Aileen Kirby

Respiratory secretion analyses in the evaluation of ventilator-associated pneumonia: a survey of current practice in pediatric critical care.

Objective: Ventilator-associated pneumonia is among the most common nosocomial infections in the PICU. Respiratory secretion cultures and Gram stains are frequently obtained for diagnosis and to guide therapy, but their specificity is questionable. We conducted a scenario-based survey of pediatric intensivists to assess their antibiotic use in response to hypothetical tracheal aspirate culture and Gram stain results. Design: Scenario-based survey. Setting: A hypothetical PICU. Patients: Three hypothetical scenarios of intubated children with fever and leukocytosis: a 4-month-old child with respiratory syncytial virus infection; a 7-year-old child with acute respiratory distress syndrome; and a 10-year-old child with aspiration pneumonia. Interventions: Scenario-based survey of pediatric intensivists from the Pediatric Acute Lung Injury and Sepsis Network. Measurements and Main Results: Ninety-four percent of the pediatric intensivists surveyed would obtain a respiratory secretion culture and Gram stain in the evaluation of an intubated child with fever and leukocytosis, most by simple tracheal aspiration but a minority (32%) by bronchoalveolar lavage. “Bacterial pathogenicity” was considered the most important result of the analysis. Although there were some differences across the three scenarios, most would initiate antibiotics if culture results identified methicillin-sensitive or methicillin-resistant Staphylococcus aureus or Pseudomonas and, on average, continue antibiotics for 7–10 days. Conclusions: The majority of pediatric intensivists would obtain respiratory secretion cultures and Gram stains in the evaluation of an intubated child with fever and leukocytosis and initiate antibiotics guided by the results. The specificity of respiratory secretion cultures and Gram stains for the diagnosis of ventilator-associated pneumonia requires critical evaluation as this diagnosis is responsible for more than half of antibiotic use in the PICU.

Patterns of Sedation Weaning in Critically Ill Children Recovering From Acute Respiratory Failure.

Objective: To characterize sedation weaning patterns in typical practice settings among children recovering from critical illness. Design: A descriptive secondary analysis of data that were prospectively collected during the prerandomization phase (January to July 2009) of a clinical trial of sedation management. Setting: Twenty-two PICUs across the United States. Patients: The sample included 145 patients, aged 2 weeks to 17 years, mechanically ventilated for acute respiratory failure who received at least five consecutive days of opioid exposure. Interventions: None. Measurements and Main Results: Group comparisons were made between patients with an intermittent weaning pattern, defined as a 20% or greater increase in daily opioid dose after the start of weaning, and the remaining patients defined as having a steady weaning pattern. Demographic and clinical characteristics, tolerance to sedatives, and iatrogenic withdrawal symptoms were evaluated. Sixty-six patients (46%) were intermittently weaned; 79 patients were steadily weaned. Prior to weaning, intermittently weaned patients received higher peak and cumulative doses and longer exposures to opioids and benzodiazepines, demonstrated more sedative tolerance (58% vs 41%), and received more chloral hydrate and barbiturates compared with steadily weaned patients. During weaning, intermittently weaned patients assessed for withdrawal had a higher incidence of Withdrawal Assessment Tool-version 1 scores of greater than or equal to 3 (85% vs 46%) and received more sedative classes compared with steadily weaned patients. Conclusions: This study characterizes sedative administration practices for pediatric patients prior to and during weaning from sedation after critical illness. It provides a novel methodology for describing weaning in an at-risk pediatric population that may be helpful in future research on weaning strategies to prevent iatrogenic withdrawal syndrome.

If You Build It, They Will Come: Initial Experience with a Multi-Disciplinary Pediatric Neurocritical Care Follow-Up Clinic

Pediatric Neurocritical Care diagnoses account for a large proportion of intensive care admissions. Critical care survivors suffer high rates of long-term morbidity, including physical disability, cognitive impairment, and psychosocial dysfunction. To address these morbidities in Pediatric Neurocritical Care survivors, collaboration between Pediatric Neurology and Pediatric Critical Care created a multidisciplinary follow-up clinic providing specialized evaluations after discharge. Clinic referrals apply to all Pediatric Neurocritical Care patients regardless of admission severity of illness. Here, we report an initial case series, which revealed a population that is heterogenous in age, ranging from 1 month to 18 years, and in diagnoses. Traumatic brain injuries of varying severity as well as neuroinfectious and inflammatory diseases accounted for the majority of referrals. Most patients (87%) seen in the clinic had morbidities identified, requiring ongoing evaluation and expansion of the clinic. Cognitive and psychological disturbance were seen in over half of patients at the initial clinic follow-up. Sleep disturbances, daytime fatigue, headache or chronic pain, and vision or hearing concerns were also common at initial follow-up. Data from this initial population of clinic patients reiterates the need for specialized follow-up care, but also highlights the difficulties related to providing this comprehensive care and evaluating interventions to improve outcomes.

Pediatric Ventilator-associated Infections: The Ventilator-associated Infection Study

Objective: Suspected ventilator-associated infection is the most common reason for antibiotics in the PICU. We sought to characterize the clinical variables associated with continuing antibiotics after initial evaluation for suspected ventilator-associated infection and to determine whether clinical variables or antibiotic treatment influenced outcomes. Design: Prospective, observational cohort study conducted in 47 PICUs in the United States, Canada, and Australia. Two hundred twenty-nine pediatric patients ventilated more than 48 hours undergoing respiratory secretion cultures were enrolled as “suspected ventilator-associated infection” in a prospective cohort study, those receiving antibiotics of less than or equal to 3 days were categorized as “evaluation only,” and greater than 3 days as “treated.” Demographics, diagnoses, comorbidities, culture results, and clinical data were compared between evaluation only and treated subjects and between subjects with positive versus negative cultures. Setting: PICUs in 47 hospitals in the United States, Canada, and Australia. Subjects: All patients undergoing respiratory secretion cultures during the 6 study periods. Interventions: None. Measurements and Main Results: Treated subjects differed from evaluation-only subjects only in frequency of positive cultures (79% vs 36%; p < 0.0001). Subjects with positive cultures were more likely to have chronic lung disease, tracheostomy, and shorter PICU stay, but there were no differences in ventilator days or mortality. Outcomes were similar in subjects with positive or negative cultures irrespective of antibiotic treatment. Immunocompromise and higher Pediatric Logistic Organ Dysfunction scores were the only variables associated with mortality in the overall population, but treated subjects with endotracheal tubes had significantly lower mortality. Conclusions: Positive respiratory cultures were the primary determinant of continued antibiotic treatment in children with suspected ventilator-associated infection. Positive cultures were not associated with worse outcomes irrespective of antibiotic treatment although the lower mortality in treated subjects with endotracheal tubes is notable. The necessity of continuing antibiotics for a positive respiratory culture in suspected ventilator-associated infection requires further study.

Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial

Objective To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their childs participation in a multisite pediatric critical care clinical trial. Study design We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31‐center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. Result Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non‐Hispanic White (White), non‐Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56‐2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10‐1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37‐3.36, P < .001). Conclusions Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their childs participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. Trial registration ClinicalTrials.gov: NCT00814099.

Healthcare-associated infections in the pediatric intensive care unit

Healthcare-associated infections cause significant morbidity and mortality in pediatric intensive care unit (PICU) patients. Critically ill children frequently require the placement of invasive devices, such as central venous catheters, urinary catheters, and endotracheal tubes. Each device increases a patients risk of acquiring infection. In this review, the diagnosis and management of common healthcare-associated infections in the PICU is discussed. This review also examines several infection prevention strategies used in the PICU.