Christine Pierce

Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children

Objective: To determine whether heparin bonding reduces the incidence of catheter-related thrombosis and infection in critically ill children. Design: A prospective double-blind randomized controlled study. Setting: A tertiary paediatric intensive care unit. Patients: Two hundred and nine patients, 123 males and 86 females, aged 0–16 years, admitted to the intensive care unit and needing a central venous line (CVL), were randomized to receive either a heparin-bonded (HB, n = 102) or a non-heparin-bonded line (NHB, n = 107). Nine patients were excluded owing to incomplete data. Intervention: HB or NHB CVL. Measurements: Blood cultures were carried out on insertion of the line and every 3 days thereafter. Ultrasound was performed within the first 3 days and every 3 days thereafter. On removal the line was sent for culture. Results: The two groups were comparable for age, sex, severity of illness and length of time that the catheter was in situ. Proportional hazards modelling showed that heparin bonding was associated with a significant reduction in infections (hazard ratio 0.11, P < 0.00 005). The incidence of infection was 4 % and 33 % in HB and NHB CVLs, respectively (4/97 vs. 34/103, P < 0.0005). The incidence of thrombosis was 0 % and 8 % in HB and NHB CVLs, respectively (0/97 vs. 8/103, P = 0.006). The number of HB CVLs which would need to be used to avoid one episode of infection or thrombosis was 3 and 13, respectively. Conclusion: Our study shows a significant reduction in the incidence of infection and thrombosis associated with the use of HB CVLs.

Children's Factual and Delusional Memories of Intensive Care

RATIONALE Delusional memories are significantly associated with post-traumatic stress in adult patients after intensive care. OBJECTIVES In this study, we attempted to establish whether this relationship was found in children. We also examined the association between factual memory and distress. METHODS One hundred two consecutive children, aged between 7 and 17 years, were interviewed about their pediatric intensive care unit (PICU) experience 3 months after discharge from a PICU. Principal measures were the ICU Memory Tool (a checklist of intensive care memories) and an abbreviated version of the Impact of Event Scale (a screen for post-traumatic stress disorder). MEASUREMENTS AND MAIN RESULTS In total, 64 of 102 (63%) children reported at least one factual memory of their admission and 33 of 102 (32%) reported delusional memories, including disturbing hallucinations. Traumatic brain injury was negatively associated with factual memory (odds ratio, 0.23; 95% confidence interval [CI], 0.09-0.58; P = 0.002). Longer duration of opiates/benzodiazepines was associated with delusional memory (odds ratio, 4.98; 95% CI, 1.3-20.0; P = 0.023). Post-traumatic stress scores were higher in children reporting delusional memories (adjusted difference, 3.0; 95% CI, 0.06-5.9; P = 0.045) when illness severity and emergency status were controlled for. Factual memory was not significantly associated with post-traumatic stress. CONCLUSIONS This study indicates that delusional memories are reported by almost one-third of children and are associated both with the duration of opiates/benzodiazepines and risk of post-traumatic stress. More research is needed on the presence of delusional memories and associated risk factors in children receiving intensive care treatment.

Is leukocytosis a predictor of mortality in severe pertussis infection

Abstract Bordetella pertussis causing severe respiratory failure in infants that is unresponsive to treatment is well described. Pulmonary hypertension is a prominent feature of such cases. In this series of 13 critically ill infants with B. pertussis, hyperleukocytosis (>100×109/l) was an independent predictor of death. We suggest that such extreme leukocytosis may contribute to disease severity via the formation of aggregates in the pulmonary vasculature.

Characteristics of deaths occurring in hospitalised children: changing trends

Background: Despite a gradual shift in the focus of medical care among terminally ill patients to a palliative model, studies suggest that many children with life-limiting chronic illnesses continue to die in hospital after prolonged periods of inpatient admission and mechanical ventilation. Objectives: To (1) examine the characteristics and location of death among hospitalised children, (2) investigate yearwise trends in these characteristics and (3) test the hypothesis that professional ethical guidance from the UK Royal College of Paediatrics and Child Health (1997) would lead to significant changes in the characteristics of death among hospitalised children. Methods: Routine administrative data from one large tertiary-level UK children’s hospital was examined over a 7-year period (1997–2004) for children aged 0–18 years. Demographic details, location of deaths, source of admission (within hospital vs external), length of stay and final diagnoses (International Classification of Diseases-10 codes) were studied. Statistical significance was tested by the Kruskal–Wallis analysis of ranks and median test (non-parametric variables), χ2 test (proportions) and Cochran–Armitage test (linear trends). Results: Of the 1127 deaths occurring in hospital over the 7-year period, the majority (57.7%) were among infants. The main diagnoses at death included congenital malformations (22.2%), perinatal diseases (18.1%), cardiovascular disorders (14.9%) and neoplasms (12.4%). Most deaths occurred in an intensive care unit (ICU) environment (85.7%), with a significant increase over the years (80.1% in 1997 to 90.6% in 2004). There was a clear increase in the proportion of admissions from in-hospital among the ICU cohort (14.8% in 1998 to 24.8% in 2004). Infants with congenital malformations and perinatal conditions were more likely to die in an ICU (OR 2.42, 95% CI 1.65 to 3.55), and older children with malignancy outside the ICU (OR 6.5, 95% CI 4.4 to 9.6). Children stayed for a median of 13 days (interquartile range 4.0–23.25 days) on a hospital ward before being admitted to an ICU where they died. Conclusions: A greater proportion of hospitalised children are dying in an ICU environment. Our experience indicates that professional ethical guidance by itself may be inadequate in reversing the trends observed in this study.

Human albumin administration in critically ill patients. Evidence needs to be shown in paediatrics.

Editor—We are concerned that the Cochrane Injuries Group’s meta-analysis regarding administration of albumin1 may alter the practice of resuscitating hypovolaemic hypotensive children, infants, and neonates. Although we are affiliated to the Institute of Child Health, we want to emphasise that this article does not reflect our own clinical practice, and at present we believe that it provides no compelling evidence to change our practice. We reviewed the 32 articles in the three groups. We identified only one paediatric study (So et al) in the hypovolaemia group, in which 63 preterm infants received albumin for hypotension. In the burns group there is only one paediatric study (n=70), in which albumin was given to maintain arbitrary serum concentrations (Greenhalgh et al). Finally, in the hypoproteinaemic group there are two studies of 64 neonates that addressed several hypotheses, including whether albumin was detrimental to respiratory status (Greenough et al) and was beneficial in weight gain (Kanarek et al). In a third study (n=27) that assessed the use of bicarbonate in acidotic neonates only the control groups of 5% dextrose and albumin were compared (Bland et al). We are now faced with concerns from parents about the “killer fluid,” and our junior staff are confused about the appropriate fluid to use for resuscitation of critically ill children. Have we been put into a legally indefensible position by this report from the Cochrane Injuries Group? We continue to use albumin for several reasons. To produce the same sustained increase in blood pressure as a 20 ml/kg bolus of albumin, up to five times as much volume of crystalloid would have to be given based on their relative oncotic pressures.2 This increased volume of crystalloid may lead to problems with fluid overload, hyperchloraemia in renal dysfunction, and pulmonary oedema. One leading manufacturer supplies £11.5 million of albumin to British hospitals each year.3 We must be certain that stopping the use of albumin is not a financially driven decision. We would be prepared to accept that albumin may be detrimental on the basis of appropriate data. At present we do not think, however, that there is enough evidence for us to stop using albumin for resuscitation in this population. In an attempt to resolve this controversy in a responsible manner we are about to embark on a prospective study to assess the safety of albumin use in children. Would the authors of the meta-analysis be prepared to enrol patients into such a study or would they consider it unethical?

Adenosine infusion for the management of persistent pulmonary hypertension of the newborn

Objective To determine the effect of adenosine for the management of persistent pulmonary hypertension of the newborn. Design Prospective, observational case series report. Setting A single, tertiary referral neonatal intensive care unit. Patients Nine neonates with persistent pulmonary hypertension of the newborn requiring mechanical ventilation and inhaled nitric oxide at 20 parts per million. Interventions A continuous intravenous infusion of adenosine at 50 &mgr;g/kg/min. Measurements and Main Results Peripheral arterial oxygen saturation, arterial oxygen tension, invasive systemic arterial blood pressure, and pulmonary arterial pressure, estimated using echocardiography, were recorded. There was a significant improvement in arterial oxygenation tension in six of nine neonates who responded to adenosine: Pao2 increased from 66.8 (range, 47–70.5) torr (8.8 kPa) to 73.5 (range, 58.5–94.2) (p = .02) and pulmonary arterial pressure decreased significantly from 63 (range, 42.5–64.0) to 43.5 (range, 32.75–49) mm Hg (p = .002). The pulmonary to systemic mean artery pressure ratio fell from 1.27 (range, 0.88–1.5) to 0.81 (range, 0.64–0.84) (p = .002). Three neonates did not respond to adenosine infusion. Conclusions The use of adenosine infusion in combination with inhaled nitric oxide may be a potentially valuable therapeutic option for the treatment of pulmonary hypertension of the newborn. Neonates with irreversible lung pathology may not respond to adenosine infusion.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children.

Objective:To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection. Design:A prospective observational case–control study. Setting:Two PICUs. Subjects:A consecutive sample of 88 children aged 5–16 years (median age = 10.00, interquartile range = 6.00–13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder. Interventions:None. Measurements and Main Results:Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p < 0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps = 0.001), as well as performing below average on aspects of executive function and attention (ps < 0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps < 0.02). Conclusions:Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Children’s Self-reported Quality of Life After Intensive Care Treatment*

Objectives: Study was to establish children’s own views of their outcome. Design: Prospective cohort study: A number of studies have reported on parental/clinician reports of childrens quality of life after intensive care treatment. The aim of this Setting: Twenty-one bed PICU in a tertiary Children’s Hospital. Patients: Ninety-seven children aged over 7 yr, with no preexisting learning difficulties, consecutively admitted to PICU over an 18 month periodInterventions: Patients completed the Pediatric Quality of Life Inventory and a post-traumatic stress screener, at 3 months and again at 1 year (n = 72) after discharge from PICU. Measurements and Main Results: At 3 months post-discharge, the mean total Pediatric Quality of Life Inventory score reported by the PICU group was lower than that reported in the literature for a non-clinical community sample (PICU mean = 79.1 vs community mean = 83.9, p = 0.003), but by 1 year, they were comparable (82.2, p = 0.388). The mean physical functioning subscale score remained lower (PICU mean=81.6 vs. community mean=88.5, p = 0.01), but improved significantly from 73.4 at 3 months (p = 0.001). Sub-group analyses revealed that the elective group reported higher emotional functioning than the community sample (91.0, p=0.005 at 3 months and 88.2, p = 0.038 at 1 year vs community mean=78.5), and made significant gains in social functioning between timepoints (79.1 to 91.4, p = 0.015). Finally, although total PedsQL scores at 1 year were not associated with measures of severity of illness during admission, they were significantly negatively associated with concurrent post-traumatic stress symptom scores (r = –0.40, p = 0.001). Conclusions: The self-report version of the Pediatric Quality of Life Inventory proved to be a feasible and sensitive tool for assessing health related quality of life in this group of PICU survivors.

Prevalence of Retinal Hemorrhages in Critically Ill Children

BACKGROUND: Retinal hemorrhages (RHs) with encephalopathy and subdural bleeding are considered suggestive of abusive head trauma (AHT). Existing studies describing RH focus on AHT and have potential selection bias. We undertook a prospective observational study to define the prevalence, distribution, and extent of RH in critically ill children. METHODS: From February 2008 to December 2009, emergency intensive care admissions ≥6 weeks of age underwent dilated retinal examination by either a pediatric ophthalmologist or RetCam (retinal photograph) imaging after written informed consent. Patients with suspected or proven AHT, penetrating eye trauma, and elective admissions were excluded. RESULTS: The prevalence of RH was 15.1% (24/159; 95% confidence interval [CI]: 9.5%–21%); 16/24 (66%) mild, and 2/24 (8%) moderate. Severe multilayered RH were seen in only 6 patients (3.7%), 3 with myeloid leukemia and sepsis, 2 with severe accidental head injury, and 1 with severe coagulopathy secondary to late onset hemorrhagic disease of newborn. There was no detectable impact of age, gender, seizures, coagulopathy or cardiopulmonary resuscitation on prevalence of severe multilayered RH; however, sepsis (odds ratio: 3.2; 95% CI: 1.3–8.0, P = .018) and coagulopathy (odds ratio: 2.8; 95% CI: 1.2–7.0, P = .025) were significantly associated with any RH. Only admission diagnosis was independently associated with severe multilayered RH on logistic regression. CONCLUSIONS: RHs were seen in critically ill children with a prevalence of 15.1% (24/159); however, most were mild. Severe multilayered RH resembling those described in AHT were rare (6/24) and were only seen in patients with fatal accidental trauma, severe coagulopathy, sepsis with myeloid leukemia, or a combination of these factors.

Life-threatening hypernatraemic dehydration in breastfed babies

We describe five babies, who were exclusively breast fed, with life-threatening complications of hypernatraemic dehydration secondary to inadequate breast feeding. An increased awareness among health professionals is required so that this potentially devastating condition can be prevented.