Peter Silver

Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation.

OBJECTIVE To test the hypothesis that the need to attain immobility during pediatric sedation for procedures determines the depth of sedation, which cannot always be predicted. DESIGN A retrospective review of sedation documents of 301 consecutive sedations of pediatric patients undergoing various procedures SETTING Division of Critical Care sedation service within a childrens hospital. MEASUREMENTS AND MAIN RESULTS The medical records and sedation forms of our most recent 301 consecutive sedations were retrospectively reviewed. Based on the data gathered, the patients were categorized according to their achieved level of immobility, their level of consciousness according to the definitions of the American Academy of Pediatrics, the procedures for which sedation was administered, and the sedatives used. A total of 125 males and 89 females received 301 sedations. Their ages ranged from 22 days to 29 years (mean 7 y + 6 y). We recognized four categories of immobility for procedures. In category 1, some motion was allowed during painless and noninvasive procedures to the extent that it did not risk the patient nor hinder the successful performance of the procedures. In category 2, the patients were kept motionless during painless and noninvasive procedures. In category 3, the patients were kept motionless during painful and invasive procedures with the addition of local anesthetic. In category 4, the patients remained motionless throughout their painful or invasive procedure without the use of local anesthetics. There were 32, 10, 156 and 103 sedations in each category, respectively. Conscious sedation (CS) was observed in six sedations (19%) in category 1 of immobility; it was observed in none (0%) in category 2, in 4 sedations (2.6%) in category 3, and in 1 sedation (1%) in category 4. Deep sedation (DS) was noted in 26 category 1 sedations (81%), in 10 category 2 sedations (100%), in 136 category 3 sedations (87%), and in 63 category 4 sedations (61%). General anesthesia (GA) was only observed in categories 3 and 4 in 16 sedations (10%) and 39 sedations (38%), respectively. Intravenous (IV) ketamine, as a single agent or in combination with other agents, was the most frequently used sedative (88%) followed by IV benzodiazepines (64%), propofol (39%), opiates (15%), and barbiturates (5%). A total of 59 (19%) adverse events were encountered during the 301 sedations. In categories 1 and 2, no adverse event (0%) was encountered. In category 3, 19 adverse events took place (32%), and 40 adverse events (68%) (P< 0.05) occurred in category 4. CONCLUSIONS Pediatric sedation results in 4 categories of immobility. Complete immobility during painful and invasive procedures is associated with a higher incidence of adverse events. The depth of sedation (ie, CS, DS, or GA) required to achieve each category of immobility is unpredictable and varies from patient to patient. Thus, granting a limited sedation authority (conscious sedation only) to physicians may be of limited practical value.

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.

Continuous flow peritoneal dialysis as a method to treat severe anasarca in children with acute respiratory distress syndrome.

OBJECTIVE To describe a method of rapid fluid removal in children with anasarca and the acute respiratory distress syndrome (ARDS) secondary to sepsis or the systemic inflammatory response syndrome. DESIGN Consecutive case series. SETTING Pediatric Intensive Care Unit of a childrens hospital. PATIENTS Six patients with ARDS secondary to sepsis or systemic inflammatory response syndrome, who had persistent anasarca complicating their respiratory course despite intravenous diuretic therapy. INTERVENTIONS Continuous flow peritoneal dialysis (CFPD) was instituted after percutaneously inserting two Tenckhoff dialysis catheters into the peritoneal cavity of each patient and tunneling them through the subcutaneous tissue to exit from opposite lower abdominal quadrants. A dialysis solution with 2.5% dextrose was administered continuously via one of the catheters at a rate ranging from 10-30 mL/kg/hr, and concomitantly drained via the other catheter. The concentration of the dialysis solution and rate of inflow were adjusted as needed to achieve the desired peritoneal outflow rate. CFPD was discontinued when adequate weight loss had occurred and the patients daily urine output exceeded their daily fluid intake. The patients overall fluid balance and change in weight were recorded daily. The PaO2/FiO2 ratio, alveolar-arterial oxygen gradient, and oxygenation index were also calculated daily. MEASUREMENTS AND MAIN RESULTS Six patients with ARDS, mean age 18.7+/-37.0 months were mechanically ventilated for 8.0+/-4.0 days before CFPD, during which time average body weight increased to 63%+/-22% above admission body weight, despite the use of intravenous diuretic therapy. They underwent CFPD for 126.7+/-60.0 hrs, during which time their body weight decreased to 30%+/-12% above admission weight (p<.05). During dialysis, the dialysis outflow rate exceeded the inflow rate by 4.2+/-0.9 mL/kg/hr. When compared with values calculated immediately before starting CFPD, post-CFPD PaO2/FiO2 increased from 97.0+/-32.0 to 215.0+/-40.4 mm Hg (12.9+/-4.3 to 28.7+/-5.4 kPa) (p<.05), post-CFPD alveolar-arterial oxygen gradient decreased from 390.7+/-85.8 to 206.7+/-72.8 mm Hg (52.1+/-11.4 to 27.6+/-9.7 kPa) (p<.05), and post-CFPD the oxygenation index decreased from 29.6+/-9.8 to 11.8+/-5.6 (p<.05). There were no complications associated with dialysis catheter insertion or CFPD therapy. Four patients survived. Two patients had an irreversible course of infections and septic shock and died. CONCLUSION Severe anasarca in the course of ARDS can be effectively treated in pediatric patients with continuous flow peritoneal dialysis, resulting in a significant improvement in respiratory status.

Respiratory failure from corn starch aspiration: a hazard of diaper changing.

Corn starch powder is widely used for routine infant skin care as a substitute for talcum powder, as it is believed to have fewer respiratory hazards. We describe a one-month-old infant who presented to an emergency department with respiratory failure and a severe pneumonitis from aspiration of corn starch powder. The patient recovered after five days of mechanical ventilatory support. We conclude that careless use of corn starch for infant skin care can lead to accidental aspiration of this substance and severe respiratory disease.

The needle-wire-dilator technique for the insertion of chest tubes in pediatric patients

We evaluated the needle-wire-dilator (NWD) technique, using commercially available sets, for insertion of chest tubes in 24 pediatric patients who were admitted to our pediatric intensive care unit (PICU). Fourteen patients had pneumothoraces, three had hemothoraces, two had pneumonia with empyema, four had pleural transudate effusions, and one had chylothorax. The ages of the patients ranged from four months to 24 years, and the sizes of the inserted chest tubes ranged from 10F to 20F. All insertions were successful, and the time from invasion of the pleural space by the needle to completion of chest tube insertion and connection to the tubing drainage system ranged from four to seven minutes. In four patients the procedure had to be performed while a significant coagulopathy existed. However, none of the 24 patients developed hemorrhagic complications. The only complication observed was a kink in the chest tube in five patients, resulting in recurrence of pneumothorax in four and pleural effusion in one. These adverse occurrences were corrected by repositioning the chest tubes in three patients, and by replacing the chest tubes with the stiffer, trochar type, chest tubes in the other two. We conclude that the NWD technique for chest tube insertion is quick, safe, and easy to perform in all pediatric age groups. The commercially available chest tubes used in our study were somewhat softer than the trochar type chest tubes available, which explains the occurrence of kinks in some of them.

Transvenous right ventricular pacing during cardiopulmonary resuscitation of pediatric patients with acute cardiomyopathy

We describe the cardiopulmonary resuscitation efforts on five patients who presented in acute circulatory failure from myocardial dysfunction. Three patients had acute viral myocarditis, one had a carbamazepine-induced acute eosinophilic myocarditis, and one had cardiac hemosiderosis resulting in acute cardiogenic shock. All patients were continuously monitored with central venous and arterial catheters in addition to routine noninvasive monitoring. An introducer sheath, a pacemaker, and sterile pacing wires were made readily available for the patients, should the need arise to terminate resistant cardiac dysrhythmias. All patients developed cardiocirculatory arrest associated with extreme hypotension and dysrhythmias within the first 48 hours of their admission to the pediatric intensive care unit (PICU). Right ventricular pacemaker wires were inserted in all of them during cardiopulmonary resuscitation (CPR). In four patients, cardiac pacing was used, resulting in a temporary captured rhythm and restoration of their cardiac output. These patients had a second event of cardiac arrest, resulting in death, within 10 to 60 minutes. In one patient, cardiac pacing was not used, because he converted to normal sinus rhythm by electrical defibrillation within three minutes of initiating CPR. We conclude that cardiac pacing during resuscitative efforts in pediatric patients suffering from acute myocardial dysfunction may not have long-term value in and of itself; however, if temporary hemodynamic stability is achieved by this procedure, it may provide additional time needed to institute other therapeutic modalities.

An Analysis of the Daily Work-Rounding Process in a Pediatric Intensive Care Unit.

Objective: To complete an objective analysis of the activities that occur during the course of daily rounds in a high acuity academic tertiary care pediatric intensive care unit (PICU). Design: Prospective observational work sampling design. Setting: Tertiary care academic Childrens Hospital Pediatric Intensive Care Unit. Subjects: Multidisciplinary PICU teams. Interventions: None. Methods: Intensive care unit rounds were observed as part of an initiative to improve efficiency over a 2-month period. The number of observations required was determined by Neibels work sampling method. Rounds were broken into various constituent events and then later classified as “value-added/essential,” “value-added/nonessential,” and “nonessential” based on whether the observed event was essential to the core mission of PICU rounds. Results: The mean time spent per patient for all observed teams was 17.9 min (SD 1.3 min). Teams spent 64% of their time doing value-added/essential tasks (11.2 min, SD 2.2 min) and 13% of their time doing value-added/nonessential tasks (2.4 min, SD 0.9 min). Teams spent 23% of their time on non–value-added activities (4.1 min, SD 2.3 min). The top three non–value-added activities conducted during rounds were travel, waiting, and interruptions regarding care of other patients. Given the consistency of time spent on value-added activities among attendings, these non–value-added activities might explain the significant variability observed among attendings in total time spent rounding. Conclusions: This was an observational study to characterize the activities that occur during the course of a routine PICU work rounds. Although there was significant consistency in the time spent per patient in value-added activities, there was significant disparity in time spent on nonessential activities, such as travel and waiting. A dedicated attempt to reduce time spent on nonessential activities can substantially reduce rounding times and improve the efficiency and value of rounds.

Using Pleth Variability as a Triage Tool for Children With Obstructive Airway Disease in a Pediatric Emergency Department.

Objectives Patients with obstructive airway disease have varying degrees of pulsus paradoxus that correlate with illness severity. Pulsus paradoxus can be measured using plethysmography. We investigated whether plethysmograph (pleth) variability on admission to the pediatric emergency department (ED) could predict patient disposition. We hypothesized that patients with a larger pleth variability would have a higher likelihood of being admitted to a general pediatrics unit or the intensive care unit (ICU). Methods We conducted a prospective single-center study of children aged 1 to 18 years who presented to a pediatric ED with a diagnosis of asthma or reactive airway disease. The pleth variability index (PVI) was calculated from their initial plethysmography tracing. Disposition from the ED was recorded as discharge, admission to the floor, or admission to the ICU. Results A total of 117 patients were included in our study. Forty-eight patients were discharged home, 61 were admitted to the floor, and 8 were admitted to the ICU. The median PVI for each of these groups was 0.27 (interquartile range [IQR], 0.19–0.39) for discharges, 0.29 (IQR, 0.20–0.44) for patients admitted to the floor, and 0.56 (IQR, 0.35–0.70) for patients admitted to the ICU. A Kruskal-Wallis test demonstrated a significant difference in the PVI between each of the groups (P = 0.0087). Conclusions Our results suggest that PVI may be a useful tool in the triage of children who present to the ED with obstructive airway disease. Further studies should aim to assess the validity of PVI in predicting the response to bronchodilator therapy during the course of a patients hospitalization.

1070: USING PLETH VARIABILITY INDEX TO ASSESS THE COURSE OF ILLNESS IN CHILDREN WITH ASTHMA

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) 165 (54.8%); GOLD 3: 96 (31.9%). During 2-year follow-up, 26 patients were admitted to the ICU. Age (yrs): 67.7 ± 10.3 female sex: 4 (15.4%); pack-years: 43.6 ± 22.8; GOLD 1: 3 (11.5%); GOLD 2: 19 (73.1%); GOLD 3: 4 (15.4%). Admission diagnosis: medical 14 (53.8%); planned surgical 10 (38.5%) and emergency surgical 2 (7.7%). General population. Age (yrs): 64; female sex: 40%. Admission diagnosis: medical 50.5%; planned surgical 37.2% and emergency surgical 12.3%. ICU admission rates COPD patients vs general population: 8.6% vs 0.5%, p< 0.001, OR 18.8. Subgroup analyses: GOLD 1 7.5%, p=0.002, OR 16.0, GOLD 2 11.5%, p<0.001, OR 25.8, GOLD 3 4.2%, p=0.003, OR 8.6. Conclusions: ICU admission rates were significantly higher in patients with COPD compared to the general population.

A New Band in Town: A Novel Approach to Identify Seasonal Surge in the PICU.

880 www.pccmjournal.org November 2015 • Volume 16 • Number 9 healthy young adult kidneys because they have a longer predicted graft survival than smaller pediatric kidneys, and they preferentially receive kidneys donated by DNDD because they have a longer predicted graft survival than DCDD kidneys (13). Bennett et al (1) provide important evidence that parents do not consent for DCDD as often as they consent for DNDD. As PICU providers, we can hypothesize about the reasons families decline DCDD even though they support organ donation, but we do not know which of these factors weigh most heavily in their decision. Further study and a deeper understanding are required to help us ensure that eligible families who would benefit from donating their child’s organs are given the maximal opportunity to do so.