Definitions and Pathophysiology of Sepsis Sagy, Mayer, MD; Al-Qaqaa, Yasir, MD; Kim, Paul, MD
Current problems in pediatric and adolescent health care,
11/2013, Letnik:
43, Številka:
10
Journal Article
Recenzirano
Mortality rates for sepsis and septic shock have not improved in the past decade. The Surviving Sepsis Campaign (SSC) guidelines released in 2012 emphasize early recognition and treatment of sepsis, ...in an effort to reduce the burden of sepsis worldwide. This series of review articles will discuss the pathophysiology of sepsis; comorbidities, such as multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and endocrine issues; and finally, management of sepsis and septic shock.
Severe pediatric asthma, if not immediately and aggressively treated, may progress to acute respiratory failure requiring mechanical ventilation in the pediatric intensive care unit (PICU). ...Intravenous (IV) terbutaline, a β2 agonist, is dispensed when the initial treatment does not improve the clinical condition.
To investigate the influence of early initiation of IV terbutaline on the incidence of acute respiratory failure requiring mechanical ventilation in severe pediatric asthma.
A retrospective chart review was conducted of 120 subjects (35 patients from an outside hospital emergency department ED with late start of terbutaline and 85 patients from the authors' hospital ED with early initiation of IV terbutaline) admitted to the PICU with severe asthma treated with continuous IV terbutaline. Responses to terbutaline treatment and outcomes were evaluated.
Patients transported from outlying hospital EDs had shorter pre-PICU mean durations of IV terbutaline than those transferred from the authors' ED (0.69 ± 1.38 and 2.91 ± 2.47 hours, respectively, P = .001). Twenty-one of 35 patients (60%) from outlying EDs required mechanical ventilation compared with 14 of 85 patients (16%) from the authors' ED (P = .001). Durations of pre-PICU terbutaline infusion for patients requiring mechanical ventilation were significantly shorter than those with no such requirement (P = .015).
The results of the present study, conducted in the largest number of subjects to date, suggest that early administration of continuous terbutaline in the ED may decrease acute respiratory failure and the need for mechanical respiratory (invasive and noninvasive) support in severe pediatric asthma.
Objective:
To compare pressure characteristics of mechanical ventilation and their impact on pediatric patients with severe ARDS in the
pre-protective lung strategy (PLS) and post-PLS eras.
Methods:
...Medical records of 33 patients admitted to our pediatric ICU with ARDS from 1992 through 1994 (pre-PLS) and 52 patients with
ARDS admitted from 2000 through 2003 (post-PLS) were retrospectively reviewed.
Results:
Patient age and gender distribution were identical in both eras. Fifty-five percent of the patients in the pre-PLS era had
pneumothorax, compared to 17% in the post-PLS era (p < 0.05). Overall mortality rates for patients in the pre-PLS and post-PLS
eras were 42% and 25%, respectively (p = 0.09; not significant). Mean duration of exposure to peak inspiratory pressure (PIP)
values > 40 cm H 2 O was significantly longer in the pre-PLS era than in the post-PLS era. Pre-PLS patients with pneumothorax received mean maximum
PIP of 72 ± 17 cm H 2 O, mean maximum positive end-expiratory pressure (PEEP) of 20 ± 5 cm H 2 O, and maximum mean airway pressure (MAP) of 46 ± 8 cm H 2 O, while patients in the post-PLS era required mean maximum PIP of 42 ± 2 cm H 2 O, mean maximum PEEP of 14 ± 2 cm H 2 O, and maximum MAP of 30 ± 6 cm H 2 O, respectively (p < 0.05 for all pressure parameters). There were no significant differences in mechanical ventilation pressure
characteristics among patients who did not have pneumothorax during their course of management in both eras.
Conclusions:
A significantly more aggressive use of ventilator pressure characteristics distinguished the pre-PLS era from the post-PLS
era, and was found to be associated with a markedly higher incidence of pneumothorax. Outcome in both eras did not differ
significantly, presumably due to insufficient statistical power.
ARDS
lung protective strategy
outcome
pediatric patients
pneumothorax
tube thoracostomy
A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and ...regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).
OBJECTIVE: We evaluated whether or not changes in bispectral index (BIS) are associated with concomitant changes in autonomic variables that are in agreement with the different level of sedation that ...the changes in BIS indicate. DESIGN: A retrospective chart review. SETTING: A pediatric ICU of a children's hospital.Methods and main results: Charts of patients who were receiving mechanical ventilation and IV sedation, neuromuscular blockade, and continuous BIS monitoring were enrolled in the study. Changes in BIS values > or = 30% from previous readings were evaluated to determine whether or not concomitant changes of > or = 10% in autonomic variables, in the same direction, coexisted. Forty-seven patients (35 male and 12 female) were enrolled in our study; ages ranged from 10 days to 18 years (mean, 4.2 +/- 6.2 years +/- SD). Twenty-five patients were < 1 year of age (53%). All patients were sedated and pharmacologically paralyzed. Overall, 387 BIS readings (15%) showed a > or = 30% change from the previously documented BIS number. These BIS changes were in agreement with heart rate (HR) changes, mean arterial pressure (MAP) changes, and both HR and MAP changes in 10.6%, 23.8%, and 5.7% of the time, respectively. The same analysis of agreement was done for patients < or = 1 year old, and results were no different from those of older patients. Among 21 patients who were not receiving any vasoactive drugs (alpha- and/or beta-adrenergic agonists) during the study period, 157 BIS recordings (15%) showed a > or = 30% change from the previously documented BIS number. The percents of agreement with HR, MAP, and HR and MAP for these patients were 14.6%, 17.2%, and 7.6%, respectively. In 26 patients who were receiving vasoactive medications during the study, 230 BIS recordings (15%) showed a > or = 30% change from the previously documented BIS number. For these patients, the percentages of agreement were 7.8%, 28.3%, and 4.3%, respectively. Agreement with MAP was significantly better than with HR for this group of patients (p < 0.05; Fisher Exact Test).Summary: While significant changes in BIS are thought to reflect significant changes in depth of sedation, they have a very low rate of agreement with changes in vital signs. In the absence of BIS, the level of sedation of chemically paralyzed pediatric patients can be better guided by changes in MAP than in HR, particularly in patients receiving vasoactive drug treatment.
OBJECTIVES/SPECIFIC AIMS: To build a multisite de-identified database of female adolescents, aged 12–21 years (January 2011–December 2012), and their subsequent offspring through 24 months of age ...from electronic health records (EHRs) provided by participating Community Health. METHODS/STUDY POPULATION: We created a community-academic partnership that included New York City Community Health Centers (n=4) and Hospitals (n=4), The Rockefeller University, The Sackler Institute for Nutrition Science and Clinical Directors Network (CDN). We used the Community-Engaged Research Navigation model to establish a multisite de-identified database extracted from EHRs of female adolescents aged 12–21 years (January 2011–December 2012) and their offspring through 24 months of age. These patients received their primary care between 2011 and 2015. Clinical data were used to explore possible associations among specific measures. We focused on the preconception, prenatal, postnatal periods, including pediatric visits up to 24 months of age. RESULTS/ANTICIPATED RESULTS: The analysis included all female adolescents (n=122,556) and a subset of pregnant adolescents with offspring data available (n=2917). Patients were mostly from the Bronx; 43% of all adolescent females were overweight (22%) or obese (21%) and showed higher systolic and diastolic blood pressure, blood glucose levels, hemoglobin A1c, total cholesterol, and triglycerides levels compared with normal-weight adolescent females (
p
<0.05). This analysis was also performed looking at the nonpregnant females and the pregnant females separately. Overall, the pregnant females were older (mean age=18.3) compared with the nonpregnant females (mean age=16.5), there was a higher percentage of Hispanics among the pregnant females (58%) compared with the nonpregnant females (43.9%). There was a statistically significant association between the BMI status of mothers and infants’ birth weight, with underweight/normal-weight mothers having more low birth weight (LBW) babies and overweight/obese mothers having more large babies. The odds of having a LBW baby was 0.61 (95% CI: 0.41, 0.89) lower in obese compared with normal-weight adolescent mothers. The risk of having a preterm birth before 37 weeks was found to be neutral in obese compared with normal-weight adolescent mothers (OR=0.81, 95% CI: 0.53, 1.25). Preliminary associations are similar to those reported in the published literature. DISCUSSION/SIGNIFICANCE OF IMPACT: This EHR database uses available measures from routine clinical care as a “rapid assay” to explore potential associations, and may be more useful to detect the presence and direction of associations than the magnitude of effects. This partnership has engaged community clinicians, laboratory, and clinical investigators, and funders in study design and analysis, as demonstrated by the collaborative development and testing of hypotheses relevant to service delivery. Furthermore, this research and learning collaborative is examining strategies to enhance clinical workflow and data quality as well as underlying biological mechanisms. The feasibility of scaling-up these methods facilitates studying similar populations in different Health Systems, advancing point-of-care studies of natural history and comparative effectiveness research to identify service gaps, evaluate effective interventions, and enhance clinical and data quality improvement.
To evaluate changes in oxygenation index (OI) in pediatric patients with ARDS during the first 24 h of prone positioning (PP), and to determine whether or not longer periods of PP (> 12 h) result in ...a more pronounced improvement in oxygenation.
A retrospective chart review of patients with ARDS who had been placed in PP for their management.
Pediatric ICU of a children’s hospital.
We retrieved the charts of patients with ARDS who had been admitted to our pediatric ICU over a 3-year period and placed in PP for their management. The patients received mechanical ventilation, were sedated and pharmacologically paralyzed, and underwent arterial blood gas analysis, with concomitant documentation of ventilator settings, at a frequency of once every 4 h or more often. We divided the first 24 h of PP into two periods, brief and prolonged. The brief period was defined as duration of PP between 6 h and 10 h, and the prolonged period was between 18 h and 24 h. We compared pre-PP OI values to values after brief periods and prolonged periods of PP. Values of the Pao2/fraction of inspired oxygen (P/F) ratio and the mean airway pressure (MAP) were similarly evaluated. We also evaluated the degree of OI fluctuations during 24 h of PP by identifying the time points at which the best OI and the worst OI were observed. Data from a total of 40 pediatric patients with ARDS were evaluated. Twenty-one of the patients were male, and 19 were female; their ages ranged from 1 month to 18 years (mean ± SD, 6.22 ± 6.27 years). Thirty-two patients received conventional mechanical ventilation, and 8 patients received high-frequency oscillatory ventilation. Thirty-three patients survived, and 7 patients (21%) died. The mean duration of PP was 67 ± 64 h (2.8 ± 2.7 days), the mean number of ventilator days was 32 ± 32, and the mean interval between endotracheal intubation and placing the patients in PP was 107 ± 108 h (4.5 ± 4.5 days). Thirty-seven patients completed 20 h of PP or more. The mean post-PP time points at which OI values were actually evaluated for these patients were 8 ± 2 h (brief) and 21 ± 4 h (prolonged), respectively. Overall, the OI decreased from a pre-PP value of 24.8 ± 13.0 to 16.7 ± 13.7 after a brief period of PP (p < 0.05 when compared to baseline) and 11.4 ± 6.3 after prolonged period (p < 0.05 when compared to baseline and brief period values). This improvement in OI followed the improvement seen in the P/F ratio, whereas the MAP remained unchanged. The best mean OI value, with patients in PP, was 11 ± 9 (p < 0.05 when compared to baseline) that occurred at 16 ± 6 h, and the worst was 22 ± 15 (p = not significant when compared to baseline) that occurred at 9 ± 7 h.
PP of pediatric patients with ARDS for prolonged periods (18 to 24 h) results in a more pronounced and more stable reduction in their OI values than those observed after brief periods (6 to 10 h). This improvement in OI was not associated with changes in MAP during the first 24 h of mechanical ventilation. OI values tend to fluctuate more during the first 12 h of PP then they do during the subsequent 12 h.
We evaluated whether or not changes in bispectral index (BIS) are associated with concomitant changes in autonomic variables that are in agreement with the different level of sedation that the ...changes in BIS indicate.
A retrospective chart review.
A pediatric ICU of a children's hospital.
Charts of patients who were receiving mechanical ventilation and IV sedation, neuromuscular blockade, and continuous BIS monitoring were enrolled in the study. Changes in BIS values ≥ 30% from previous readings were evaluated to determine whether or not concomitant changes of ≥ 10% in autonomic variables, in the same direction, coexisted. Forty-seven patients (35 male and 12 female) were enrolled in our study; ages ranged from 10 days to 18 years (mean, 4.2 ± 6.2 years ± SD). Twenty-five patients were < 1 year of age (53%). All patients were sedated and pharmacologically paralyzed. Overall, 387 BIS readings (15%) showed a ≥ 30% change from the previously documented BIS number. These BIS changes were in agreement with heart rate (HR) changes, mean arterial pressure (MAP) changes, and both HR and MAP changes in 10.6%, 23.8%, and 5.7% of the time, respectively. The same analysis of agreement was done for patients ≤ 1 year old, and results were no different from those of older patients. Among 21 patients who were not receiving any vasoactive drugs (α- and/or β-adrenergic agonists) during the study period, 157 BIS recordings (15%) showed a ≥ 30% change from the previously documented BIS number. The percents of agreement with HR, MAP, and HR and MAP for these patients were 14.6%, 17.2%, and 7.6%, respectively. In 26 patients who were receiving vasoactive medications during the study, 230 BIS recordings (15%) showed a ≥ 30% change from the previously documented BIS number. For these patients, the percentages of agreement were 7.8%, 28.3%, and 4.3%, respectively. Agreement with MAP was significantly better than with HR for this group of patients (p < 0.05; Fisher Exact Test).
While significant changes in BIS are thought to reflect significant changes in depth of sedation, they have a very low rate of agreement with changes in vital signs. In the absence of BIS, the level of sedation of chemically paralyzed pediatric patients can be better guided by changes in MAP than in HR, particularly in patients receiving vasoactive drug treatment.
The flow in the human trachea is turbulent. Thus, the tracheal resistance (R) and the pressure gradient (ΔP) required to maintain a given flow across the trachea is inversely related to its radius ...raised to the fifth power. If the caliber reduction ratio (X) after endotracheal intubation is calculated as X = radius of the endotracheal tube (rETT)/radius of the trachea (rT), then ΔP and/or R will be increased by (1/X)5.
To measure the actual ratio between rETT and rT following endotracheal intubation of pediatric patients with respiratory failure and to calculate the resulting increase in the tracheal R and ΔP for a given inspiratory flow rate.
Retrospective chart review.
Pediatric ICU in a tertiary-care teaching children's medical center.
Twenty consecutive pediatric patients (mean ± SD age, 6.4 ± 7.2 years) whose tracheas had been intubated for various causes of respiratory failure, and who had received a CT scan, were included in our study. All patients received an endotracheal tube the size of which was derived from the following formula: (age in years/4) + 4.
rT and rETT were measured from CT scan sections at and around the level of the thoracic inlet, and the average values were used to calculate X. These values ranged from 0.33 to 0.65 (mean, 0.55 ± 0.8). The factor (1/X)5 was calculated for each patient and then was multiplied by the known normal value for tracheal R for adolescents and adults (0.07 cm H2O/L/s) to obtain the value of R resulting from the artificial airway, (1/X)5 × 0.07. Our results showed that tracheal R increased due to caliber reduction of the trachea after endotracheal intubation by 33.9 ± 52.5-fold (range, 8.6- to 255.5-fold). In order to maintain an inspiratory flow of 1 L/s, the value of P for the intubated trachea would increase from 0.07 cm H2O to a mean of 2.4 ± 3.7 cm H2O (range, 0.6 to 18 cm H2O). In two of our patients, the rT/rETT ratios were < 0.5 (0.33 and 0.44, respectively); this translated into a more significant increase in the calculated ΔPs, 18 and 4.2 cm H2O, respectively.
The common value of X due to endotracheal intubation is between 0.5 and 0.6, which in and of itself results in an increase in R across the intubated trachea up to 32-fold. The calculated increase in P as a result of this is between 2 and 3 cm H2O for adolescents or young adults. The addition of pressure support of at least 3 cm H2O during spontaneous ventilation via an endotracheal tube, which is common practice in pediatric critical care, should alleviate any respiratory distress emanating from the increased R. However, a value for X < 0.5, which was found in 10% of our patients (2 of 20 patients), results in a much higher calculated increase in the pressure gradient and, therefore, a higher level of pressure support is required to overcome this increase.
Background:
To introduce an updated version of the original Therapeutic Intervention Scoring System (TISS) applicable to critically ill children (TISS-C). This version was designed to assess patient ...acuity and nursing workload (NW) and to determine a relationship between such assessment and the incidence of adverse events.
Methods:
Reviewing previous versions of TISS, an updated TISS-C was developed. Items inapplicable to pediatric critical care were eliminated; items current to critical care were added; and items still valid were edited. The point system accounts for the wide range of care provided. Random patients from a predetermined period had TISS-C scores calculated. The TISS-C scores were also calculated on patients with documented adverse events. Baseline scores were compared with scores of patients in whom adverse events had occurred. We determined the pediatric intensive care unit (PICU) NW to be the product of the TISS-C score and the patient–nurse ratio (PNR).
Results:
One hundred twenty-five random patients had a mean TISS-C of 14.6 ± 11.8. Patients with any adverse event (98) had a TISS-C of 19.9 ± 11.6 (P < .05). Using our PICU mean PNR of 1.4 (20 patients/14 nurses), the NW for patients with more severe events was 33.6 ± 15.9.
Conclusions:
Critically ill pediatric patients are more vulnerable to experience adverse events when their derived NW values are high. It is postulated that a critical NW exists, where adverse events are more likely to occur.
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