Anthony D. Slonim

Cardiopulmonary resuscitation in pediatric intensive care units

OBJECTIVE To determine the effectiveness of cardiopulmonary resuscitation (CPR) in the pediatric intensive care unit (ICU). DESIGN A nonconcurrent cohort study of consecutive admissions. SETTING Thirty-two pediatric ICUs. PATIENTS Consecutive admissions to 32 pediatric ICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric ICU patients were followed for the occurrence of a cardiopulmonary arrest (external cardiac massage for at least 2 mins). Patients who were in a state of continuous cardiopulmonary arrest on admission, or who never achieved stable vital signs, were excluded from the study. A total of 205 patients, from a sample of 11,165 (1.8%) pediatric admissions, experienced a cardiopulmonary arrest. Overall, 28 (13.7%) patients survived to hospital discharge. Neither mean ages nor age distribution affected survival. Only two diagnostic categories, traumatic illness, and other etiologies, were associated with survival. None of the patients fitting this category survived (p = .0028). The durations of CPR for survivors and nonsurvivors were 22.5 +/- 10.1 and 24.8 +/- 1.9 mins, respectively (p = .015). For CPR durations of <15 mins, 15 to 30 mins, and >30 mins, the survival rates were 18.6%, 12.2%, and 5.6%, respectively (linear trend p = .022). Thirty-five (17.1%) patients had a cardiopulmonary arrest before pediatric ICU admission and another arrest in the pediatric ICU. Only two (5.7%) of these 35 patients survived to discharge. Pediatric ICU survival decreased as the number of pediatric ICU arrests increased. Patients with one arrest (n = 155), two arrests (n = 29), and more than three arrests (n = 21) experienced survival rates of 14%, 14%, and 9.5%, respectively. Severity of illness, as measured by the Pediatric Risk of Mortality III score, was a significant predictor of survival (p < .001). CONCLUSIONS Pediatric ICU cardiac arrest is an uncommon event. When it does occur, prehospital CPR, duration of resuscitation, traumatic etiology, and severity of illness are important factors associated with survival.

How Well Can Hospital Readmission Be Predicted in a Cohort of Hospitalized Children? A Retrospective, Multicenter Study

BACKGROUND. Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization. METHODS. This was a retrospective cohort study. Hospital administrative data were collected from 38 childrens hospitals in the United States for the years 2003–2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission. RESULTS. Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model. CONCLUSIONS. Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary?

OBJECTIVES To determine whether clinical features can be used in a decision rule to prospectively identify a subgroup of internal jugular catheter placements that are correctly positioned and free from mechanical complications, thus obviating the need for routine postprocedural chest radiographs in selected patients. DESIGN Prospective cohort study. SETTING Tertiary care teaching hospital. PATIENTS A total of 107 consecutive patients who presented to our catheter service for internal jugular catheter insertion because of clinical indications between November 1995 and April 1996. Exclusion criteria were mechanical ventilation, an altered mental status, an age of <15 years, and a height of <152 cm. INTERVENTIONS Right or left internal jugular vein catheter placement followed by a postprocedural chest radiograph. MEASUREMENTS The operating physician completed a detailed questionnaire for each catheter insertion, designed to detect potential complications and to predict the necessity, or lack of necessity, for a postprocedural chest radiograph. The questionnaire documented patient characteristics, the number of needle passes, difficulty establishing access, operator experience, poor anatomical landmarks, number of previous catheter placements, resistance to wire or catheter advancement, resistance to aspiration of blood or flushing of the catheter ports, sensations in the ear, chest, or arm, and development of signs or symptoms suggestive of pneumothorax. After catheter insertion, chest radiographs were obtained to assess for mechanical complications and malpositioned catheters. MAIN RESULTS In 46 cases, the decision rule predicted either a complication or a malposition and, thus, the need for a chest radiograph. In 61 cases, neither was predicted (no chest radiograph was needed). Radiographs confirmed one complication (pneumothorax) and 15 catheter tip malpositions (nine in the right atrium and six in the right axillary vein). Among the 46 cases predicted to have a potential complication or malposition, there were one actual complication (pneumothorax) and six actual malpositions (three axillary vein malpositions and three right atrial malpositions). The positive predictive value of this decision rule is 15%. Among the 61 cases predicted to be free from complications or malpositions and not to require a postprocedural chest radiograph, there were nine unexpected malpositions (three axillary vein malpositions and six right atrial malpositions). The negative predictive value is 85%. The overall sensitivity of the decision rule for detecting complications and malpositions is 44%, and the specificity is 55%. CONCLUSIONS In experienced hands, internal jugular venous catheterization is a safe procedure. However, the incidence of axillary vein or right atrial catheter malposition is 14%, and clinical factors alone will not reliably identify malpositioned catheters. Chest radiographs are necessary to ensure correct internal jugular catheter position.

Long-stay patients in the pediatric intensive care unit.

ObjectiveLength of stay in the pediatric intensive care unit (PICU) is a reflection of patient severity of illness and health status, as well as PICU quality and performance. We determined the clinical profiles and relative resource use of long-stay patients (LSPs) and developed a prediction model to identify LSPs for early quality and cost saving interventions. DesignNonconcurrent cohort study. SettingA total of 16 randomly selected PICUs and 16 volunteer PICUs. PatientsA total of 11,165 consecutive admissions to the 32 PICUs. InterventionsNone. Measurements and Main Results LSPs were defined as patients having a length of stay greater than the 95th percentile (>12 days). Logistic regression analysis was used to determine which clinical characteristics, available within the first 24 hrs after admission, were associated with LSPs and to create a predictive algorithm. Overall, LSPs were 4.7% of the population but represented 36.1% of the days of care. Multivariate analysis indicated that the following factors are predictive of long stays: age <12 months, previous ICU admission, emergency admission, no CPR before admission, admission from another ICU or intermediate care unit, chronic care requirements (total parenteral nutrition and tracheostomy), specific diagnoses including acquired cardiac disease, pneumonia, and other respiratory disorders, having never been discharged from the hospital, need for ventilatory support or an intracranial catheter, and a Pediatric Risk of Mortality III score between 10 and 33. The performance of the prediction algorithm in both the training and validation samples for identifying LSPs was good for both discrimination (area under the receiver operating characteristics curve of 0.83 and 0.85, respectively), and calibration (goodness of fit, p = .33 and p = .16, respectively). LSPs comprised from 2.1% to 8.1% of individual ICU patients and occupied from 15.2% to 57.8% of individual ICU bed days. ConclusionsLSPs have less favorable outcomes and use more resources than non-LSPs. The clinical profile of LSPs includes those who are younger and those that require chronic care devices. A predictive algorithm could help identify patients at high risk of prolonged stays appropriate for specific interventions.

The costs associated with nosocomial bloodstream infections in the pediatric intensive care unit.

Objective To assess the operational and subsidiary costs and length of stay (LOS) attributable to nosocomial bloodstream infections (BSI) in a pediatric intensive care unit (PICU). Design Matched case-control study. Setting Sixteen bed PICU in a 250-bed tertiary-care pediatric hospital. Patients Cases with BSI were prospectively identified from PICU patients who developed a nosocomial BSI from August 1996 to July 1998. Controls were PICU patients who were matched for age, severity of illness, diagnosis, and admission date who did not develop a nosocomial BSI. Results A total of 38 cases and 38 controls form the basis for this study. The cases and controls were similar with respect to the matching criteria. In addition, the cases and controls did not differ with respect to demographic characteristics or PICU survival. There was a trend toward increased hospital mortality among cases (23.7% vs. 10.5%, p = .084). Significant differences were encountered in the utilization of PICU therapeutic modalities. Cases were significantly less likely to be managed care plan enrollees (36.8% vs. 60.5%, p = .043). Total operational and subsidiary costs for radiology, pharmacy, and laboratory services were significantly higher for cases than controls (

Blood transfusions in children: a multi‐institutional analysis of practices and complications

78,272 vs.

Assessing sedation in the pediatric intensive care unit by using BIS and the COMFORT scale.

35,005,

Off-label use of cardiovascular medications in children hospitalized with congenital and acquired heart disease.

3,622 vs.

Quality and Safety in the Intensive Care Unit

1,432,

A Multicenter Study of Factors Influencing Cerebrospinal Fluid Shunt Survival in Infants and Children

8,635 vs.