Lia Lowrie

Optimal sedation of mechanically ventilated pediatric critical care patients.

Objective: To derive a target range of optimal sedation for the COMFORT Scale and to prospectively test that target range against intensivist assessment of adequacy of sedation. Design: Serial prospective agreement cohort studies. Setting: Twelve‐bed pediatric intensive care unit in an urban academic teaching hospital. Patients: Eighty‐five mechanically ventilated children (aged 0 to 102 months). Interventions: Three serial prospective studies comparing simultaneous, independent ratings conducted by trained observers using an objective scale and intensive care physicians using global assessment. The initial study was designed to derive the target range. The second study was conducted to verify that target range in a second population. The third study was added to evaluate relative variability in methods used in the second study. Measurements and Main Results: Adequacy of sedation using visual analog scale and descriptive ratings or the COMFORT Scale (a previously validated behaviorally anchored scale to rate eight behavioral or physiologic dimensions of distress). The first study comprised 100 observations. Groups of patients described by the intensivist as inadequately sedated, optimally sedated, and excessively sedated had different mean COMFORT scores (30.5 ± 0.7 vs. 22.9 ± 5.8 vs. 14.3 ± 0.7, respectively, p < .05). The target range of optimal sedation was defined as COMFORT scores of 17 to 26. The second study verified the target range prospectively in a second group of 96 observations. The COMFORT score was strongly associated with the sedation adequacy rating by the intensivist (p < .001; r2 = .662). COMFORT scores accurately predicted the patient assignment to adequacy of sedation categories by the intensivist in 66.1% of observations. Discrepancy between physicians occurred in 38.5% of 16 paired physician ratings in the second study. In the third study, 120 observations comparing paired COMFORT scores to paired physician ratings of the same subjects demonstrated significantly less variability in COMFORT assessment of adequacy of sedation. COMFORT scores were similarly unbiased (1.1% vs. 0.22%) but more precise (8.0% vs. 16.7%) than intensivist ratings (p < .025). Conclusion: Adequacy of sedation is measured more consistently by observers using the COMFORT Scale than by intensivist global assessment. (Crit Care Med 1994; 22:163‐170)

Extubation failure in pediatric intensive care: A multiple-center study of risk factors and outcomes

ObjectiveTo determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure. DesignTwelve-month prospective, observational, clinical study. SettingSixteen diverse PICUs in the United States. PatientsPatients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial. InterventionsNone. Measurements and Main ResultsA descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3–7.1). Patient features associated with extubation failure (p < .05) included age ≤24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, sd ± 207.8 vs. success, 107.9 hrs, sd ± 171.3; p < .001), longer PICU length of stay (17.5 days, sd ± 15.6 vs. 7.6 days, sd ± 11.1; p < .001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%; p < .001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not. ConclusionA variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.

Renal replacement therapies in pediatric multiorgan dysfunction syndrome.

Abstract Both peritoneal dialysis (PD) and continuous hemodiafiltration (CHDF) techniques are used in children who develop acute renal failure as part of multiorgan dysfunction syndrome (MODS). An important goal of renal support in MODS is treatment and prevention of fluid overload. This report describes an experience with PD and CHDF in children with MODS and presents an analysis of fluid balance for each modality. Medical records of patients with MODS treated with PD/CHDF were reviewed. Fluid balance was studied only in patients with documented fluid overload treated with PD/CHDF for more than 24 h. Successful fluid control was defined as more fluid output than input over the course of PD/CHDF. CHDF was used in 37 patients, median age 47 months (range 0.2–284 months), for a mean of 110 h (range 4–733 h). PD was initiated in 25 patients, median age 4 months (range 0.1–156 months), for a mean of 145 h (range 7–992 h). Successful fluid control was achieved in 17 of 26 (65%) CHDF patients and in 5 of 14 (36%) PD patients (P<0.01, chi-squared). In conclusion, CHDF is more effective than PD in treating and preventing fluid overload in children with MODS.

Physiologic Monitoring Practices During Pediatric Procedural Sedation: A Report From the Pediatric Sedation Research Consortium

OBJECTIVES To describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation; to describe how physiologic monitoring varies among different classes of patients, health care providers (ie, ranging from anesthesiologists to emergency medicine physicians to nurse practitioners), procedures, and sedative medications employed; and to determine the proportion of sedations meeting published guidelines for physiologic monitoring. DESIGN This was a prospective, observational study from September 1, 2007, through March 31, 2011. SETTING Data were collected in areas outside of the operating room, such as intensive care units, radiology, emergency departments, and clinics. PARTICIPANTS Thirty-seven institutions comprise the Pediatric Sedation Research Consortium that prospectively collects data on procedural sedation/anesthesia performed outside of the operating room in all children up to age 21 years. MAIN OUTCOME MEASURES Data including demographics, procedure performed, provider level, adverse events, medications, and physiologic monitors used are entered into a web-based system. RESULTS Data from 114 855 subjects were collected and analyzed. The frequency of use of each physiologic monitoring modality by health care provider type, medication used, and procedure performed varied significantly. The largest difference in frequency of monitoring use was seen between providers using electrocardiography (13%-95%); the smallest overall differences were seen in monitoring use based on the American Society of Anesthesiologists classifications (1%-10%). Guidelines published by the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists for nonanesthesiologists were adhered to for 52% of subjects. CONCLUSIONS A large degree of variability exists in the use of physiologic monitoring modalities for pediatric procedural sedation. Differences in monitoring are evident between sedation providers, medications, procedures, and patient types.

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium

To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation.

Great Expectations—Defining Quality in Pediatric Sedation: Outcomes of a Multidisciplinary Consensus Conference

Purpose:Recognizing the inconsistencies in sedation practices, the Society for Pediatric Sedation convened this meeting to begin the process of defining quality as it relates to the field of pediatric sedation. Scope:Millions of procedures are performed each year on children. Caring for children, even for routine procedures, can be challenging. Children may not have the ability to follow commands, tolerate painful stimuli, or even lie still for a diagnostic study. Therefore, pharmacologic sedation with medications designed to blunt the awareness of the patient and provide relief of pain and anxiety is necessary. Methods:A multidisciplinary group of sedation providers and quality methodology experts met in November 2011. Through 2 days of didactics, small workgroups, and consensus discussions, the attendees met the objectives of exploring quality in pediatric sedation around the Institute of Medicines (IOM, 2001) six aims of quality: Safe, Effective, Patient Centered, Timely, Efficient, and Equitable. Results:The conference findings outlined in this document address the Agency for Healthcare Research and Qualitys (AHRQ) mission of improving quality healthcare for all Americans, especially for underrepresented groups such as children. The conference outlines a key next step in defining and achieving quality in pediatric procedural sedation.

Diuretic therapy of heart failure in infants and children

Diuretics are the mainstay of traditional therapy for congestive heart failure. The syndrome of heart failure is now understood to involve complex interactions of neurohumoral substances released in response to poor cardiac function. Developmental changes during infancy and childhood will affect both the activation of systemic neurohumoral responses and the pharmacokinetic and pharmacodynamic actions of diuretics. Few human studies directly evaluate the efficacy of diuretic therapy in heart failure in adults. The pharmacodevelopmental aspects of diuretic therapy in infants and children are also incompletely studied. This review will describe the kidneys role in the pathogenesis of sodium and water retention in heart failure and the developmental changes in the kidney related to fluid retention. Known principles of diuretic therapy in congestive heart failure will be described. All these factors can then be used by the reader to evaluate the role of diuretic therapy in the complex syndrome of heart failure in infants and children.

Development, implementation, and initial participant feedback of a pediatric sedation provider course.

Background: No standardized educational curriculum exists for pediatric sedation practitioners. We sought to describe the curriculum and implementation of a pediatric sedation provider course and assess learner satisfaction with the course curriculum. Description: The course content was determined by formulating a needs assessment using published sedation guidelines, reports of sedation related adverse events, and a survey of sedation practitioners. Students provided feedback regarding satisfaction with the course immediately following the course and 6 months later. Evaluation: The course consisted of 5 didactic lectures, 1 small-group session, 6 simulation scenarios, a course syllabus, and a written examination. The course was conducted over 1 day at 3 different locations. Sixty-nine students completed the course and were uniformly satisfied with the course curriculum. Conclusions: A standardized pediatric sedation provider course was developed for sedation practitioners and consisted of a series of lectures and simulation scenarios. Overall satisfaction with the course was positive.

Assessment of Sedation Depth

Dosing of medications for sedation and analgesia has always been based on a clinical assessment of patient response. The proliferation of medications with specific hypnotic or analgesic effects and the continued development of diagnostic and therapeutic procedures requiring some degree of patient sedation and pain control have resulted in wide variations in management. Although toxicity and safety are easily monitored by trained clinicians using standard cardiopulmonary equipment, efficacy is more difficult to standardize. The desired “level” of sedation and analgesia depends on the psychological and physiological state of the patient and the procedure being performed, and varies during the procedure itself.