Emily L. Dobyns

Hospitalized children with 2009 pandemic influenza A (H1N1): comparison to seasonal influenza and risk factors for admission to the ICU.

Background Limited data are available describing the clinical presentation and risk factors for admission to the intensive care unit for children with 2009 H1N1 infection. Methods We conducted a retrospective chart review of all hospitalized children with 2009 influenza A (H1N1) and 2008–09 seasonal influenza at The Childrens Hospital, Denver, Colorado. Results Of the 307 children identified with 2009 H1N1 infections, the median age was 6 years, 61% were male, and 66% had underlying medical conditions. Eighty children (26%) were admitted to the ICU. Thirty-two (40%) of the ICU patients required intubation and 17 (53%) of the intubated patients developed acute respiratory distress syndrome (ARDS). Four patients required extracorporeal membrane oxygenation. Eight (3%) of the hospitalized children died. Admission to the ICU was significantly associated with older age and underlying neurological condition. Compared to the 90 children admitted during the 2008–09 season, children admitted with 2009 H1N1 influenza were significantly older, had a shorter length of hospitalization, more use of antivirals, and a higher incidence of ARDS. Conclusions Compared to the 2008–09 season, hospitalized children with 2009 H1N1 influenza were much older and had more severe respiratory disease. Among children hospitalized with 2009 H1N1 influenza, risk factors for admission to the ICU included older age and having an underlying neurological condition. Children under the age of 2 hospitalized with 2009 H1N1 influenza were significantly less likely to require ICU care compared to older hospitalized children.

Evaluation of a Scoring System for Assessing Prognosis in Pediatric Acute Liver Failure

BACKGROUND & AIMS Pediatric acute liver failure (PALF) results in death or need for liver transplantation (LT) in up to 50% of patients. A scoring system for predicting death or LT (Liver Injury Units [LIU] score) in PALF was previously derived by our group, and used peak values during hospital admission of total bilirubin, prothrombin time/international normalized ratio, and ammonia as significant predictors of outcome. The aims of this study were to test the predictive value of the LIU score in a subsequent validation set of patients and to derive a hospital admission LIU (aLIU) score predictive of outcome. METHODS Data were obtained from 53 children admitted with PALF from 2002 to 2006. Outcome was defined at 16 weeks as alive without LT, death, or LT. RESULTS Survival without LT at 16 weeks for each LIU score quartile was 92%, 44%, 60%, and 12%, respectively (P < .001). The receiver operating characteristic C index for predicting death or LT by 4 weeks was 86.3. An admission LIU score was derived using admission total bilirubin and prothrombin time/international normalized ratio. Survival without LT at 16 weeks for each quartile using the aLIU score was 85%, 77%, 69%, and 31% (P = .001). The receiver operating characteristic C index for predicting death or LT by 4 weeks was 83.7. CONCLUSIONS The original LIU score is a valid predictor of outcome in PALF. The aLIU score is promising and needs to be validated in subsequent patients.

Elevated plasma endothelin-1 and cytokine levels in children with severe acute respiratory distress syndrome.

We performed serial measurements of plasma endothelin-1 and cytokine levels (interleukin-1, interleukin-6, and tumor necrosis factor-alpha) in 23 children with severe acute respiratory distress syndrome during their first 7 days of disease. We report plasma endothelin-1 and interleukin-6 levels are increased in patients with acute respiratory distress syndrome, and that plasma endothelin-1 levels are significantly greater early in the clinical course of nonsurvivors than survivors. We conclude that plasma endothelin-1 levels are markedly increased in children with severe acute respiratory distress syndrome and speculate that high levels may serve as an early marker of poor outcome.

Infant lung function after inhaled nitric oxide therapy for persistent pulmonary hypertension of the newborn

Our objectives were to determine whether the use of inhaled nitric oxide (iNO) for severe persistent pulmonary hypertension of the newborn (PPHN) causes impaired lung function during infancy. We therefore performed a prospective study of lung function in 22 infants after neonatal intensive care unit (NICU) discharge who had been treated for severe persistent pulmonary hypertension of the newborn (PPHN) with (n = 15) or without (n = 7) iNO, and compared these findings in lung function to those of healthy control infants (n = 18). Five infants with interstitial lung disease (ILD) were included to assure that the pulmonary function tests (PFT) were sensitive enough to detect abnormalities of lung function in this age group. We measured passive respiratory mechanics and functional residual capacity (FRC) using a commercially available system. All data were expressed as means and standard deviation. Statistical analysis was performed by analysis of variance (ANOVA). A Bonferroni multiple comparisons test was used for variables that showed overall group differences.

An Interdisciplinary Initiative to Reduce Unplanned Extubations in Pediatric Critical Care Units

OBJECTIVE: Unplanned extubations in pediatric critical care units can result in increased mortality, morbidity, and length of stay. We sought to reduce the incidence of these events by reliably measuring occurrences and instituting a series of coordinated interdisciplinary interventions. METHODS: This was an internal review board–approved quality improvement project. Data were prospectively collected from the electronic medical record, and analyzed over 24 months (January 1, 2009–December 2010), and divided into 3 periods: baseline (9 months), intervention with multiple rapid improvement cycles (8 months), and postintervention (7 months). Interventions included standardization of endotracheal tube taping practices upon admission, improved patient handoffs, systematic review of unplanned events, reexamination of sedation practices, and promotion of transparency of performance measures. RESULTS: The PICU experienced 21 events in the 9 months before the initiative, 13 events over the 8-month intervention period, and 5 events in the 7-month postintervention period. The cardiac intensive care unit (CICU) experienced 11, 4, and 0 events, respectively. Mean event rates per 100 patient days for each interval were 0.80, 0.50, and 0.29 for the PICU and 0.74, 0.44, and 0 for the CICU. Monthly event rates for the CICU were significantly different by using the Kruskal-Wallis test (P < .05) but not for the PICU (P = .36) CONCLUSIONS: Through accurate tracking, multiple practice changes, and promoting transparency of efforts and data, an interdisciplinary team reduced the number of unplanned extubations in both ICUs. This reduction has been sustained throughout the postintervention monitoring period.

Thrombosis risk factor assessment and implications for prevention in critically ill children.

Objectives: To describe nursing compliance with a computer-based pediatric thrombosis risk assessment tool; to generate an estimate of risk factors present in our population; and to explore relationships between risk factors and confirmed thrombotic events. Design: Institutional review board-approved prospective, observational cohort study. Setting: Pediatric intensive care unit within a tertiary care children’s hospital. Patients: All infants and children admitted to the pediatric intensive care unit during a 6-month study period (January 1, 2010–June 30, 2010). Measurements and Main Results: Eight hundred admissions were enrolled, representing 742 patients. Thrombosis risk assessment scores were recorded for 707 admissions (88% of total). Mean age = 6.95 ± 6 yrs, mean weight = 28 ± 23 kg, 45% female. A total of 32 thrombi (14 prehospital and 18 in-hospital) were present in the study group. This translated to an overall occurrence rate of 4.3% (1.9% for prehospital and 2.4% for in-hospital). Logistic regression identified that for every 1-point increase in total thrombosis score, the risk of developing a symptomatic thrombus increased by 1.57-fold (95% confidence interval 0.192–5.5) to 2.12-fold (95% confidence interval 0.175–18.34), for prehospital and in-hospital thrombi, respectively (p < .05). The most important risk factors identified for development of any thrombus were thrombophilia (acquired or inherited) (p < .001), presence of a central catheter (p = .01), and age <1 or >14 yrs (p = .052). Conclusions: Incorporation of a scoring system into the bedside nursing assessment flow sheet was successful and identified children at risk for in-hospital thrombosis. The overall score appears to be most indicative of thrombus risk. These data may serve as a platform for future development of routine screening and possible interventional trials in critically ill children.

Persistent Hiccups Associated with Epidural Ropivacaine in a Newborn

OBJECTIVE: To report a case of persistent hiccups associated with epidural ropivacaine in a newborn infant. CASE SUMMARY: A term female infant (3.05 kg) received epidural ropivacaine for pain control during and after an operative procedure to correct a tracheoesophageal fistula. Three intermittent doses of ropivacaine were administered during the operative period (total dose 2.29 mg/kg) followed by a continuous epidural (caudal) infusion (0.1% ropivacaine; initial dose 0.23 mg/kg/h plus fentanyl 0.46 μg/kg/h). The infant was extubated in the recovery area and transferred to the intensive care unit. Within hours of transfer, she developed persistent hiccups. The epidural infusion was titrated for pain control, up to 0.32 mg/kg/h (ropivacaine). The hiccup frequency increased to every 10-30 seconds, with the patient appearing hypotonic with lip trembling and intermittent tongue fasciculation. An electroencephalogram did not show any epileptiform activity or focal features consistent with seizure activity. The epidural infusion was reduced to 0.26 mg/kg/h (ropivacaine), with dramatic improvement in hiccups and tone. The infusion was discontinued and complete resolution of hiccups was observed. DISCUSSION: Ropivacaine is commonly used for infiltration anesthesia and peripheral and epidural block anesthesia. Use of the Naranjo probability scale determined that our patients hiccups were probably caused by ropivacaine. To our knowledge, this is the first report of persistent hiccups associated with epidural ropivacaine. CONCLUSIONS: Clinicians should consider the potential of neurotoxicity, manifested as persistent hiccups, when epidural ropivacaine is administered to young infants.

Elevated Plasma Endothelin-1 Levels in Children with Severe Acute Respiratory Distress Syndrome

Elevated Plasma Endothelin-1 Levels in Children with Severe Acute Respiratory Distress Syndrome

Multicenter Randomized Trial of the Effects of Inhaled Nitric Oxide Therapy on Gas Exchange in Children with Acute Hypoxemic Respiratory Failure • 189

Multicenter Randomized Trial of the Effects of Inhaled Nitric Oxide Therapy on Gas Exchange in Children with Acute Hypoxemic Respiratory Failure • 189

FOLLOW-UP PULMONARY FUNCTION IN INFANTS AFTER INHALED NITRIC OXIDE TREATMENT OF PERSISTENT PULMONARY HYPERTENSION. 2294

Although inhaled nitric oxide (iNO) is used in the treatment of persistent pulmonary hypertension of the newborn (PPHN), little is known of its potential long term toxic effects. By decreasing intrapulmonary and extrapulmonary shunt iNO may decrease lung injury due to barotrauma and oxygen toxicity. Despite these benefits, there may be a potential risk of additional lung injury with NO therapy secondary to NO and the formation of NO related by-products(NO2, ONOO-). In this study we sought to determine if there were any differences in lung function of infants with PPHN treated with iNO compared to healthy control infants. Five infants (ages 6 to 9 mos) with a history of PPHN treated with iNO were compared with five normal control infants (5.5 to 6 mos of age). None of the infants were on home oxygen. Pulmonary function tests were performed using the Sensormedics 2600 Infant PFT system. Oxygen saturations were not different between study groups. Thus, NO treated infants at follow-up have normal lung mechanics, but mild elevation of FRC in comparison with normal controls. We conclude that these infants have normal lung mechanics but may have a tendency for gas trapping.Table