Jitladda Deerojanawong

Effect of frequency of ventilator circuit changes (3 vs 7 days) on the rate of ventilator-associated pneumonia in PICU

PURPOSE Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality in pediatric intensive care unit (PICU). Our purpose was to evaluate the effects of ventilator circuit change on the rate of VAP in the PICU. METHODS A prospective randomized controlled trial was conducted at a university hospital PICU. Children (younger than 18 years) who received mechanical ventilation from December 2006 to November 2007 were randomly assigned to receive ventilator circuit changes every 3 or 7 days. RESULTS Of 176 patients, 88 were assigned to receive ventilator circuit every 3 days and 88 patients had a change weekly. The rate of VAP was 13.9/1000 ventilator days for the 3-day circuit change (n = 12) vs 11.5/1000 ventilator days (n = 10) for the 7-day circuit change (odds ratio, 0.8; confidence interval, 0.3-1.9; P = .6). There was a trend toward decreased PICU stay and mortality rate in 7-day change group compared to 3-day change group but did not reach statistical significance. Furthermore, switching from a 3-day to a 7-day change policy could save costs up to US

Incidence and risk factors of upper gastrointestinal bleeding in mechanically ventilated children.

22,000/y. CONCLUSIONS The 7-day ventilator circuit change did not contribute to increased rates of VAP in our PICU. Thus, it may be used as a guide to save workload and supply costs.

Levels of protein C activity and clinical factors in early phase of pediatric septic shock may be associated with the risk of death.

Objective: To identify the incidence and factors related to upper gastrointestinal (UGI) bleeding in children requiring mechanical ventilation for longer than 48 hrs. Design: Prospective analytic study. Setting: Ten-bed-pediatric intensive care unit of a tertiary care University Hospital. Patients: A total of 110 patients requiring mechanical ventilation for longer than 48 hrs from January 1, 2005 to December 31, 2005. Measurements and Results: UGI bleeding was defined by evidence of blood in nasogastric aspirates, hematemesis, or melena within 5 days of pediatric intensive care unit admission. We prospectively collected data on patient demographics, admission diagnosis, operative status, and pediatric risk of mortality score. UGI bleeding and the potential risk factors including organ failure, coagulopathy, maximum ventilator setting, enteral feeding, stress ulcer prophylaxis as well as sedation were daily monitored. Of the 110 patients who required mechanical ventilation for >48 hrs, the incidence of UGI bleeding was 51.8%, in which 3.6% of the cases presented with clinically significant bleeding (shock, requiring blood transfusion and/or surgery). Significant risk factors were thrombocytopenia, prolonged partial thromboplastin time, organ failure, high pressure ventilator setting ≥25 cm H2O, and pediatric risk of mortality score ≥ 10 using univariate analysis. However, the independent factors of UGI bleeding in the multivariate analysis were organ failure (relative risk = 2.85, 95% confidence interval 1.18–6.92) and high pressure ventilator setting ≥25 cm H2O (relative risk = 3.73, 95% confidence interval 1.59–8.72). Conclusion: The incidence of UGI bleeding is high in children requiring mechanical ventilation. Organ failure and high pressure ventilator setting are significant risk factors for UGI bleeding.

Disseminated cytomegalovirus infection associated with Pneumocystis carinii pneumonia in a previously normal infant.

Severe sepsis and septic shock are major causes of morbidity and mortality among children in pediatric intensive care units (PICUs) worldwide. Activated protein C (PC) is a critical endogenous regulator of coagulation and inflammation in patients with sepsis. However, the role of PC in pediatric sepsis is still obscure. We prospectively recruited infants and children aged between 1 month and 15 years old who were admitted to PICU with a clinical diagnosis of systemic inflammatory response syndrome, sepsis, or septic shock. Clinical data were recorded and blood samples kept for further analysis. We then measured the levels of PC activity. Of the approximately 1,100 pediatric patients admitted to PICU from January 1, 2004 to December 31, 2005, 75 were diagnosed with septic shock (6.8%), and 67 samples were available for analysis. Out of these, 41 (61%) were survivors, and 26 (39%) were nonsurvivors. The average plasma PC activity (%) was at 37.8 ± 4.4. Plasma PC activity (%) was significantly lower in the nonsurvivors compared with the survivors at 23.6 ± 4.3 and 46.8 ± 6.3 (P = 0.002), respectively. D-Dimer levels were not significantly different between the survivors (1,461 ± 266 ng/mL) and the nonsurvivors (1,989 ± 489 ng/mL) (P = 0.68). Also, there was no correlation between plasma PC activity and D-dimer levels (r = −0.07; P = 0.6). Importantly, the odds of dying were significantly higher in patients whose level of PC activity was less than 25% (odds ratio = 5.6; P = 0.02). Pediatric patients with septic shock demonstrate very low levels of PC activity, and this may be associated with an increased risk of death.Abbreviations-PICU-pediatric intensive care unit; rhAPC-Recombinant human activated protein C; APC-Activated protein C; PC-Protein C; PRISM-score Pediatric risk of mortality score; SIRS-Systematic inflammatory response syndrome; PCR-Polymerase chain reaction; PT-Prothrombin time; PTT-Partial thromboplastin time; iCa-ionized calcium

Smooth muscle progenitor cells involved in the development of airway remodeling in a murine model of asthma.

We reported a rare case of dual opportunistic infections of Pneumocystis carinii pneumonia and disseminated cytomegalovirus (CMV) infection in a previously normal female infant. Transient T-cell dysfunction was demonstrated and returned to normal after treatment of CMV infection.

Multidrug-resistant hospital-associated infections in a pediatric intensive care unit: a cross-sectional survey in a Thai university hospital

BACKGROUND The mechanisms regulating airway remodeling changes remain poorly understood. Recently, a smooth muscle progenitor cell was identified in the peripheral circulatory system that plays an important role in the reconstruction of injured blood vessels. However, to the best of our knowledge, there is no report in the medical literature regarding the role of smooth muscle progenitor cells (SPCs) in asthma. OBJECTIVE The aim of this study was to investigate the relationship between SPCs and the development of airway remodelling in a murine model of asthma. METHODS Chronic asthma with airway remodeling was generated by sensitizing and stimulating BALB/c mice with atomized ovalbumin (OVA). Bronchoalveolar lavage fluid (BALF) was collected for eosinophils (EOS) counting and histological analysis. The Ficoll method was used to isolate mononuclear cells from peripheral blood. Smooth muscle myosin heavy chain (SM-MHC) and highly glycosylated type I transmembrane protein (CD34⁺) were selected as two markers to detect the expression of SPCs by Flow Cytometry. RESULTS Long-term inhalation of OVA produced thickening of the epithelial and smooth muscle layer, goblet cell hyperplasia, collagen deposition around smooth muscle, luminal exudates and inflammatory cell infiltration. The number of SPCs in the asthma group was significantly higher than in the control group. CONCLUSION Long-term inhalation of OVA results in airway remodeling and the smooth progenitor muscle cell are involved in the development of airway remodeling.BACKGROUND Little is known about the level of asthma control in Thai elementary school students living in the inner city of Bangkok. Our study aimed to evaluate the prevalence of asthma, level of asthma control and factors associated with asthma control in Thai students. METHODS We conducted a cross-sectional descriptive study in students aged between 6-12 years at 3 public schools and 3 private schools in Bangkok. The parent-completed questionnaire used to assess the prevalence of asthma and asthma symptoms was translated from the Phase I ISAAC (The International Study of Asthma and Allergies in Childhood) questionnaire. Univariate analysis was used to identify possible risk factors related to partly and uncontrolled asthma. RESULTS A population of 1,428 students was recruited by screening questionnaires (66.1% of response rate). The mean age was 9.5 years. Prevalence of physician-diagnosed asthma was 9% and the most common asthma symptom was night cough (23.8%). The level of asthma control was assessed in students with current asthma and classified as controlled (46.7%), partly controlled (43.3%) and uncontrolled (10%). Around 27% of students with current asthma in this study use controller medications. Factors associated with asthma control were analyzed but none approached significance. CONCLUSIONS The prevalence of asthma in elementary school students living in Bangkok has decreased since the previous survey and the use of controller medications has increased. Asthma management strategies should focus on encouraging awareness among physicians and parents about the importance of using controller medications to achieve better control of asthma.

Optimal level of physical activity in children with chronic lung diseases

OBJECTIVE To determine the incidence and associated factors of multidrug-resistant hospital-associated infections (MDR-HAI) in a pediatric intensive care unit (PICU) of a university hospital in Thailand. METHOD A prospective study was performed in the PICU of King Chulalongkorn Memorial Hospital during the period May-December 2005. Children aged < or = 15 years who developed a PICU-related HAI were studied. RESULTS Forty-four patients (median age 6 months; male:female = 1.4:1) developed 58 episodes of PICU-related HAI. The HAI rate was 28.3 per 1000 patient-days. Thirty episodes (52%) were MDR-HAI. The following were found more frequently in MDR-HAI when compared to non-MDR-HAI: Acinetobacter baumannii (50% vs. 23%, p = 0.04), female sex (60% vs. 29%, p = 0.02), admission to the PICU with a medical condition (90% vs. 64%, p = 0.03), PICU stay longer than 7 days prior to the development of HAI (67% vs. 36%, p = 0.03), and previous use of broad-spectrum antibiotics (83% vs. 43%, p = 0.002). Independent risk factors for MDR-HAI included female sex (OR = 5.5, p = 0.03) and previous use of a broad-spectrum antibiotic (OR = 9.7, p = 0.01). CONCLUSION The incidence of MDR-HAI was high in the PICU. Female sex and previous use of a broad-spectrum antibiotic were independent risk factors for MDR-HAI.

Does nebulized hypertonic saline shorten hospitalization in young children with acute viral wheezing

Aim: To determine the optimal level of physical activity and its relationship with disease severity in children with chronic lung diseases (CLD).

Mechanical Insufflation-Exsufflation Versus Conventional Chest Physiotherapy in Children With Cerebral Palsy

Although previous studies have shown benefits of nebulized hypertonic saline (HS) for improving airway clearance and shortening hospitalization in infants with bronchiolitis, prospective blinded studies in preschool children with acute viral wheezing are limited.

Exhaled nitric oxide, pulmonary function, and disease activity in children with systemic lupus erythematosus

BACKGROUND: The cough mechanism is often impaired in children with quadriplegic spastic cerebral palsy, accounting for the high prevalence of pneumonia and atelectasis requiring prolonged hospitalization. Conventional chest physiotherapy (CPT) is a current technique recommended at the onset of lower-respiratory infections in cerebral palsy. Previous studies have demonstrated the usefulness of mechanical insufflation-exsufflation (MI-E) in children with neuromuscular disease. To date, there has been no study of MI-E in children with quadriplegic spastic cerebral palsy. The objective of the study is to compare the efficacy in reducing hospital stay and improvement of atelectasis between MI-E and CPT in children with quadriplegic spastic cerebral palsy with lower-respiratory infections. METHODS: This study is a randomized controlled trial. Children with quadriplegic spastic cerebral palsy, age 6 months to 18 y, admitted for lower-respiratory infections and/or atelectasis at King Chulalongkorn Memorial Hospital between June 1, 2014, and March 31, 2015, were recruited. Those with pneumothorax, severe pneumonia, active tuberculosis, and shock were excluded. Children were randomized into the MI-E or CPT group. The MI-E group received MI-E (3 therapies/d), and the CPT group received CPT (1 therapy/d). Vital signs per protocol and chest radiograph as needed were recorded. RESULTS: There were 22 children enrolled in the study, 11 in the MI-E and 11 in the CPT group. Demographic data were comparable in both groups. The length of hospital stay was similar in both groups (MI-E 4–24 d vs CPT 6–42 d, P = .15). There were 17 subjects with atelectasis (MI-E [n = 9] versus CPT [n = 8]). In this atelectasis subgroup, MI-E had shortened therapy time when compared with CPT (2.9 ± 0.8 d vs 3.9 ± 0.6 d, P = .01). No complications were observed. CONCLUSIONS: MI-E is proven to be beneficial in shortening the duration of airway clearance in children with quadriplegic spastic cerebral palsy presenting with lower-respiratory infections and atelectasis. MI-E is a safe and efficient intervention for airway clearance.