in-depth understanding of citrate as regional anticoagulant during continuous renal replacement therapy. We searched the PubMed.gov database using the initial key words: citrate anticoagulation [title] AND continuous; citrate [title] AND pediatric AND continuous; prospective pediatric renal replacement AND citrate; and regional citrate anticoagulation. Additional searchers were performed using EMBASE, CINAHL, and SCOPUS with similar keywords and limits. Further articles were gathered from bibliographic references of relevant studies and reviews. Only articles published in English were reviewed. In the pediatric population, there are no prospective interventional or randomized studies comparing regional versus systemic anticoagulation. However, there are 11 (retrospective and prospective observational studies) in the pediatric population using citrate anticoagulation. These studies have shown that regional citrate anticoagulation in the pediatric population can be effective, provide equivalent circuit survival, and decrease bleeding compared with heparin anticoagulation. In the adult population, there are six prospective randomized controlled trials comparing the efficacy of regional citrate anticoagulation versus heparin. Two systematic reviews with meta-analysis of these six trials have been performed. The adult data on the use of regional citrate anticoagulation during continuous renal replacement therapy show a decreased risk of bleeding and at the least equivalent circuit survival as compared to heparin. Current pediatric and adult studies support regional citrate anticoagulation as an effective alternative to systemic heparin anticoagulation in most patient populations. Continuous renal replacement therapy is the most common modality of renal replacement in the critical care setting. Regional anticoagulation is an ideal option in a critically ill child after recent surgery or with coagulopathy. Therefore, regional citrate anticoagulation in the pediatric critical care population requiring renal replacement therapy is commonly employed. Complications of citrate anticoagulation can be avoided with a greater understanding of the properties and clearance of citrate. Continued reporting of observational data and the development of prospective multicenter trials using citrate anticoagulation are needed to ensure safe and standardized care in the pediatric population.

Expositions des enfants aux lessives capsules, écodoses ou pods : plus toxiques que les lessives traditionnelles ?

New concentrated laundry pods, available on the European market for approximately 10 years, are associated with more severe intoxications compared to classic laundry detergents. To compare symptoms and severity after exposure to classic laundry detergents and new laundry pods in a pediatric population. Retrospective study conducted between 1st January 2002 and 30th June 2013 including all laundry detergent exposure patients admitted to our tertiary level pediatric emergency unit. Collected data were age, sex, date, time and location of exposure, type of product (powder, liquid, tablets, pods), estimated ingested quantity, time of admission, clinical symptoms, severity, complications, and progression. Descriptive analysis: eighty-nine children were included. The mean age was 2.1 ± 1.5 years (range, 36 days to 10 years), 65% of patients were aged less than 2 years. The male:female ratio was 1.5 (males, 60%). After exposure, 57% of children were symptomatic and most frequently developed digestive symptoms (75%). Comparative analysis: compared to classic laundry detergent, children exposed to laundry pods were more symptomatic (96% versus 51%, P<0.0001), had more digestive signs (P=0.003), more frequently had bronchospasm (P=0.02), had a higher risk of ocular lesions (P=0.04), and exposure was more severe (poisoning severity score grade 2, 92% versus 59%, P<0.0001). Laundry pod toxicity is more severe. The chemical composition of laundry pods has a higher concentration of surfactants and ethoxylated alcohols; they have a higher viscosity and hydrotropic power. The addition of water seems to modify the alkalinity, which explains the severity of ENT, gastric, and corneal lesions. The declaration to national poison centers of these intoxications should be pursued by emergency pediatricians, physicians, and pediatric intensivists. Family physicians can encourage parents to declare adverse effects to the National Consumer Product Safety Commission. Parents need to be better informed of the risk of laundry pods and strictly keep this type of product out of the reach of children. Given that it took 7 years after the first warning by the French poison centers to obtain safety recommendations for manufacturers, it is important to maintain pressure on companies to obtain the necessary modification of the physicochemical properties and child-resistant packaging.

ABSTRACT 188

Background and aims: Brain death (BD) still represents an enormous dilemma for some Brazilian intensivists. Our previous studies have demonstrated that pediatric intensivists are more prone to handle terminal ill patients than adult intensivists. There are not studies comparing these two groups regarding BD management. Aims: Compare the management with the non-donator brain death between pediatric and adult intensive care units belonging to 16 hospital located in a metropolitan region in the southern region of Brazil. Methods: We selected and reviewed the records of all BD notified in 2013 (up to November 30) occurred in the 16 hospital of the metropolitan region of Porto Alegre (Brazil), being evaluated: demographic data, cause of death, cause for donation refusal and management after donation refusal. The local Ethical and Research committee approved the study. Results: These 16 hospitals notified 161 possible BD, being confirmed 129 cases: 114 involving adult patients and 15 pediatric patients. Organ donation was more frequently observed among adults than pediatric patients (53.5% x 40%; p<0.01). Considering the group with BD that donation was not performed, it was observer that the vital support was immediately withdrawn much more frequently in the pediatric group than in adults (88.8% versus 39.6%; p<0.01). Conclusions: Organ donation is more frequent among adults with brain death. However, Brazilian pediatric intensivists demonstrate a more coherent attitude to handle those cases that will not be organ donators.

ABSTRACT 786

Background and aims: Currently there are no national guidelines in the UK for clearing the cervical spine (C-spine) of children following trauma. In children aged 0–3 years clinical examination is considered unreliable often leading to unnecessary cervical immobilisation and imaging. Aims: The aim of this study was to investigate the current practice of C-spine clearance at the major paediatric trauma centres across the UK. Methods: 144 consultants and registrars, including A&E doctors, orthopaedic surgeons, neurosurgeons, radiologists and paediatric intensivists at 16 major UK paediatric trauma centres were contacted to complete a 12 question survey. They were questioned on who was responsible for clearing C-spines in their hospital, the imaging they used, their level of paediatric experience, as well as the usage and presence of protocols in their hospital. Results: From 144 doctors contacted, 31 completed questionnaires were received from 6 different trauma centres. The results showed 82.1% of respondents used clinical judgement to clear the C-spine, the National Emergency X-Radiography Utilization Study (NEXUS) was used by 17.9% and the Canadian C-spine Rules (CCR) by 14.3%. The most frequently used imaging modality was CT (74.2%), with X-ray at 61.3%, MRI 41.9% and no imaging in 19.4% of cases. Only 22% of respondents reported having a local protocol. Conclusions: This study shows great diversity in current practice for clearance of the C-spine in young children following trauma. There were discrepancies between clinicians at the same hospital, as well as between different trauma centres, thus highlighting the need for consensus guidelines.

ABSTRACT 343

Background and aims: Propofol is an effective agent to provide sedation for children undergoing diagnostic imaging. Most regimens use propofol with a bolus induction dose followed by continuous infusion. We report the effectiveness of an intermittent bolus regimen for children undergoing MRI on an ambulatory basis. Aims: To establish the safety and efficacy of an intermittent low dose propofol regimen for children undergoing MRI. Methods: A retrospective chart review identified children who received this regimen from 2009–2012. The protocol includes comprehensive evaluation by a pediatric intensivist, premedication with midazolam 0.1 mg/kg, induction with propofol 1.5–2 mg/kg, followed by intermittent boluses of 1–1.5 mg/kg titrated to need. We report the induction time, sedation time, time to discharge, adverse events, need for additional agents, and failed sedation. Results: Data included 183 children, four were infants. Mean age was 4.8 years (SD 3.2), and body weight was 18.3 kg (SD 10). The mean induction dose was 2.1mg/kg (SD 0.5). The median induction time was 4 minutes (range 1–7 min.), sedation time 26 minutes (range 8–60), and time to discharge 14 minutes (range 5–45). Mean total dose of propofol was 2.7mg/kg (SD 1.1). 93 children (50.5%) completed the study with a single induction dose, while 15 (8.2%) required more than two doses. Sedation with a second agent was needed in 9 children (4.9%). Eight children (4.3%) needed airway manoeuvres and 27 (14.8%) experienced significant bradycardia. Three (1.6%) failed sedation. Conclusions: Intermittent dosing regimen of propofol was effective and well tolerated with mild events, but rarely some children failed or needed a second agent.

ABSTRACT 918

Background and aims: Massive hemorrhage (MH) is a clinical situation that necessitates the ability to work in interdisciplinary team. Aims: To evaluate the application of a MH protocol and the ability to work in interdisciplinary teams using simulation and targeted training. Methods: This prospective observational study was held at the simulation lab of a tertiary health care facility. Participants were nurses, respiratory therapists, orderlies, anesthetists, obstetricians, pediatric emergency physicians, intensivists and hematologists. Teams were submitted to high fidelity simulated MH scenarios. All sessions were videotaped. Targeted training consisted of a debriefing session and a presentation reviewing the protocol as well as teamwork skills. Documents were given during the first session to prepare for the post session two weeks later. Confidence questionnaires were filled out during both sessions. Four blinded independent trained raters reviewed the videos and assessment of performance was done using two checklists. Performances scores were compared using an ANOVA test; confidence questionnaires were compared using a Mann Whitney test. IRB approval was obtained for this study. Results: Sixty-two healthcare professionals involved in 8 interdisciplinary teams participated in the study. Following training, scores for the application of the MH protocol improved by 24% (10-39), p=.002. Scores for the ability to work in teams improved by 17% (6-28), p=0.006. Confidence levels in the ability to apply the MH protocol and work in teams improved by 13% (11-16), p<0.0001. Conclusions: Targeted training using simulation improved participant ability to apply the MH protocol, improved interdisciplinary teamwork skills and confidence levels among participants from all disciplines.

ABSTRACT 651

Background and aims: Several decades ago, the beneficial effects of goal-directed therapy in cases of intra-abdominal hypertension (IAH), were proven in the context of closures of abdominal-wall-defects and large-for-size transplantations. Different neonatologic and pediatric disease patterns are also known to increase intra-abdominal pressure (IAP). Nevertheless, a considerable knowledge transfer regarding such risk factors has hardly taken place. When left untreated, IAH threatens to evolve into abdominal compartment syndrome (ACS), which is accompanied by a mortality rate of 60% in children. Aims: Therefore, the present study looks at the recognition and knowledge of IAH/ACS among Alpine pediatric intensivists. Methods: In June 2010, a questionnaire was mailed to the heads of pediatric intensive care units of 85 Austrian and Swiss pediatric hospitals. Results: Response rate was 34%. At least one case of IAH was reported by 29% of respondents; at least one case of ACS, by 20%. Compared with adolescents, younger children appeared to develop IAH/ACS more often. Routine measurements of IAP were said to be performed by 26% of respondents. Bladder pressure was used most frequently to assess IAP. In 2009, 8% of respondents claimed to have performed a DL. Surgical decompression was indicated if signs of organ dysfunction were present or if an IAP of 15 mmHg was surpassed. Conclusions: Although awareness among pediatricians has increased over the last decade, definitions and guidelines regarding diagnosis and management of IAH/ACS are not applied uniformly. This variability could express an ever present lack of awareness and solid prospective data.

ABSTRACT 650

Background and aims: Some pediatricians seem to take Intra-abdominal Hypertension and Abdominal Compartment Syndrome for epiphenomenons of disorders which exclusively accompany illnesses that are treated only in specialized centres. Since the majority of ACS results from inflammation and capillary leakage, also disorders can lead to IAH/ACS, which superficially seem to be harmless pediatric entities. Thereby, the majority of IAH/ACS might be overseen and not be treated adequately. Aims: The present study looks at the recognition and knowledge of IAH/ACS among pediatric intensivists of different medical care levels. Methods: In June 2010, a questionnaire was mailed to the heads of ICUs of 265 German, Austrian and Swiss pediatric hospitals. Results: Response rate was 59%. The more specialized departments are, the more often IAH/ACS is diagnosed. Predominantly, non-university hospitals (NUH) underestimated critical IAP-thresholds and did not recognize IAH-/ACS-definitions. 2/3 of university hospitals (UH) at least diagnosed one case of IAH; nearly 50% at least one ACS (NUH: 25% and 17%). Prevalence of IAH/ACS at high-level ICUs was stated to be more than twice as high. Stated underlying risk factors only marginally varied between UHs and NUHs. Regular IAP-measurements are performed by 13% of small departments in contrast to >40% of bigger ones. Main reason is the lack of equipment. At least one decompressive laparotomy was performed by 50% of UH´s in contrast to 10% of NUHs. Conclusions: Definitions and guidelines regarding diagnosis and management of IAH/ACS are not applied uniformly. This variability could express an ever present lack of awareness and solid prospective data.

Welcoming new Associate Editors to The Journal

Welcoming new Associate Editors to The Journal

P08 Is it taking longer to die in Paediatric Intensive Care?

Aims and backgroundThe admission numbers to PICUs in the UK is rising. This increase is most probably attributable to rising birth rates, as admission rates have remained stable. The increase...

G351 Outcome of non-cardiac surgery in children with congenital heart disease performed outside a cardiac centre

BackgroundApproximately 30% of children with congenital heart disease (CHD) require surgery within the first year of life for extracardiac anomalies. CHD increases short- and long-term mortality risks for non-cardiovascular procedures1....

The fallacy of chasing after work-life balance.

The fallacy of chasing after work-life balance.

Understanding of Abdominal Compartment Syndrome among Turkish Pediatric Healthcare Providers: A Questionnaire Study

Introduction: To establish the recognition and knowledge of intra-abdominal hypertension (IAH)/Abdominal Compartment Syndrome (ACS) among Turkish pediatric health care providers (PHCP). Material Methods: A questionnaire was mailed to general pediatricians, pediatric intensivists and pediatric surgeons from different Turkish hospitals. Results: The response rate was 44.5%. Although 86.5% of participants have taken care of intensive care patient, only 34.3% had knowledge about ACS. 86.7% (13/15) of pediatric intensivists, 66.1% (37/56) of pediatric surgeons and 10.3% (11/107) of general pediatricians have had knowledge about ACS. Intra-vesical route was the most common method used to measure intra-abdominal pressure (IAP). Of the respondents, 44.4% measure IAP in patients expected to develop ACS. Conclusions: Turkish PHCP are not familiar enough with ACS. Education is absolutely necessary for PHCP in Turkey to establish clear diagnostic criteria and appropriate management for this life-threatening condition.

Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians

BackgroundFocused echocardiographic examinations performed by intensivists and emergency room physicians can be a valuable tool for diagnosing and managing the hemodynamic status of critically ill children. The aim of this study was to evaluate the learning curve achieved using a theoretical and practical training program designed to enable pediatric intensivists and emergency physicians to conduct targeted echocardiograms.MethodsTheoretical and practical training sessions were conducted with 16 pediatric intensivist/emergency room physicians. The program included qualitative analyses of the left ventricular (LV) and right ventricular (RV) functions, evaluation of pericardial effusion/cardiac tamponade and valvular regurgitation and measurements of the distensibility index of the inferior vena cava (dIVC), ejection fraction (EF) and cardiac index (CI). The practical training sessions were conducted in the intensive care unit; each student performed 24 echocardiograms. The students in training were evaluated in a practical manner, and the results were compared with the corresponding examinations performed by experienced echocardiographers. The evaluations occurred after 8, 16 and 24 practical examinations.ResultsThe concordance rates between the students and echocardiographers in the subjective analysis of the LV function were 81.3% at the first evaluation, 96.9% at the second evaluation and 100% at the third evaluation (p < 0.001). For the dIVC, we observed a concordance of 46.7% at the first evaluation, 90.3% at the second evaluation and 87.5% at the third evaluation (p = 0.004). The means of the differences between the students’ and echocardiographers’ measurements of the EF and CI were 7% and 0.56 L/min/m2, respectively, after the third stage of training.ConclusionsThe proposed training was demonstrated to be sufficient for enabling pediatric physicians to analyze subjective LV function and to measure dIVC, EF and CI. This training course should facilitate the design of other echocardiography training courses that could be implemented in medical residency programs to improve these physicians’ technical skills and the care of critically ill patients.

Survey of In-House Coverage by Pediatric Intensivists

To characterize the current state of 24/7 in-hospital pediatric intensivist coverage in academic PICUs, including perceptions of faculty and trainees regarding the advantages and disadvantages of in-hospital coverage. Cross-sectional observational study via web-based survey. PICUs at North American academic institutions. Pediatric intensivists, pediatric critical care fellows, and pediatric residents. None. A total of 1,323 responses were received representing a center response rate of 74% (147 of 200). Ninety percent of respondents stated that in-hospital coverage is good for patient care, and 85% stated that in-hospital coverage provides safer care. Sixty-three percent of intensivists stated that working in in-hospital models limits academic productivity, and 65% stated that in-hospital models interfere with nonclinical responsibilities. When compared with intensivists in home coverage models, intensivists working in in-hospital models generally had more favorable perceptions of the effects of in-hospital on patient care (p < 0.0001) and faculty quality of life. Physician burnout was measured with the abbreviated Maslach Burnout Inventory. Although 57% of intensivists responded that working in in-hospital models increases burnout risk, burnout scores were not different between coverage models. Seventy-nine percent of intensivists currently working at institutions with in-hospital coverage stated that they would prefer to work in an in-hospital coverage model, compared with 31% of those working in a home coverage model (p < 0.0001). Although concerns exist regarding the effect of 24/7 in-hospital coverage on faculty, the majority of pediatric intensivists and critical care trainees responded that in-hospital coverage by intensivists is good for patient care. The majority of intensivists also state that they would prefer to work at an institution with in-hospital coverage. Further research is needed to objectively delineate the effects of in-hospital coverage on both patients and faculty.

A Chicken in Every Pot—A Pediatric Intensivist in Every Unit/All the Time?*

A Chicken in Every Pot—A Pediatric Intensivist in Every Unit/All the Time?*

Ultrasound–Guided Left Brachiocephalic Vein Cannulation in Children With Underlying Bleeding Disorders

To evaluate the safety and effectiveness of ultrasound-guided left brachiocephalic vein cannulation in infants and children with underlying bleeding conditions. Retrospective cohort. PICU of a tertiary pediatric hospital. Thirty-four patients requiring central venous catheterization from January 2011 to January 2012. None. Two pediatric intensivists, experienced in ultrasound-guided vessel cannulation, performed the ultrasound catheterization of the left brachiocephalic vein. Ultrasound equipment consisted of a standard ultrasound monitor with a linear 6-13 MHz probe. The ultrasound monitor was set on a resolution with a depth of 1.8 cm for infants and 2.2 cm for children. The "in-plane" technique was used for all patients. Thirty-four catheterizations were performed. Patient median age was 12.5 months (5.75-63.5 mo) and median weight was 9.25 kg (7-16.25 kg). The population of infants and children analyzed was composed of 25 patients with hematologic disorder (73%) treated with hematopoietic stem cell transplantation, five patients (15%) supported with extracorporeal membrane oxygenation for viral pneumonias, and four patients (12%) with uremic hemolytic syndrome. A 4F catheter was used in 79% of cases. Left brachiocephalic vein cannulation was successful in all 34 patients. Median time needed for cannulation was 350 seconds (277.5-450 s). The overall complication rate was 9% (3 of 34) and consisted of difficulty in advancing the guidewire after having pierced the vein. The time required for catheter positioning and complications was not associated with both lower body weight and body surface area of the patients (p > 0.05). Mean central venous catheter duration was 32 ± 4 days. Data reported in this retrospective study confirm the safety and effectiveness of ultrasound-guided left brachiocephalic vein catheterization in infants and children with underlying bleeding disorders.