Mayer Sagy

Continuous infusion of ketamine in mechanically ventilated children with refractory bronchospasm.

ObjectiveTo determine whether ketamine infusion to mechanically ventilated children with refractory bronchospasm is beneficial.DesignRetrospective chart review.SettingPediatric intensive care unit (PICU) of a childrens hospital.PatientsSeventeen patients, ages ranging from 5 months to 17 years (mean 6±5.7 years), were admitted to our PICU over a 3-year period and received ketamine infusion during a course of mechanical ventilation. The patients had acute respiratory failure associated with severe bronchospasm due to status asthmaticus (n=11), bronchiolitis caused by respiratory syncytial virus (n=4), and bacterial pneumonia (n=2).InterventionsAll patients had been mechanically ventilated for 1–5 days (2.2±1.5 days) and received conventional treatment to relieve bronchospasm for more than 24 h prior to the initiation of ketamine treatment. An intravenous bolus of ketamine of 2 mg/kg, followed by continuous infusions of 20–60 μg/kg per minute (32±10 μg/kg per minute) was administered to all patients without changing their preexisting bronchodilatory regimen. Benzodiazepines were also given intravenously to all patients during the ketamine treatment.Measurements and main resultsThe PaO2/FIO2 ratio in all patients (n=17) and the dynamic compliance in the volume-preset mechanically ventilated patients (n=12) were calculated. The PaO2/FIO2 ratio increased significantly from 116±55 before ketamine, to 174±82, 269±151, and 248±124 at 1, 8, and 24 h respectively, after the initiation of the ketamine infusion (p<0.0001). Dynamic compliance increased from 5.78±2.8 cm3/cmH2O to 7.05±3.39, 7.29±3.37, and 8.58±3.69, respectively (p<0.0001). PaCO2 and peak inspiratory pressure followed a similar trend of improvement with ketamine administration. The mean duration of the ketamine infusion was 40±31 h. One patient required glycopyrrolate 0.4 mg/day to control excessive airway secretions and one patient required an additional dose of diazepam to control hallucinations while emerging from ketamine. All patients were successfully weaned from mechanical ventilation and discharged from the PICU.ConclusionContinuous infusion of ketamine to mechanically ventilated patients with refractory bronchospasm significantly improves gas exchange and dynamic compliance of the chest.

Use of Bilevel Positive Airway Pressure (BIPAP) in End-Stage Patients with Cystic Fibrosis Awaiting Lung Transplantation

Nine consecutive end-stage patients with cystic fibrosis (CF) awaiting lung transplantation were admitted to the pediatric intensive care unit (PICU) in respiratory decompensation. They all received noninvasive bilevel positive airway pressure (BIPAP) support and were evaluated to determine whether or not it improved their oxygenation and provided them with long-term respiratory stability. BIPAP was applied to all patients after a brief period of assessment of their respiratory status. Inspiratory and expiratory positive airway pressures (IPAP, EPAP) were initially set at 8 and 4 cm H2O respectively. IPAP was increased by increments of 2 cm H2O and EPAP was increased by 1 cm H2O increments until respiratory comfort was achieved and substantiated by noninvasive monitoring. Patients were observed in the PICU for 48 to 72 hours and then discharged to home with instructions to apply BIPAP during night sleep and whenever subjectively required. Regular follow-up visits were scheduled through the hospital-based CF clinic. The patients final IPAP and EPAP settings ranged from 14 to 18 cm H2O and 4 to 8 cm H2O, respectively. All nine patients showed a marked improvement in their respiratory status with nocturnal use of BIPAP at the time of discharge from the PICU. Their oxygen requirement dropped from a mean of 4.6 ± 1.1 L/min to 2.3 ± 1.5 L/min (P<0.05). Their mean respiratory rate decreased from 34 ± 4 to 28 ± 5 breaths per minute (P<0.05). The oxygen saturation of hemoglobin measured by pulse oximetry, significantly increased from a mean of 80% ± 15% to 91% ± 5% (P<0.05). The patients have been followed up for a period of 2 to 43 months and have all tolerated the use of home nocturnal BIPAP without any reported discomfort. Six patients underwent successful lung transplantation after having utilized nocturnal BIPAP for 2, 6, 14, 15, 26, and 43 months, respectively. Three patients have utilized home BIPAP support for 2, 3, and 19 months, respectively, and continue to await lung transplantation. An acute development of refractory respiratory failure resulted in the demise of the remaining three patients after having utilized BIPAP for 3, 6, and 10 months, respectively. The authors conclude that BIPAP therapy improves the respiratory status of decompensating end-stage CF patients. It is well tolerated for long-term home use and provides an extended period of respiratory comfort and stability for CF patients awaiting lung transplantation.

Utilizing a Pediatric Disaster Coalition Model to Increase Pediatric Critical Care Surge Capacity in New York City

A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).

(P1-78) Utilizing New York City Pediatric Disaster Coalition Site Visits to Create Hospital Pediatric Critical Care Surge Plans

Prehospital and Disaster Medicine Vol. 26, Supplement 1 (P1-78) Utilizing New York City Pediatric Disaster Coalition Site Visits to Create Hospital Pediatric Critical Care Surge Plans A. Flamm,1 G. Foltin,2 K. Uraneck,3 A. Cooper,4 B.M. Greenwald,5 E. Conway,6 K. Biagas,7 M. Sagy,1 M. Frogel1 1. Cohen Children’s Medical Center of New York, New York, United States of America 2. Center for Pediatric Emergency Medicine, New York, United States of America 3. Department of Health and Mental Hygiene, New York, United States of America 4. Trauma and Pediatric Surgical Services, New York, United States of America 5. Division of Pediatric Critical Care Medicine, New York, United States of America 6. Department of Pediatrics, New York, United States of America 7. New York, United States of America

Acute lung injury/Airway

Background Acute respiratory distress syndrome (ARDS) is a therapeutic challenge in pediatric intensive care in view of the high mortality. In 1992 about 50 German paediatric hospitals founded a working group aiming on collaborative clinical research in this field. Aim and methods The aim of both a prospective and retrospective survey conducted in German pediatric intensive care units in 1993 was to accumulate data on the epidemiology, risk factors, natural history and treatment strategies in a large group of pediatric ARDS patients who were treated in the three year period from 1991 to 1993.All patients had acute bilateral alveolar infiltration of noncardiogenic origin and a pO2/FiO2 ratio < 150mmHg. The influence of sex, underlying disease and single organ failure was analyzed using the Fischers exact test, the influence of additional organ failure on mortality was tested with the Cochran-Mantel-Haenszel statistics. Results 112 patients were reported giving an incidence of 7 cases per 1000 admissions to pediatric ICUs. Median age was 24 month. In 43% of the cases, ARDS was associated with a pulmonary, in 39% with a systemic underlying disease. In 20% immunocompetence was impaired. Mortality was 46% and not dependent on age, sex and triggering event. The number of associated organ failures, however, strongly influenced mortality. Mortality in immunocompromised patients was 81%. The Analysis of treatment modalities employed in the patients revealed a lack of uniform therapeutic strategies. On the other hand, the patients were exposed to interventions not yet supported by controlled trials. Conclusions The observation of the lack of uniform treatment strategies led to the elaboration of recommendations on ventilator therapy and patient monitoring within the working group. The data gathered in this survey provide the basis for the design of prospective multicenter studies urgently needed to evaluate innovative treatment modalities in pediatric ARDS.