Angela S. Czaja

Symptoms of Posttraumatic Stress Disorder Among Pediatric Acute Care Nurses

In their work, pediatric acute care nurses may encounter traumatic events and be at risk for posttraumatic stress disorder (PTSD). This survey-based study examines the potential diagnosis of PTSD among nurses at a tertiary childrens hospital with a Level 1 trauma center. Twenty-one percent of respondents had strong PTSD symptoms without significant difference between units. Nurses with potential PTSD had more comorbid symptoms of anxiety, depression, and burnout and were more often considering a career change. Furthermore, symptoms affected not only their work but also their personal lives. Future research should focus upon identifying pediatric nurses with PTSD to provide therapeutic interventions and reducing high-risk events and their potential impact.

The use of dexmedetomidine in critically ill children.

Objective: To describe the use of dexmedetomidine for sedating intubated children in a general medical/surgical pediatric intensive care unit (PICU). Design: Retrospective, observational study. Setting: Multidisciplinary PICU of a tertiary, university-affiliated children’s hospital. Patients: All children receiving dexmedetomidine within the PICU during the period of August 2003 to August 2005. Interventions: None. Measurements and Main Results: During the study period, 121 mechanically ventilated patients, median age 36 months (range 2 months to 21 years), who received dexmedetomidine infusions. The infusion was initiated and adjusted per our PICU protocol. The average dose was 0.55 &mgr;g/kg/hr (range 0.15–0.70 &mgr;g/kg/hr) and average length of use was 25.8 hours (range 20 minutes to 60 hours). During the dexmedetomidine infusion, the mean decrease in total benzodiazepine and opiate dose as compared with the 24 hours prior was 42% and 36%, respectively. Most patients were able to reduce their benzodiazepine and opiate dose by at least 20% with the dexmedetomidine infusion (70% and 73% of patients, respectively). After discontinuing dexmedetomidine, the average change in total benzodiazepine and opiate dose as compared with the 24 hours before infusion was an increase of 14% and 1.5%, respectively. Fewer patients were able to maintain at least a 20% reduction in benzodiazepine and opiate after cessation of dexmedetomidine compared with the 24 hours before initiation (38% and 40% of patients, respectively). Hypotension and/or bradycardia requiring clinical intervention occurred in 33 of 121 (27%) patients. Discontinuation secondary to clinical concern was necessary in 12 of 121 (10%) patients. Conclusions: Our study suggests that many, although not all, mechanically ventilated children may be able to reduce their need for other sedation medications with the use of dexmedetomidine. However, the potential side effects of dexmedetomidine necessitates close hemodynamic monitoring with its use.

Performance of the Pediatric Index of Mortality 2 for pediatric cardiac surgery patients

Objective: To evaluate the performance of the Pediatric Index of Mortality 2 (PIM-2) for pediatric cardiac surgery patients admitted to the pediatric intensive care unit (PICU). Design: Retrospective cohort analysis. Setting: Multi-institutional PICUs. Patients: Children whose PICU admission had an associated cardiac surgical procedure. Interventions: None. Measurements and Main Results: Performance of the PIM-2 was evaluated with both discrimination and calibration measures. Discrimination was assessed with a receiver operating characteristic curve and associated area under the curve measurement. Calibration was measured across defined groups based on mortality risk, using the Hosmer-Lemeshow goodness-of-fit test. Analyses were performed initially, using the entire cohort, and then based on operative status (perioperative defined as procedure occurring within 24 hrs of PICU admission and preoperative as occurring >24 hrs from the time of PICU admission). A total of 9,208 patients were identified as cardiac surgery patients with 8,391 (91%) considered as perioperative. Average age of the entire cohort was 3.3 yrs (median, 10 mos, 0–18 yrs), although preoperative children tended to be younger (median, <1 month). Preoperative patients also had longer PICU median lengths of stay than perioperative patients (12 days [1–375 days] vs. 3 days [1–369 days], respectively). For the entire cohort, the PIM-2 had fair discrimination power (area under the curve, 0.80; 95% confidence interval, 0.77–0.83) and poor calibration (p < .0001). Its predictive ability was similarly inadequate for quality assessment (standardized mortality ratio, 0.81; 95% confidence interval, 0.72–0.90) with significant overprediction in the highest-decile risk group. For the subpopulations, the model continued to perform poorly with low area under the curves for preoperative patients and poor calibration for both groups. PIM-2 tended to overpredict mortality for perioperative patients and underpredict for preoperative patients (standardized mortality ratios, 0.69 [95% confidence interval, 0.59–0.78] and 1.48 [95% confidence interval, 1.27–1.70], respectively). Conclusions: The PIM-2 demonstrated poor performance with fair discrimination, poor calibration, and predictive ability for pediatric cardiac surgery population and thus cannot be recommended in its current form as an adequate adjustment tool for quality measurement in this patient group.

Off-label antidepressant use in children and adolescents compared with young adults: extent and level of evidence

To estimate the degree of, and level of evidence supporting, off‐label antidepressant (AD) prescribing for children and adolescents compared with young adults.

Unscheduled readmissions to the PICU: epidemiology, risk factors, and variation among centers.

Objectives: To determine the rate of, and potential risk factors for, unscheduled PICU readmission and assess for variability among PICUs within the United States. Design and Data Source: This retrospective cohort study used 2005–2008 data from 73 PICUs in the Virtual PICU Systems database. Methods and Measurements: Early (within 48 hr of PICU discharge) and late (later than 48 hr) unscheduled readmission rates were calculated. Hierarchical logistic regression, with a random intercept for site, was used to identify factors independently associated with early readmission. Significant random effects identified sites with an outlying risk of readmission, adjusting for patient and admission characteristics. Main Results: For 117,923 children meeting inclusion criteria, the unscheduled readmission rate was 3.7% with 38% (1.4%) occurring early. Half of early readmissions had the same primary diagnosis as the first admission. Patients with late readmissions had a higher mortality (6.6% vs 3.3%, p < 0.001) and longer median total PICU length of stay (11 d vs 6 d, p < 0.0001) than those with early readmission. Patient characteristics strongly associated with increased risk of early readmission included the following: age < 6 months, acute respiratory and renal disease, and several underlying chronic conditions such as liver disease, bone marrow transplant, airway stenosis, and abnormal antidiuretic hormone balances. An initial PICU admission that was unscheduled, originated from the general floor, or with a discharge time between 4 PM and 8 AM was associated with higher risk of readmission. A quarter of sites were identified as potential high (16%) or low (8%) outliers. Conclusions: The rate of unscheduled PICU readmission was low but associated with worse outcomes. Patient and admission/discharge characteristics associated with increased risk of readmissions could be used to target high-risk populations or modifiable factors to improve outcome. Variation of risk among centers suggests room for improvement.

Late outcomes of trauma patients with infections during index hospitalization.

BACKGROUND Injured patients have significant risk of infection during initial hospitalization. We hypothesized that infected trauma patients would have worse late outcomes. METHODS From 69 centers, patients with moderate-severe injuries and at least one selected infection during hospitalization were compared with those without an infection. Outcomes measured at 3 months and 12 months postinjury included death, subscales on the Medical Outcomes Short Form Health Survey (SF-36), Revised Center for Epidemiologic Studies Depression Scale, the cognitive subscale of the Functional Capacity Index, the Mobility and Fine Motor subscales of the Musculoskeletal Function Assessment, return to work, and healthcare utilization postdischarge. RESULTS Of 4,732 patients, 668 had >or=1 infection. Patients with hospitalizations complicated by infection had a higher risk of death within 1 year after injury, hazard ratio 1.56 (95%confidence interval [CI] 1.13-2.15). Surviving patients with infections had lower SF-36 physical function scores and patients older than 65 years also demonstrated lower scores in general health, vitality, emotional and social function. Postdischarge, infected patients were more likely to have repeat hospitalizations, need home health services (relative risk [RR] 1.19, 95% CI 1.03-1.37 and RR 1.68, 95% CI 1.12-2.52, respectively) and require 3 more hours of care from family/friends per month. They were also less likely to have returned to work (odds ratio 1.67, 95% CI 1.20-2.32). However, infected patients were at less risk of being depressed 12 months postinjury (RR 0.77, 95% CI 0.62-0.97). CONCLUSIONS Trauma patients with an infection during hospitalization demonstrate worsened functional status and increased healthcare usage up to a year after injury compared with those without an infection. Future interventions need to target decreasing infection risk as well as close follow-up after discharge.

Unplanned pediatric intensive care unit readmissions: A single-center experience

PURPOSE The purpose of the study was to compare patients readmitted to the pediatric intensive care unit (PICU) unexpectedly within 48 hours (early), more than 48 hours from transfer (late), or not readmitted during the same hospitalization. MATERIALS AND METHODS A retrospective study (2007-2009) was performed at a tertiary care pediatric academic hospital. Readmitted at-risk patients were grouped by timing of readmission, and a sample of nonreadmitted patients was randomly selected. Early readmissions were compared to late readmissions and to nonreadmissions. RESULTS Of 3805 eligible patients, 3.9% had an unplanned PICU readmission with almost half occurring within 48 hours. Median times to readmission were 21.5 hours (early) and 7 days (late). Compared with late readmissions, early readmissions were more often admitted from and transferred to a surgical service, transferred on a weekend, and readmitted with the same primary diagnosis. Compared with nonreadmitted patients, independent risk factors for early readmission were admission source and respiratory support at PICU transfer. Readmitted patients had longer total PICU and hospital lengths of stay than nonreadmitted patients. Late readmissions had a higher mortality than early readmissions. CONCLUSIONS Patients requiring an unplanned PICU readmission had worse outcomes than those without a readmission. Future studies should focus on identifying modifiable risk factors for targeted interventions.

Propofol as a bridge to extubation for high-risk children with congenital cardiac disease.

BACKGROUND Children with congenital cardiac defects may have associated chromosomal anomalies, airway compromise, and/or pulmonary hypertension, which can pose challenges to adequate sedation, weaning from mechanical ventilation, and successful extubation. Propofol, with its unique properties, may be used as a bridge to extubation in certain cardiac populations. MATERIALS AND METHODS We retrospectively reviewed 0-17-year-old patients admitted to the Cardiac Intensive Care Unit between January, 2007 and September, 2008, who required mechanical ventilation and received a continuous infusion of propofol as a bridge to extubation. Medical charts were reviewed for demographics, associated comorbidities, as well as additional sedation medications and haemodynamic trends including vital signs and vasopressor support during the peri-infusion period. Successful extubation was defined as no re-intubation required for respiratory failure within 48 hours. Outcomes measured were successful extubation, evidence for propofol infusion syndrome, haemodynamic stability, and fluid and inotropic requirements. RESULTS We included 11 patients for a total of 12 episodes. Propofol dose ranged from 0.4 to 5.6 milligram per kilogram per hour with an average infusion duration of 7 hours. All patients were successfully extubated, and none demonstrated worsening metabolic acidosis suggestive of the propofol infusion syndrome. All patients remained haemodynamically stable during the infusion with average heart rates and blood pressures remaining within age-appropriate ranges. One patient received additional fluid but no increase in vasopressors was needed. CONCLUSIONS This study suggests that propofol infusions may allow for successful extubation in a certain population of children with congenital cardiac disease. Further studies are required to confirm whether propofol is an efficient and safe alternative in this setting.

A critical appraisal of a randomized controlled trial: Willson et al: Effect of exogenous surfactant (calfactant) in pediatric acute lung injury (JAMA 2005, 293: 470-476).

Objective: To evaluate the use of exogenous surfactant in pediatric acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in decreasing the duration of respiratory failure. Design: A critical appraisal of a randomized controlled trial. Findings: This was a multiple-center, randomized, double-blinded, placebo-controlled trial evaluating the effect of calfactant via endotracheal tube in pediatric ALI/ARDS. The primary outcome was duration of respiratory failure measured by ventilator-free days at 28 days. Secondary outcomes included hospital course, adverse events, and failure of conventional mechanical ventilation (use of high-frequency oscillatory ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation). One hundred and fifty-two patients were enrolled and randomized with strict inclusion and exclusion criteria. Aside from the experimental interventions, the treatment and placebo groups were similar at baseline. Ventilator management guidelines were defined a priori. No significant difference in ventilator-free days was found, although the treatment group had a greater improvement in oxygenation. Mortality rate was significantly greater in the placebo group (relative risk, 1.9; 95% confidence interval, 1.1–3.2). However, when controlled for immunocompromised status, the statistical significance is lost. Subgroup analysis of infants showed a greater effect on mortality (relative risk, 3.3; 95% confidence interval, 1.1–10.5) and a significant difference in ventilator-free days (15.2 days vs. 7.0 days, p = .01) for the placebo group. No other differences in measured outcomes were seen. The treatment group had an increased rate of hypotension and transient hypoxia but not of airleaks or nosocomial pneumonias. Conclusions: This is a well-designed study with an appropriate intention-to-treat analysis, but it is underpowered, making it difficult to identify which patients with pediatric ALI/ARDS might benefit from calfactant. Given the uncertainty of the benefits, calfactant cannot be routinely recommended in pediatric ALI/ARDS.

Development of recommendations for dosing of commonly prescribed medications in critically ill obese children

PURPOSE The development and use of a decision support tool to help formulate recommendations for dosing of commonly prescribed medications in critically ill obese children are described. METHODS Medications prescribed in 2010 to critically ill infants and children (younger than 18 years) were identified from the Pediatric Health Information System. The most commonly prescribed and therapeutically monitored medications were extracted. Supportive evidence for obesity dosing was identified through a standardized computerized search involving medical subject heading terminology and age filters using PubMed and Ovid. A usefulness scoring system was developed to rate the strength and applicability of the literature to critically ill obese children. A decision supporttool was then created to aid in the formulation of a dosing weight for each medication based on the usefulness score, published pharmacokinetic properties, clinical studies available in the primary literature, and consideration of clinical consequences of underdosing or overdosing. RESULTS A total of 113 medications were evaluated, and 122 discrete citations, supporting 66 medications, were reviewed. Seventy-two percent of citations had general obesity dosing information, and 13% had pediatric-specific information. The overall mean usefulness score was 5.1±4.7 (median, 7). The decision support tool was incorporated to make final dosing weight recommendations for obese children. Ultimately, total body weight was recommended for 52 medications, adjusted weight for 43 medications, and ideal body weight for 18 medications. CONCLUSION The inadequacy of obesity dosing information for most medications commonly ordered for children admitted to a pediatric intensive care unit led to the development of a decision support tool to aid in formulating dosing recommendations.