Amanda Menchaca

Mechanical ventilation in pediatric intensive care units during the season for acute lower respiratory infection: a multicenter study

Objective: To describe the characteristics and outcomes of mechanical ventilation in pediatric intensive care units during the season of acute lower respiratory infections. Design: Prospective cohort of infants and children receiving mechanical ventilation for at least 12 hrs. Setting: Sixty medical-surgical pediatric intensive care units. Patients: All consecutive patients admitted to participating pediatric intensive care units during a 28-day period. Measurements and Main Results: Of 2,156 patients admitted to pediatric intensive care units, 1185 (55%) received mechanical ventilation for a median of 5 days (interquartile range 2–8). Median age was 7 months (interquartile range 2–25). Main indications for mechanical ventilation were acute respiratory failure in 78% of the patients, altered mental status in 15%, and acute on chronic pulmonary disease in 6%. Median length of stay in the pediatric intensive care units was 10 days (interquartile range 6–18). Overall mortality rate in pediatric intensive care units was 13% (95% confidence interval: 11–15) for the entire population, and 39% (95% confidence interval: 23 – 58) in patients with acute respiratory distress syndrome. Of 1150 attempts at liberation from mechanical ventilation, 62% (95% confidence interval: 60–65) used the spontaneous breathing trial, and 37% (95% confidence interval: 35–40) used gradual reduction of ventilatory support. Noninvasive mechanical ventilation was used initially in 173 patients (15%, 95% confidence interval: 13–17). Conclusion: In the season of acute lower respiratory infections, one of every two children admitted to pediatric intensive care units requires mechanical ventilation. Acute respiratory failure was the most common reason for mechanical ventilation. The spontaneous breathing trial was the most commonly used method for liberation from mechanical ventilation.

Vancomycin pharmacokinetic-pharmacodynamic parameters to optimize dosage administration in critically ill children.

Objective: Critically ill children may present changes in pharmacokinetic parameters and may not reach effective concentrations of vancomycin with current dosages. The objective of this study is to calculate vancomycin pharmacokinetic parameters in critically ill children and to estimate area under the curve at 24 hrs/minimal inhibitory concentration reached for Staphylococcus aureus. Design, Setting, and Patients: Children treated with vancomycin, hospitalized in the Intensive Care Unit of the Pediatric Hospital–Centro Hospitalario Pereira Rossell, were included. Samples to determine vancomycin serum concentration were obtained on first and third days of treatment, 1 hr after the end of the third daily dose administration (maximum drug concentration) and 15 mins before the fourth (minimum drug concentration). Half-life elimination, volume of distribution, clearance, and area under the curve at 24 hrs were estimated. Vancomycin concentration values of 20–40 &mgr;g/mL (maximum drug concentration) and 5–10 &mgr;g/mL (minimum drug concentration) were considered therapeutic. Measurements and Main Results: Twenty-two children were included. On day 1, seven of 18 children for maximum drug concentration and 16 of 22 for minimum drug concentration reached concentrations in therapeutic range; on day 3, seven of 16 children for maximum drug concentration and 11 of 17 for minimum drug concentration did. Mean values of maximum drug concentration and minimum drug concentration were higher in children with negative water balance. Mean value of half-life elimination increased from day 1 to day 3. Considering a value of minimal inhibitory concentration for S. aureus of 1 &mgr;g/mL, nine of 18 children reached a relationship area under the curve at 24 hrs/minimal inhibitory concentration >400 on day 1 and seven of 15 on day 3. Considering a minimal inhibitory concentration of 2 &mgr;g/mL, one child reached it on day 1 and one on day 3. Conclusions: Critically ill children show changes in pharmacokinetic parameters. Serum concentration monitorization is necessary for dosage individualization. Most children do not reach an area under the curve at 24 hrs/minimal inhibitory concentration >400 with current dosage.