Current prevalence estimates of gastrostomy tube (GT)/tracheostomy placement in hospitalized patients with anoxic/hypoxic ischemic encephalopathic injury (AHIE) post cardiopulmonary resuscitation ...(CPR) are unknown. We sought, to estimate the prevalence of AHIE in hospitalized patients who had CPR and to identify patient/hospital level factors that predict the performance of GT/tracheostomy in those with AHIE.
We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2004-2010). All patients who developed AHIE following CPR were included. In this cohort the odds of having GT and tracheostomy was computed by multivariable logistic regression analysis. Patient and hospital level factors were the independent variables.
During the study period, a total of 686,578 CPR events occurred in hospitalized patients. Of these, 94,336 (13.7%) patients developed AHIE. In this AHIE cohort, 6.8% received GT and 8.3% tracheostomy. When compared to the 40-49 yrs age group, those aged >70 yrs were associated with lower odds for GT (OR = 0.65, 95% CI:0.53-0.80, p<0.0001). Those aged <18 years & those >60 years were associated with lower odds for having tracheostomy when compared to the 40-49 years group (p<0.0001). Each one unit increase in co-morbid burden was associated with higher odds for having GT (OR = 1.23,p<0.0001) or tracheostomy (OR = 1.17, p<0.0001). Blacks, Hispanics, Asians/Pacific Islanders, and other races were associated with higher odds for having GT or tracheostomy when compared to whites (p<0.05). Hospitals located in northeastern regions were associated with higher odds for performing GT (OR = 1.48, p<0.0001) or tracheostomy (OR = 1.63, p<0.0001) when compared to those in Western regions. Teaching hospitals (TH) were associated with higher odds for performing tracheostomy when compared to non-TH (OR = 1.36, 1.20-1.54, p<0.0001).
AHIE injury occurs in a significant number of in-hospital arrests requiring CPR. Certain predictors of GT/ Tracheostomy placement are identified. Patients in teaching hospitals were more likely to receive tracheostomy than their counterparts.
Outcomes of tonsillectomy (with or without adenoidectomy w/woA) in hospitalized children are unclear. We sought, to describe the characteristics of hospitalized children who underwent tonsillectomy ...(w/woA), to estimate the prevalence of complications and to evaluate the relative impact of different comorbid conditions (CMC) on the risk of occurrence of common complications following these procedures. All patients aged ≤21years who underwent a tonsillectomy (w/woA) were selected from the Nationwide Inpatient Sample (NIS 2001-2010). The associations between several patient/hospital-level factors and occurrence of complications were generated using multivariable logistic regression models. Over a decade, a total of 141 599 hospitalized patients underwent tonsillectomy (w116 319; woA 25 280). A total of 58.1% were males. Majority of the procedures were performed in teaching hospitals (TH, 73.7%), in large (bed-size) hospitals (LH, 57.8%), and in those who were electively admitted (EA, 67.3%). Frequently present CMC in patients included obstructive sleep apnea (OSA, 26.4%), chronic pulmonary disease (CPD, 14.6%), neurological disorders (ND, 6.7%), and obesity (4.8%). Majority of patients were discharged routinely (98%). Overall complication rate was 6.4% with common complications being postoperative pneumonia (2.3%), bacterial infections (1.4%), respiratory complications (1.3%), and hemorrhage (1.2%). All-cause mortality included a total of 60 patients. Patients in TH (odds ratio OR = 0.72, 95%CI = 0.62-0.85), LH (OR = 0.80, 95% CI = 0.69-0.93), and those who had the procedures during EA (OR = 0.64, 95% CI = 0.56-0.74) had significantly lower odds of complications compared with their counterparts. CMC such as anemia, CPD, coagulopathy, HT, ND, and fluid/electrolyte disorders were independent predictors of significantly higher complication risk (P < .05). In conclusion, hospitalized children who underwent tonsillectomy (w/woA) in large or teaching hospitals, or during elective admissions had lower risk of complications. Comorbidity is an important independent predictor of complications in this cohort.
Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria ...predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist?
A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed.
A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist.
Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research.
Systematic review study, level II.
Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.
We conducted this trial of two ...targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.
A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval CI, 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.
In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).
A 3-month-old boy was admitted from his pediatrician's office for failure to thrive and vomiting. On admission, he weighed barely more than his birth weight and was cachectic with muscle wasting. His ...abdomen was grossly distended but soft and nontender. A trial of nasogastric feeds resulted in a worsening of his clinical status. He was transferred to the ICU, and diagnostic imaging was concerning for a distal bowel obstruction. Surgical pathology revealed a surprising diagnosis, which is described in detail in the following case.
To describe neurobehavioral outcomes and investigate factors associated with survival and survival with good neurobehavioral outcome 1 year after in-hospital cardiac arrest for children who received ...extracorporeal cardiopulmonary resuscitation.
Secondary analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital trial.
Thirty-seven PICUs in the United States, Canada, and the United Kingdom.
Children (n = 147) resuscitated with extracorporeal cardiopulmonary resuscitation following in-hospital cardiac arrest.
Neurobehavioral status was assessed using the Vineland Adaptive Behavior Scales, Second Edition, at prearrest baseline and 12 months postarrest. Norms for Vineland Adaptive Behavior Scales, Second Edition, are 100 (mean) ± 15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival, 12-month survival with Vineland Adaptive Behavior Scales, Second Edition, decreased by less than or equal to 15 points from baseline, and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition, greater than or equal to 70.
Of 147 children receiving extracorporeal cardiopulmonary resuscitation, 125 (85.0%) had a preexisting cardiac condition, 75 (51.0%) were postcardiac surgery, and 84 (57.1%) were less than 1 year old. Duration of chest compressions was greater than 30 minutes for 114 (77.5%). Sixty-one (41.5%) survived to 12 months, 32 (22.1%) survived to 12 months with Vineland Adaptive Behavior Scales, Second Edition, decreased by less than or equal to 15 points from baseline, and 39 (30.5%) survived to 12 months with Vineland Adaptive Behavior Scales, Second Edition, greater than or equal to 70. On multivariable analyses, open-chest cardiac massage was independently associated with greater 12-month survival with Vineland Adaptive Behavior Scales, Second Edition, decreased by less than or equal to 15 points and greater 12-month survival with Vineland Adaptive Behavior Scales, Second Edition, greater than or equal to 70. Higher minimum postarrest lactate and preexisting gastrointestinal conditions were independently associated with lower 12-month survival with Vineland Adaptive Behavior Scales, Second Edition, decreased by less than or equal to 15 points and lower 12-month survival with Vineland Adaptive Behavior Scales, Second Edition, greater than or equal to 70.
About one third of children survived with good neurobehavioral outcome 1 year after receiving extracorporeal cardiopulmonary resuscitation for in-hospital arrest. Open-chest cardiac massage and minimum postarrest lactate were associated with survival with good neurobehavioral outcome at 1 year.
This study was designed to define the prevalence of colonization with antibiotic-resistant gram-negative bacilli among children residing in long-term care facilities and to determine the frequency of ...cross-colonization with these organisms. Pharyngeal and rectal specimens were obtained from subjects residing in 2 pediatric extended-care facilities and were processed to identify gram-negative organisms resistant to ceftazidime, gentamicin, meropenem, and piperacillin-tazobactam. Horizontal transmission was assessed by analyzing all resistant isolates by pulsed-field gel electrophoresis. Forty percent of subjects were colonized with ⩾1 resistant bacillus;>60% of organisms were resistant to ⩾2 of the antibiotics tested. Colonization was disproportionate among residents with a tracheostomy or other prosthesis. More than 65% of colonized subjects shared ⩾1 organism with another resident, with cross-colonization occurring among both enteric and nonenteric species. Children residing in chronic-care facilities represent a large reservoir for resistant bacilli. Such colonization may be amenable to simple barrier infection-control procedures.
We evaluated clinical features, treatment practices and early outcome in a multicentre cohort of children with cerebral sinovenous thrombosis (CSVT).
Children with CSVT from 10 countries were ...enrolled from January 2003 to July 2007 in the International Paediatric Stroke Study. We analysed clinical symptoms, underlying conditions, antithrombotic treatment and neurological outcome at hospital discharge in 170 children.
Of 170 children enrolled, 60% were male; median age 7.2 years (IQR 2.9-12.4). Headache, altered consciousness, focal deficits and seizures were common presenting clinical features. Infarction affected 37% and intracranial haemorrhage 31%. Risk factors included chronic disease in 50%; acute systemic illness or head/neck disorders 41%; prothrombotic state 20% and other haematological abnormality 19%. Discharge neurological status was normal in 48%, abnormal in 43% and unknown in 5%. Antithrombotic therapy was common, most often low molecular weight heparin was common, with significant regional variation in treatment practices. Mortality was low (4%) and was associated with no anticoagulation but not underlying chronic disease, anatomic extent of thrombosis or intracranial haemorrhage. Abnormal neurological status at discharge or death was associated with decreased level of consciousness at presentation and the presence of an identified prothrombotic state.
Our study extends the observations of previously published smaller studies in children with CSVT that this is a morbid disease with diverse underlying causes and risk factors. Divergent treatment practices among highly specialised centres as well as limited data on treatment efficacy and safety suggest that further study of this condition is warranted.
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