Tertiary-care Pediatric Intensive Care Unit Research Articles

Respiratory syncytial virus infections in the pediatric intensive care unit: clinical characteristics and risk factors for adverse outcomes.

To describe the clinical characteristics of infants admitted to a pediatric intensive care unit (PICU) with respiratory syncytial virus (RSV) infection, including the prevalence of indications for RSV passive antibody prophylaxis (as currently recommended by the American Academy of Pediatrics), and to identify risk factors that predict adverse outcomes among this population. Retrospective medical record review. Tertiary care PICU. Children <2 yrs of age admitted to PICU for the management of RSV disease during the 1994-95, 1995-96, and 1996-97 RSV seasons. The medical records of 89 infants were reviewed. Of these, 55% were born before 36-wks gestation, 14% had chronic lung disease that required medical therapy within the previous 6 months, and 30% met at least one indication for RSV passive antibody prophylaxis. Seven infants had congenital heart disease, five had upper airway abnormalities, and six had various noncardiac congenital malformations. Logistic regression was used to determine which characteristics were associated with prolonged durations (>75th percentile) of mechanical ventilation, PICU stay, and hospital stay. Prolonged mechanical ventilation was associated with congenital heart disease (p = 0.014), chronic lung disease (p = 0.007), and noncardiac congenital malformations (p = 0.022). Only congenital heart disease was associated with prolonged PICU stay (p = 0.004) or prolonged hospital stay (p = 0.006). All of the infants with airway abnormalities had prolonged ventilator days, PICU days, and hospital days. Currently recommended indications for RSV passive antibody prophylaxis were not predictive of prolonged ventilation, PICU stay, or hospital stay. A minority of infants admitted to our PICU for severe RSV disease meet currently recommended indications for RSV passive antibody prophylaxis. Risk factors that predict prolonged durations of ventilation, PICU stay, or hospital stay among this population include congenital heart disease, chronic lung disease, upper airway abnormalities, and noncardiac congenital malformations.

The Severity and Cost of Child Abuse in the Pediatric Intensive Care Unit

The objective of this study was to describe the severity of illness, costs, and outcomes of child abuse (CA) patients in the pediatric intensive care unit (PICU) and to assess the importance of CA in predicting costs adjusting for severity of illness and diagnosis. A retrospective, cohort study was performed on a consecutive sample of 1, 376 patients admitted and discharged to a tertiary care PICU during fiscal year 1994. Demographic data, diagnoses, pediatric risk of mortality (PRISM) score, length of stay, and deaths were recorded. Hospital charges were converted into costs using cost:charge ratios. Functional outcomes of the CA patients were assessed at the time of discharge. There were 17 cases of CA in 1,376 admissions (1.24%). CA accounted for 6 of 85 deaths (7.06%) and the mortality rate was significantly higher than the rest of the PICU population (35–3% versus 5.8%, p &lt; 0.01). In the traumatic brain injury (TBI) subgroup, total costs and daily costs were significantly higher in the CA patients ($11,926 versus $7,798, p = 0.013 and $3,400 versus $2,479, p = 0.01). Adjusting for severity of illness with multiple regression, there were no differences in costs identified in the CA patients. Nine of 11 (81.8%) CA patients with TBI were severely disabled or died. CA patients have an increased severity of illness, explaining much of the differences in costs seen with these patients. Further resources should be allocated toward prevention given the high costs and high morbidity and mortality in these patients.

Colonization with antibiotic-resistant gram-negative organisms in a pediatric intensive care unit.

To measure the prevalence of colonization with antibiotic-resistant Gram-negative organisms and its association with potential risk factors, including antibiotic exposure, in a pediatric intensive care unit (ICU). Prospective, observational study. A 16-bed tertiary care pediatric ICU. All children admitted to the pediatric ICU for > 24 hrs over a 5-month period. Two hundred ninety-six patients, approximately half of all patients admitted to the ICU, were enrolled in the study; 236 patients had sufficient data collected for analysis and were prospectively examined for nasopharyngeal and gastrointestinal colonization by antibiotic-resistant Gram-negative organisms (ceftazidime minimal inhibitory concentration of > 16 micrograms/mL, or tobramycin minimal inhibitory concentration > 8 micrograms/mL). Association between colonization and potential predisposing factors including demographics, diagnosis, Pediatric Risk of Mortality (PRISM) score, invasive instrumentation, and prior ICU antibiotic exposure was assessed. More than 20% of patients were found to be colonized with an antibiotic-resistant Gram-negative organism. Examination of the timing of colonization indicated that more than half were identified within 72 hrs of admision. Colonization was associated by unadjusted analysis to prior ICU antibiotic exposure, as well as by factors associated with the severity of illness (PRISM score and invasive instrumentation) and young age. However, when the independence of these factors was tested by logistic regression, prior antibiotic exposure was no longer associated with resistant organism colonization. These data suggest that antibiotic-resistant Gram-negative organisms are a significant risk to intensively III children and that in many instances, they are imported into the unit or rapidly acquired from environmental reservoirs. Since risk factors for colonization are multiple, policies confined to antibiotic utilization within the ICU may have fixed, and possibly limited, benefit in their control.

Purpose of family photographs displayed in the pediatric intensive care unit

OBJECTIVE: To investigate why parents frequently display family photographs on their children's beds in the intensive care unit (ICU). DESIGN: Questionnaire. SETTING: Tertiary-care pediatric ICU. SUBJECTS: Twenty-three parents who displayed pictures, 25 parents who did not, and 50 ICU nurses. OUTCOME MEASURE: Content analysis. RESULTS: Parents' stated primary reasons for displaying pictures were (1) to motivate the staff and (2) to comfort themselves. Parents not displaying photographs had not thought of displaying them, and the idea had not been suggested to them. Sixty-eight percent of the nurses surveyed reported that they invite parents to display photographs. CONCLUSIONS: We recommend that ICU staff consider discussing with parents the potential benefit of displaying photographs of their children. Pictures may open an avenue for communication, allow parents to express unspoken concerns, and give parents comfort or a goal to strive for and thus alleviate some of the stress associated with having a child in the ICU. (Heart Lung® 1997; 26: 68–75.)

Idiopathic Pulmonary Hemorrhage in Infancy: Clinical Features and Management With High Frequency Ventilation

To describe the clinical characteristics of infants with severe acute pulmonary hemorrhage and the effects of mechanical ventilation on gas exchange. Tertiary care pediatric ICU in a university hospital. Case records of patients with severe acute pulmonary hemorrhage from January 1992 to July 1995 were reviewed. Acute pulmonary hemorrhage was defined as hemoptysis and/or epistaxis or blood obtained from endotracheal tube which could not be attributed to cardiac or vascular malformation, infectious process, or known trauma. Patients were initially managed with conventional ventilation. High frequency ventilation (HFV) was utilized when hypoxemia (PaO2/PAO2 < 0.2) and/or respiratory acidosis (PaCO2 > or = 60 mm Hg with pH < 7.25) persisted. Six African-American male infants from Detroit, with a median age 2.3 months, presented with severe acute pulmonary hemorrhage. Chest radiographs showed diffuse bilateral infiltrates or opacification with a normal sized heart. All infants were managed with HFV, four by oscillation and two by jet. The indications for HFV were persistent hypoxemia (2), respiratory acidosis (1), and a combination of both (3). There was an improvement in pH and PaCO2, and a decreased need for oxygen 6 and 24 h after initiating HFV. PaO2/PAO2 and oxygenation index showed a tendency toward improvement. All infants survived, and there were no complications. No cause for pulmonary hemorrhage was found in any of the infants. Idiopathic acute pulmonary hemorrhage is a potentially life-threatening disorder encountered among inner-city infants. HFV is highly effective and safe in rapidly reversing the severe oxygenation and ventilation deficits in this setting.