Brian R. Jacobs

Anemia, Blood Loss, and Blood Transfusions in North American Children in the Intensive Care Unit

RATIONALE Minimizing exposure of children to blood products is desirable. OBJECTIVES We aimed to understand anemia development, blood loss, and red blood cell (RBC) transfusions in the pediatric intensive care unit (PICU). METHODS Prospective, multicenter, 6-month observational study in 30 PICUs. Data were collected on consecutive children (<18 yr old) in the PICU for 48 hours or more. MEASUREMENTS AND MAIN RESULTS Anemia development, blood loss, and RBC transfusions were measured. A total of 977 children were enrolled. Most (74%) children were anemic in the PICU (33% on admission, 41% developed anemia). Blood draws accounted for 73% of daily blood loss; median loss was 5.0 ml/day. Forty-nine percent of children received transfusions; 74% of first transfusions were on Days 1-2. After adjusting for age and illness severity, compared with nontransfused children, children who underwent transfusion had significantly longer days of mechanical ventilation (2.1 d, P < 0.001) and PICU stay (1.8 d, P = 0.03), and had increased mortality (odds ratio [OR], 11.6; 95% confidence interval [CI], 1.43-90.9; P = 0.02), nosocomial infections (OR, 1.9; 95% CI, 1.2-3.0; P = 0.004), and cardiorespiratory dysfunction (OR, 2.1; 95% CI, 1.5-3.0; P < 0.001). High blood loss per kilogram body weight from blood draws (OR, 1.11; 95% CI, 1.03-1.2; P = 0.01) was associated with RBC transfusion more than 48 hours after admission. The most common indication for transfusion was low hemoglobin (42%). Pretransfusion hemoglobin values varied greatly (mean, 9.7 +/- 2.7 g/dl). CONCLUSIONS Critically ill children are at significant risk for developing anemia and receiving blood transfusions. Transfusion in the PICU was associated with worse outcomes. It is imperative to minimize blood loss from blood draws and to set clear transfusion thresholds.

Is Bacterial Tracheitis Changing? A 14-Month Experience in a Pediatric Intensive Care Unit

Bacterial tracheitis is characterized by acute upper-airway obstruction and purulent secretions within the trachea. Historically, affected children were young, stridorous, and toxic-appearing and required tracheal intubation, and morbidity and mortality were significant. Staphylococcus aureus was the most common organism involved. During the 14 months of this retrospective study, 46 children were admitted to the pediatric intensive care unit because of this diagnosis, and their medical records were reviewed. Compared with those in previous reports, children in this study were older (mean +/- standard error of the mean [SEM], 69.3 +/- 6.8 months) and less toxic. Only 26 (57%) of 46 patients required tracheal intubation. Intubated patients were significantly younger than nonintubated patients (mean +/- SEM, 46.9 +/- 6.5 vs. 98.9 +/- 9.9 months). Moraxella catarrhalis was identified in 12 (27%) of 45 bacterial respiratory cultures, while influenza A virus was recovered from 18 (72%) of 25 viral respiratory cultures. There were no major complications. This series represents the largest reported cohort of patients with this condition and suggests an epidemiological change toward a less morbid condition.

Extracellular hsp70 levels in children with septic shock.

Objective: To determine whether hsp70 is elevated in the plasma of children with septic shock. Design: Cohort study. Setting: Two academic, tertiary pediatric intensive care units. Patients: Ninety-four children admitted to the pediatric intensive care unit with septic shock and 24 control children undergoing elective surgical procedures. Interventions: Venous or arterial blood sampling. Measurements and Main Results: Children admitted to the pediatric intensive care unit with a diagnosis of septic shock were enrolled in the study following written informed consent. The control group consisted of healthy children undergoing elective surgical procedures. Blood samples from children in the septic shock or control groups were obtained within 24 hrs of admission to the pediatric intensive care unit or during the preoperative visit. Samples were collected, centrifuged, and stored at −70°C. The hsp70 levels were measured using a commercially available enzyme-linked immunosorbent assay. Results were analyzed by Wilcoxon’s rank sum test. Extracellular hsp70 levels in children with septic shock were significantly elevated compared with control patients (51.6 ng/mL vs. 8.1 ng/mL, respectively, p = .0004). Conclusions: Extracellular hsp70 levels are significantly elevated in children with septic shock compared with controls. Given the newly described cell signaling properties of hsp70, these data suggest that extracellular hsp70 may play a role in the host response during septic shock.

Postoperative management of children after single-stage laryngotracheal reconstruction.

ObjectiveTo report the safety and efficacy of a postoperative approach that avoids pharmacologic and physical restraints and allows liberal physical activity after single-stage laryngotracheal reconstruction in children. DesignRetrospective study. SettingTertiary care pediatric intensive care unit. PatientsOne hundred thirty-three children who underwent single-stage laryngotracheal reconstruction, including laryngotracheoplasty, tracheal resection, and cricotracheal resection. InterventionsFive-year period of data collection regarding postoperative care and complications. Measurements and Main ResultsThe medical records of all patients (age range, 2–336 months; mean age ± sem, 66 ± 5 months) who underwent single-stage laryngotracheoplasty, tracheal resection, or cricotracheal resection between 1993 and 1998 were reviewed. Tracheally intubated, awake, and unrestrained patients (group 1, n = 54; mean age, 113 ± 8 months) were compared with tracheally intubated, sedated, and restrained patients (group 2, n = 79; mean age, 33 ± 3 months). Pediatric intensive care unit length of stay was less in group 1 in comparison with group 2 patients (11.2 ± 0.5 days vs. 13.7 ± 0.6 days;p = .007). Hospital length of stay was less in group 1 than group 2 patients (16.7 ± 1.0 days vs. 21.1 ± 1.1 days;p = .01). Adverse events were fewer in group 1 compared with group 2 patients: atelectasis, 44% vs. 73% (p < .001); postextubation stridor, 22% vs. 53% (p < .001); and withdrawal syndromes, 0% vs. 43% (p < .001). The occurrence of pneumonia, airleak syndromes, unplanned extubation, and aspiration events was not different between groups. ConclusionsFor developmentally appropriate children, postoperative management after single-stage laryngotracheal reconstruction does not require the use of physical and pharmacologic restraints. Older children who are not sedated or restrained and who are allowed liberal physical activity have shorter pediatric intensive care unit and hospital lengths of stay, and a decreased incidence of postoperative adverse events. Centers performing single-stage laryngotracheal reconstruction should consider a postoperative management strategy that avoids sedatives, muscle relaxants, and physical restraints, and allows liberal bedside physical activity in developmentally appropriate children.

Theophylline versus terbutaline in treating critically ill children with status asthmaticus: a prospective, randomized, controlled trial.

Objective: To compare the efficacy of theophylline, terbutaline, or theophylline combined with terbutaline treatment in critically ill children with status asthmaticus who are already receiving continuous nebulized albuterol and intravenous corticosteroids. Design: Randomized, prospective, controlled, double-blind trial. Setting: Pediatric intensive care unit of a tertiary-care children’s medical center. Patients: Forty critically ill children between the ages of 3 and 15 yrs with impending respiratory failure secondary to status asthmaticus. Interventions: All patients received intravenous methylprednisolone and continuous nebulized albuterol. The three study groups received theophylline plus placebo (group 1), terbutaline plus placebo (group 2), or theophylline and terbutaline together (group 3). Measurements and Main Results: Differences in baseline characteristics, change in clinical asthma score over time, length of pediatric intensive care unit stay, and incidence of adverse events were determined. The three study groups were similar in age, gender, race, asthma severity, and treatment. There were no differences in clinical asthma score over time, length of pediatric intensive care unit stay, or incidence of adverse events between the three groups, with the exception of a higher incidence of nausea in children in group 3. The median hospital cost of medication and theophylline blood levels was significantly lower in group 1 compared with groups 2 and 3 (

Central venous catheter occlusion: a prospective, controlled trial examining the impact of a positive-pressure valve device

280 vs.

The efficacy and safety of blood sampling through peripherally inserted central catheter devices in children.

3,908 vs.

Recognizing Hypoglycemia in Children Through Automated Adverse-Event Detection

4,045, respectively, p < .0001). Conclusions: Theophylline, when added to continuous nebulized albuterol therapy and intravenous corticosteroids, is as effective as terbutaline in treating critically ill children with status asthmaticus. The addition of theophylline to baseline therapy is more cost-effective when compared with terbutaline alone or terbutaline and theophylline together. Theophylline should be considered for use early in the management of critically ill asthmatic children.

Electronic medical record, error detection, and error reduction: a pediatric critical care perspective.

BACKGROUND Central venous catheter (CVC) occlusion occurs frequently in children. This problem is often associated with disruption of intravascular therapy and monitoring. Multiple factors may predispose to catheter occlusion, but reflux of blood into the catheter lumen is a common factor. We hypothesized that use of a positive pressure valve device would reduce the incidence of catheter occlusion. METHODS In phase I of this sequential study design, newly placed CVCs were capped with a standard device. In Phase II, CVCs were capped with a positive-pressure valve device. Data collected included patient demographics, type of catheter, infusate, catheter duration, and complications. Partial and complete catheter occlusions were delineated. A user satisfaction survey was conducted. RESULTS There were 153 children (mean age 48.0 +/- 7.7 months) with 312 CVC lumens enrolled in the study. Mean catheter duration was 9.4 +/- 0.9 days. There were fewer complete occlusions in CVCs capped with the positive pressure valve device than with the standard device [6/161 (3.7%) vs 18/151 (11.9%) occlusions, respectively; p = .012)]. There were no significant differences in partial occlusions, phlebitis, or catheter-related bloodstream infection between the 2 groups. CONCLUSIONS CVCs with a positive-pressure valve cap device have a lower incidence of complete catheter occlusion than those with a standard cap device.

Post hoc analysis of calfactant use in immunocompromised children with acute lung injury: Impact and feasibility of further clinical trials.

Background The peripherally inserted central catheter (PICC) is commonly used in children for medication and fluid administration. In addition, PICCs are used occasionally for blood sampling as an alternative to venipuncture. Blood sampling from these catheters carries the hypothetical risk of catheter occlusion caused by blood remaining in the catheter, and this practice is not supported by PICC manufacturers. Children often undergo multiple needle punctures, which are associated with pain, anxiety, and dissatisfaction with care. The authors hypothesized that blood sampling through 3-Fr PICC devices is effective and safe for children. Methods After placement of a 3-Fr PICC, all the children were sequentially enrolled in one of two groups. The control group included patients that had 3-Fr PICC devices without blood sampling. The blood sampling group included patients with 3-Fr PICC devices through which blood samples were obtained. Demographic data, PICC placement and sampling data, infusate composition, catheter occlusion, mechanical complications, and blood stream infections were recorded. The primary outcome variable was the difference in occlusion rates between the two groups. Results The analysis included 204 children with 3-Fr PICCs (120 in the blood sampling group and 84 in the control group) who had a mean age, 117.7 ± 4.9 months. The mean PICC duration was 15.6 ± 1.0 days. Blood sampling was successful more than 98% of the time from all blood sampling group catheters, with a mean of 4.4 ± 0.5 samples removed from each catheter. There was a higher occlusion rate in the blood sampling group. However, this result did not reach statistical significance. There were no significant differences between the groups in terms of infection or mechanical complication rates. Conclusions Blood sampling is feasible and effective through 3-Fr PICC devices in children. This practice is not associated with a significant increase in occlusion, infection, or mechanical complication rates.