Tertiary-care Pediatric Intensive Care Unit Research Articles

Clinical Pharmacy Faculty Interventions in a Pediatric Intensive Care Unit: An Eight-Month Review

The American Academy of Pediatrics and the Society of Critical Care Medicine have documented the importance of pharmacist involvement in pediatric care. Numerous studies have reported the impact of clinical pharmacy interventions in various adult care settings. However, in the pediatric critical care setting, the impact has not been well documented. The purpose of this study was to describe clinical pharmacy faculty interventions in a pediatric intensive care unit (PICU). A pediatric clinical pharmacy faculty member performed and documented clinical interventions in a level I, 18-bed, tertiary care PICU. Information gathered included medication name, specific intervention performed, basic patient demographics, and length of stay from May to December 2009. During the study period, there were 893 interventions performed on 159 patients over 66 days of service. (Average of 5.5 interventions/patient, and 34 interventions/100 patient PICU days.) Dosing recommendations and pharmacokinetics were the most common type of intervention (28.8% and 21.4%, respectively). Antibiotics and sedatives/analgesia were the most common drug classes in which interventions were made (34.4% and 20.3%, respectively). Ninety-eight percent of all interventions were accepted by the medical staff. The estimated annual cost savings from these interventions was $119,700. The average number of interventions per patient in this study was higher than that reported in the literature to date. Dosing recommendations and pharmacokinetics were the most commonly recommended interventions documented. Although this study showed considerable cost savings by a pharmacy clinical faculty member, further study of economic benefits is needed.

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Introduction: Erythropoietin (EPO) is frequently used to enhance erythropoiesis in anemic patients to avoid unnecessary transfusions. However, data to support its utility in pediatric intensive care unit (PICU) patients is lacking. This is in part due to the fact that most transfusions occur within the first 48 hours of admission. There may be a subgroup of patients who may benefit from EPO therapy to prevent later transfusions. The purpose of this study is to explore the clinical rationale and assess the efficacy of EPO in certain PICU patients at risk of requiring blood transfusion. Hypothesis: EPO administration will result in significant rise in hemoglobin in anemic patients in the PICU. Methods: A retrospective review of all patients admitted to a tertiary care PICU in 2010 and 2011 that received EPO. Diagnosis, PRISM scores, hemoglobin values (Hgb), number of EPO doses, and transfusions were recorded. Mann-Whitney test and regression analysis were utilized. Values were expressed in means and standard deviations. Results: Of 2595 admissions, 110 received EPO. The average age of the 110 patients (51 females and 59 males) was 7.4 ± 5.4 years and the median PRISM score was 3. Of these, 8 patients had ongoing blood loss and were excluded, 33 were transfused (Group A) and 69 were not (Group B). Pre EPO Hgb was 7.6 gm/dl ± 1.4 vs. 8.8 gm/dl ± 1.2 for group A and B respectively (p =.78). Regression analysis revealed that a higher PRISM score predicted need for transfusions (p =.024). In group B, Hgb rise following EPO therapy was significant in trauma (1.0 gm/dl, p =.018, n = 9) and post-operative (± 0.87 gm/dl, p =.012, n = 31) patients, but not in patients with infections (0.23 gm/dl, p =.573, n = 20). Patients receiving? 3 doses of EPO had higher Hgb rise (1.06 gm/dl ± 1.52) compared to those receiving fewer doses (0.3 gm/dl ± 1.4), p =.05. There were no reported complications. Conclusions: EPO induced a significant hemoglobin rise in sub-acute trauma and post-operative patients but not in patients with infections. Fewer than 3 doses of EPO were not effective, and PRISM score predicted transfusion requirement. This data will be helpful in targeting specific populations in future prospective studies.

Fatal and Near-Fatal Asthma in Children: The Critical Care Perspective

To characterize the clinical course, therapies, and outcomes of children with fatal and near-fatal asthma admitted to pediatric intensive care units (PICUs). This was a retrospective chart abstraction across the 8 tertiary care PICUs of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Inclusion criteria were children (aged 1-18 years) admitted between 2005 and 2009 (inclusive) for asthma who received ventilation (near-fatal) or died (fatal). Data collected included medications, ventilator strategies, concomitant therapies, demographic information, and risk variables. Of the 261 eligible children, 33 (13%) had no previous history of asthma, 218 (84%) survived with no known complications, and 32 (12%) had complications. Eleven (4%) died, 10 of whom had experienced cardiac arrest before admission. Patients intubated outside the PICU had a shorter duration of ventilation (median, 25 hours vs 84 hours; P < .001). African-Americans were disproportionately represented among the intubated children and had a shorter duration of intubation. Barotrauma occurred in 15 children (6%) before admission. Pharmacologic therapy was highly variable, with similar outcomes. Of the children ventilated in the CPCCRN PICUs, 96% survived to hospital discharge. Most of the children who died experienced cardiac arrest before admission. Intubation outside the PICU was correlated with shorter duration of ventilation. Complications of barotrauma and neuromyopathy were uncommon. Practice patterns varied widely among the CPCCRN sites.

Epidemiology and Outcome of Sepsis in a Tertiary Care PICU of Pakistan

To determine the epidemiology and outcome of sepsis in children admitted in pediatric intensive care unit (PICU) of a tertiary care hospital. Retrospective review of children 1 mo to 14 y old, admitted to the PICU with severe sepsis or septic shock from January 2007 through December 2008 was done. Demographic, clinical and laboratory features of subjects were reviewed. The primary outcome was mortality at the time of discharge from PICU. The independent predictors of mortality were modeled using multiple logistic regression. In 2 years, 17.3% (133/767) children admitted to the PICU had sepsis. Median age was 18 mo (IQR 6-93 mo), with male: female ratio of 1.6:1. Mean PRISM III score was 9 (±7.8). One third had culture proven infection, majority (20%) having bloodstream infection. The frequency of multi-organ dysfunction syndrome (MODS) was 81% (108/133). The case specific mortality rate of sepsis was 24% (32/133). Multi-organ dysfunction (Adjusted OR 18.0, 95% CI 2.2-144), prism score of >10 (Adjusted OR 1.5, 95% CI 0.6-4.0) and the need for > 2 inotropes (Adjusted OR 3.5, 95% CI 1.3-9.2) were independently associated with mortality due to sepsis. The presence of septic shock and MODS is associated with high mortality in the PICU of developing countries.

Vancomycin-resistant enterococcus outbreak in a pediatric intensive care unit: report of successful interventions for control and prevention

The objective of this study is to retrospectively report the results of interventions for controlling a vancomycin-resistant enterococcus (VRE) outbreak in a tertiary-care pediatric intensive care unit (PICU) of a University Hospital. After identification of the outbreak, interventions were made at the following levels: patient care, microbiological surveillance, and medical and nursing staff training. Data were collected from computer-based databases and from the electronic prescription system. Vancomycin use progressively increased after March 2008, peaking in August 2009. Five cases of VRE infection were identified, with 3 deaths. After the interventions, we noted a significant reduction in vancomycin prescription and use (75% reduction), and the last case of VRE infection was identified 4 months later. The survivors remained colonized until hospital discharge. After interventions there was a transient increase in PICU length-of-stay and mortality. Since then, the use of vancomycin has remained relatively constant and strict, no other cases of VRE infection or colonization have been identified and length-of-stay and mortality returned to baseline. In conclusion, we showed that a bundle intervention aiming at a strict control of vancomycin use and full compliance with the Hospital Infection Control Practices Advisory Committee guidelines, along with contact precautions and hand-hygiene promotion, can be effective in reducing vancomycin use and the emergence and spread of vancomycin-resistant bacteria in a tertiary-care PICU.

Long-term Risk of CKD in Children Surviving Episodes of Acute Kidney Injury in the Intensive Care Unit: A Prospective Cohort Study

The development of standardized acute kidney injury (AKI) definitions has allowed for a better understanding of AKI epidemiology, but the long-term renal outcomes of AKI in the pediatric critical care setting have not been well established. This study was designed to: (1) determine the incidence of chronic kidney disease (CKD) in children 1-3 years after an episode of AKI at a tertiary-care pediatric intensive care unit (ICU), (2) identify the proportion of patients at risk of CKD, and (3) compare ICU admission characteristics in those with and without CKD. Prospective cohort study. Patients admitted to the British Columbia Children's Hospital pediatric ICU from 2006-2008 with AKI, as defined by AKI Network (AKIN) criteria. Surviving patients, most with short-term recovery from their AKI, were assessed at 1, 2, or 3 years after AKI. Severity of AKI as defined by AKIN and several ICU admission characteristics, including demographics, diagnosis, severity of illness, and ventilation data. CKD was defined as the presence of albuminuria and/or glomerular filtration rate (GFR) < 60 mL/min/1.73 m2. Being at risk of CKD was defined as having a mildly decreased GFR (60-90 mL/min/1.73 m2), hypertension, and/or hyperfiltration (GFR ≥ 150 mL/min/1.73 m2). The proportion of patients with AKI stages 1, 2, and 3 were 44 of 126 (35%), 47 of 126 (37%), and 35 of 126 (28%), respectively. The number of patients with CKD 1-3 years after AKI was 13 of 126 (10.3% overall; 2 of 44 [4.5%] with stage 1, 5 of 47 [10.6%] with stage 2, and 6 of 35 [17.1%] with stage 3; P = 0.2). In addition, 59 of 126 (46.8%) patients were identified as being at risk of CKD. Several patients identified with AKI were lost to follow-up, with the potential of underestimating the incidence of CKD. In tertiary-care pediatric ICU patients, ∼10% develop CKD 1-3 years after AKI. The burden of CKD in this population may be higher with further follow-up because several patients were identified as being at risk of CKD. Regardless of the severity of AKI, all pediatric ICU patients should be monitored regularly for long-term kidney damage.

Incidence and risk factors associated with venous thrombotic events in pediatric intensive care unit patients*

To evaluate the incidence and risk factors associated with venous thromboembolism (VTE) in children admitted to pediatric intensive care units (PICUs). Prospective observational study. Eleven tertiary care PICUs in the United States. Children who were admitted to PICUs and had radiographically confirmed VTE over a rolling 6-month period were enrolled in the study. Demographic, patient-related, and outcomes data were collected and compared with all children admitted during the same period. None. : Sixty-six symptomatic VTE were documented in sixty-two patients among 6653 patients admitted to 11 PICUs. Thirteen (19.7%) of the thrombi were present on admission. The incidence rate was 0.74% (range, 0-2.7% per PICU) with a point prevalence of 0.93%. Doppler ultrasound was most frequently used to diagnose or confirm a suspected VTE. Variables associated with unadjusted risk for VTE include: younger age (3.8 months for patients with VTE vs. 51 months for non-VTE patients, p < .001), cardiac diagnosis (41% in VTE cases vs. 15% in non-VTE, p < .001), pre-/post-operative status (63% in VTE cases vs. 40% in non-VTE, p = .001), presence of central venous catheter (88% in VTE case vs. 17% in non-VTE, p < .001), or mechanical ventilation (85% in VTE cases vs. 30% non-VTE, p < .001). Multivariate analysis showed increased risk of VTE with CVC (odds ratio 6.9; confidence interval 2.7-17.5) and mechanical ventilation (odds ratio 2.8; confidence interval 0.98-7.93). Children with VTE were sicker (Pediatric Index of Mortality 2 score risk of mortality of 3.0% vs. 0.9%; p<0.0001), stayed longer in the ICU (21.2 days vs. 1.6 days; p < .0001) and had increased mortality (10.2% vs. 2.6; p < .0001). Children admitted to the PICU have an increased risk of VTE. The presence of a CVC is the strongest risk factor for VTE in this PICU population. Children with VTE were younger, sicker, stayed longer in PICU, and had a higher mortality rate.

Use of Nasal Continuous Positive Airway Pressure as a Mode of Respiratory Support in Newborns at SAT Hospital, Trivandrum

Background: Respiratory distress is one of the leading causes of mortality in a newborn ICU. Though endotracheal intubation and mechanical ventilation is the gold standard in the management of acute respiratory failure, it is not without complications. The Continuous positive airway pressure (CPAP) is used as an alternative for maintaining an increased trans-pulmonary pressure during expiratory phase of respiration in a spontaneously breathing infant. However CPAP is considered as effective as to mechanical ventilation and has fewer complications, its usefulness in a tertiary care ICU in resource poor settings is yet to be studied. Objective: To study the use of Nasal CPAP in managing respiratory distress in a tertiary care pediatric ICU. Methods: this descriptive study was performed in the 75 consecutive newborn babies with respiratory distress admitted in inborn nursery of SAT Hospital, Trivandrum. The Outcome measures are the efficacy of nasal CPAP as measured by improvement in Downe score as assessed at intervals after intervention. Results: A total of 75 infants were treated with nasal CPAP; of these, 55 infants (73.3%) improved with CPAP alone, 44 cases had Hyaline membrane disease out of these 63.63% improved with nasal CPAP, 13 (17.3%) died and 7 (9.3%) required ventilation. All cases with meconeum aspiration improved with nasal CPAP. There were no major complications like pneumothorax. Conclusions: Nasal CPAP seems to be a safe alternative to routine intubation and mechanical ventilation in managing respiratory distress cases in resource limited settings.

Performance of PRISM (Pediatric Risk of Mortality) score and PIM (Pediatric Index of Mortality) score in a tertiary care pediatric ICU

To validate Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) score. All consecutive patients over a six month period were included in the study except patients with a PICU stay of less than 2 hours, those transferred to other PICUs, pediatric surgical cases, trauma patients and those dying within 24 hours of admission. The PRISM and PIM scores of all patients included in the study were computed and the outcome was noted in terms of survival or non-survival. Mortality discrimination was quantified by calculating the area under the receiver operating characteristic (ROC) curve. Hosmer and Lemeshow goodness-of-fit test was used to calibrate the scores. Two hundred and thirty patients were enrolled with mean age of 40.6 months and male to female ratio of 1.2:1. There were 56 deaths (mortality rate 24.3%). The mortality in infants was higher (37.8 %) as compared to non-infants (16.2 %) (p = 0.011). The predicted deaths with PRISM score was 24.3%. The area under the ROC curve was 0.851 (95% CI 0.790-0.912). The Hosmer and Lemeshow goodness-of-fit test showed good calibration (p = 0.627, chi square = 1.75, degree of freedom = 3). The predicted deaths with the PIM score was 7.38%. The area under the ROC curve for PIM score was 0.838 (95 % CI 0.776-0.899). The Hosmer and Lemeshow goodness-of-fit showed a poor calibration for PIM score (p = 0.0281, chi-square = 10.866, degree of freedom = 4). Both PRISM and PIM scores have a good discriminatory performance. The calibration with PRISM score is good but the PIM score displays poor calibration.

Implementation of Brain Trauma Foundation guidelines in children with acute traumatic brain injury in tertiary-care hospital in Pakistan

Previous reports have shown that the implementation of Brain Trauma Foundation guidelines for management of traumatic brain injury in adults has been associated with significant reduction in mortality and neurological disability. To compare two-cohorts on the clinical outcome in the management of children with TBI in the tertiary-care pediatric intensive care unit before and after the implementation of BTF guidelines, 34 children (age from 1 month to 14 years) with acute traumatic brain injury admitted in Pediatric Intensive Care Unit of AKUH from January 2000 to December 2007 were identified from electronic database. Twenty patients (Group I) were treated with traditional treatment before the implementation of BTF guidelines and 14 patients (Group II) treated with BTF guidelines as multidisciplinary team approach with special emphasis on initial prompt resuscitation to avoid hypoxia, hypotension, and maximize the cerebral oxygenation by reducing intracranial pressure, and optimize cerebral perfusion. We compared the mortality, Glasgow Outcome Scale (GOS) and length of stay (LOS) between two cohorts. Patients in two groups were similar with respect to age, gender, mode of injury, Glasgow Coma Scale and neurosurgical procedure before admission in PICU. Implementation of BTF guidelines was associated with a marked reduction in mortality from 40 % to 0% (relative risk 2.6; 95% confidence interval 1.3 -5.2; p<0.007) and decreased in the LOS (relative risk 2.2; 95% confidence interval 1.4-3.3; p<0.002). The absolute risk reduction of mortality is 0.4 Adherence to BTF guidelines in management of children with acute TBI was very effective. It can be successfully implemented in other regional hospitals.

Acute transfusion reactions in critically ill pediatric patients

This study was undertaken to determine the incidence, type, and severity of acute transfusion reactions observed in a tertiary care pediatric ICU.

Parents' Reactions to Participating in Interviews about End-of-Life Decision Making

Although in-depth interviewing is well suited to studying the sensitive topic of end-of-life decision making, no reports have been published assessing the effects on parents of participating in interviews regarding end-of-life decision making for critically ill children. To examine the reactions of pediatric intensive care unit (PICU) patients' parents to interviews on end-of-life decision making for their child. We conducted semistructured interviews on end-of-life decision making with PICU patients' parents from two tertiary care PICUs. We approached 117 parents of 102 patients. Seventy-four parents (63%) of 69 patients participated. Forty-three parents (61%) described the interview as "a good experience," 20 (29%) as "a neutral experience," and 1 (1%) as "a bad experience." The parent who judged the interview negatively stated that, "It bothers me a little bit because my son is [out] there having difficulties and I'm in here and not out there." Fifty-four of 59 parents (92%) said they would participate in another similar interview. Most parents (92%) felt the medical community should continue research on end-of-life decision making. Themes identified from the responses included: emotional reaction to the interviews; exposure to end-of-life decision-making issues; impact on parents' views; and impact on future end-of-life decision making. Parents' comments suggested that many perceived the interviews as beneficial. This study demonstrates the willingness of many parents of critically ill children to participate in study interviews regarding end-of-life decision making, a topic that most parents felt was important and warranted more research.

ROLE OF CONTINUOUS EEG MONITORING IN PEDIATRIC INTENSIVE CARE UNIT

Objectives: Continuous electroencephalographic monitoring (CEEG) is frequently performed in tertiary care pediatric intensive care units (PICU) for wide variety of indications. There is little data regarding the usefulness of CEEG monitoring in critically ill pediatric patients. In this study we report the diagnostic utility of CEEG in patients requiring long-term monitoring (LTM). Methods: We retrospectively reviewed CEEG monitoring data of 96 patients admitted to a tertiary care PICU over a 4 year period (2000–2004). All patients had 16 Channel CEEG monitoring (XLTEK) utilizing the 10–20 system. Sixty-Eight patients had Video-EEG monitoring, and 28 patients had only EEG monitoring. Clinical histories were reviewed to determine indications for CEEG. CEEG findings were categorized into two major categories, a) epileptic and b) non-epileptic.

The Use of Bilevel Positive Airway Pressure in a Tertiary Care Pediatric Intensive Care Unit

Bilevel positive airway pressure therapy (bilevel therapy) is a useful tool for noninvasive ventilation in a pediatric intensive care unit (ICU). The objective of this study was to evaluate use of bilevel therapy in a tertiary care pediatric ICU by retrospective chart review. All patients during the study period (April, 2000, to June, 2003) who received mechanical ventilation were included (189 total): 94 received bilevel therapy (group 1) and 95 underwent invasive mechanical ventilation during the same time (group 2). None were excluded. A database was developed and analyzed. Data between groups were analyzed using t test and chi-square. Mean age of total sample was 9.20 years ± 5.536 SD; mean weight, 26.49 kg ± 16.68 SD. Mean age of group 1 was 10.87 yrs ± 0.50166 SD; mean weight, 30.46 kg ± 17.490 SD. A higher number of patients treated with bilevel therapy had acute respiratory failure (ARF) of infectious etiology or postoperative respiratory failure compared with primary airway compromise or ARF associated with other organ system dysfunction (p = 0.0001.) Patients with cerebral palsy, spinal muscular atrophy, or muscular dystrophy received bilevel therapy (p = 0.001, 0.034, and 0.013, respectively). Patients with postoperative respiratory insufficiency received bilevel therapy (p = 0.022). Mean age of group 2 was 7.55 years ± 5.584 SD; mean weight, 22.57 kg ± 14.91 SD. Group 2 had higher incidence of more than one organ system dysfunction (p = 0.019). Nosocomial tracheitis or ventilator-associated pneumonia were prevalent in group 2 (p = 0.020). We believe bilevel therapy is successful in older, heavier patients who have an acute respiratory infection or postoperative respiratory distress or insufficiency, with an underlying diagnosis of cerebral palsy or muscle disease. Those with ARF combined with other organ dysfunction required invasive mechanical ventilation.

Failure of nasogastric omeprazole suspension in pediatric intensive care patients

To determine the efficacy of nasogastric administration of omeprazole suspension in raising the gastric pH >4 in critically ill pediatric patients and to determine the most appropriate dosing regimen for this indication. Open-label pharmacodynamic study. Twenty-six bed tertiary-care pediatric intensive care unit. Mechanically ventilated children aged 1-18 yrs with an additional risk factor for stress ulcer formation. Continuous gastric pH monitoring was performed during administration and dose titration of omeprazole suspension to achieve the goal of gastric pH >4 for greater than 75% of the dosing interval. Data were collected from 18 patients. Subjects were categorized based on the pharmacologic response to nasogastric administration of 1 mg/kg omeprazole suspension (maximum 20 mg) as rapid (n = 9), late (n = 5), and nonresponders (n = 4). Rapid responders required 0.72 mg/kg per day omeprazole suspension to achieve adequate gastric pH elevation for stress ulcer prophylaxis. Late responders required 1.58 mg/kg per day. Nonresponders did not achieve adequate elevation of gastric pH for stress ulcer prophylaxis. Nasogastric administration of omeprazole suspension has variable efficacy in critically ill pediatric patients. Half of the studied subjects either required significant dose titrations to achieve gastric acid suppression or did not respond to nasogastric administration of omeprazole suspension.

Comparision of two ventilation modes and their clinical implications in sick children

Objective: To compare the ventilation parameters of conventional, volume-controlled (VC), and pressure-regulated volume-controlled modes in sick children with varying lung disease, the effects of specific mode on ventilation-related complications and patient outcome, and improvement in oxygenation with any specific mode. Design: Retrospective case record analysis. Setting: Seven-bedded tertiary-care pediatric intensive care unit in North India. Patients: Twenty-eight ventilated children admitted from July to December 2000. Intervention: None. Measurements and Main Results: Twenty-eight patients were studied with equal number in VC and pressure-regulated (PR) VC groups. The demographic profile, as well as preventilation and on ventilator blood-gas analysis were comparable in the two groups. Mean airway pressure in PRVC group was 17.5% lower as compared with that in VC group ( P = 0.03). Similarly, preventilation PaO2 (65 ± 17 mmHg), PaO2/FiO2 (121 ± 41 mmHg), and respiratory index (RI) (4.91 ± 2.7) improved significantly (P Conclusion: PRVC ventilation is beneficial and improves oxygenation in initial stages of ventilation.

Procalcitonin and C-reactive protein kinetics in postoperative pediatric cardiac surgical patients

Objective: To determine the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) concentration after pediatric cardiac surgery with cardiopulmonary bypass. Design: Prospective, clinical cohort study. Setting: A fifteen-bed tertiary-care pediatric intensive care unit. Patients: Fourteen pediatric patients admitted for cardiac surgery. Measurements and Main Results: Serum PCT and CRP were measured before cardiopulmonary bypass (CPB); after CPB; and on the first, second, and third days after surgery by means of immunoluminometry and nephelometry, respectively. Reference values for systemic inflammatory response syndrome are 0.5 to 2.0 ng/mL for PCT and <5 mg/L for CRP. Baseline serum PCT and CRP concentrations were 0.24 ± 0.13 ng/mL and 4.06 ± 3.60 mg/L (median 25th percentile–75th percentile), respectively. PCT concentrations increased progressively from the end of CPB (0.62 ± 0.30 ng/mL), peaked at 24 hours postoperatively (POD1) (0.77 ± 0.49 ng/mL), and began to decrease at 48 hours or POD2 (0.35 ± 0.21 ng/mL). CRP increased just after CPB (58.82 ± 42.23 mg/L) and decreased after 72 hours (7.09 ± 9.81 mg/L). Conclusion: An increment of both PCT and CRP was observed just after CPB. However, PCT values remained within reference values, whereas CRP concentrations increased significantly after CPB until the third day. These preliminary results suggest that PCT was more effective than CRP to monitor patients with SIRS and a favorable outcome.

Procalcitonin is persistently increased among children with poor outcome from bacterial sepsis.

To examine the relationships between procalcitonin, bacterial infection, sepsis-induced multiple organ failure, and mortality rate in children. Cohort study. A multidisciplinary, tertiary-care pediatric intensive care unit. Seventy-eight children meeting criteria for sepsis or septic shock and 12 critically ill children without sepsis. Venous or arterial blood sampling. Demographic, epidemiologic, and outcome data were recorded. Plasma from children with sepsis were collected on days 1 and 3, and procalcitonin concentrations were measured by immunoluminometric assay. Organ failure index scores were determined, and multiple organ failure was defined as organ failure index > or = 3. Persistent multiple organ failure was defined by presence of multiple organ failure on day 3. Procalcitonin concentrations (median [25th percentile-75th percentile]) were increased among children with sepsis on day 1 (2.4 ng/mL [0.2-24.2], p < .01) but not on day 3 (0.8 ng/mL [0.1-8.1], p = nonsignificant) vs. controls (0.2 ng/mL [0.1-0.5]). This increase in procalcitonin concentration was particularly robust among children with bacterial sepsis on day 1 (7.1 ng/mL [0.9-44.8], p < .001) and on day 3 (2.9 ng/mL [0.1-32.4], p < .05). Procalcitonin concentrations were not increased among children with fungal, viral, or culture-negative sepsis vs. controls. Procalcitonin concentrations were persistently increased over time among patients with bacterial sepsis who had persistent multiple organ failure (p < .05) and who died (p < .01) but not among patients with nonbacterial sepsis. Procalcitonin is persistently increased among children with poor outcome from bacterial sepsis. Further study is needed to better delineate this differential procalcitonin response to bacterial vs. nonbacterial sepsis and to characterize any mechanistic role that procalcitonin might play in the development of bacterial sepsis-induced multiple organ failure and mortality.

Survey on transfusion practices of pediatric intensivists.

To describe the red blood cell transfusion practices of pediatric intensivists. Cross-sectional self-administered survey. Pediatric intensive care units. Academic pediatric intensivists. None. Scenario-based survey among English- or French-speaking intensivists from Canada, France, Belgium, or Switzerland, working in tertiary-care pediatric intensive care units. Respondents were asked to report their decisions regarding transfusion practice with respect to four scenarios: cases of bronchiolitis, septic shock, trauma, and the postoperative care of a patient with Fallot's tetrad. The response rate was 71% (163 of 230). The overall baseline hemoglobin transfusion threshold that would have prompted intensivists to transfuse a patient ranged from 7 to 13 g/dL (70-130 g/L) within almost all scenarios. There was a significant difference between scenarios of the average baseline hemoglobin transfusion thresholds (p < .0001). A low Pao2, a high blood lactate concentration, a high Pediatric Risk of Mortality score, active gastric bleeding, emergency surgery, and age (2 wks) were important determinants of red blood cell transfusion, whereas none of the respondents' personal characteristics were. The average volume of packed red blood cells transfused in the four scenarios did not differ significantly. This survey documented a significant variation in transfusion practice patterns among pediatric critical care practitioners with respect to the threshold hemoglobin concentration for red blood cell transfusion. The volume of packed red blood cells given was not adjusted to the hemoglobin concentration.

Detection of pulsus paradoxus associated with large pericardial effusions in pediatric patients by analysis of the pulse-oximetry waveform.

To determine whether analysis of the pulse-oximetry waveform can be useful in detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients. A retrospective review of charts of 8 pediatric patients (age range: 5-19 years) who had echocardiographic evidence of large pericardial effusion, subsequently underwent pericardiocentesis, and had pulse-oximetry waveform tracings obtained before and after pericardiocentesis within an 18-month period was conducted in 2 tertiary-care pediatric intensive care units. We analyzed the pulse-oximetry waveform tracings for the presence of a pulsus paradoxus. Other abstracted data included clinical evidence of tamponade, echocardiographic findings, and the volume of pericardial fluid aspirated. Before pericardiocentesis, a decrease in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform was observed during inspiration in each patient. Echocardiographic evidence of large pericardial effusion with compromised cardiac filling was also present in each patient. Only 6 of these patients had clinical evidence of cardiac tamponade at that time, 4 with a documented pulsus paradoxus using standard methods of blood pressure analysis. After pericardiocentesis, the inspiratory fall in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform lessened in every patient. Echocardiography documented a decrease in the size of the effusion and resolution of the compromised cardiac filling in every patient. Analysis of pulse-oximetry waveforms may be a widely available, easily interpretable, and reliable method of detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.