Richard Speicher

Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline flights worldwide.

Objectives: We conducted this study to characterize in-flight pediatric fatalities onboard commercial airline flights worldwide and identify patterns that would have been unnoticed through single case analysis of these relative rare events. Design: Retrospective cohort study of pediatric in-flight medical emergencies resulting in fatalities between January 2010 and June 2013. Setting: A ground-based medical support center providing remote medical support to commercial airlines worldwide. Patients: Children (age 0–18 yr) who experienced a medical emergency resulting in death during a commercial airline flight. Interventions: None. Measurements and Main Results: There were a total of 7,573 in-flight medical emergencies involving children reported to the ground-based medical support center, resulting in 10 deaths (0.13% of all pediatric in-flight emergencies). The median subject age was 3.5 months with 90% being younger than 2 years, the age until which children are allowed to travel sharing a seat with an adult passenger, also known as lap infants. Six patients had no previous medical history, with one suffering cardiorespiratory arrest after developing acute respiratory distress during flight and five found asystolic (including four lap infants). Four subjects had preflight medical conditions, including two children traveling for the purpose of accessing advanced medical care. Conclusions: Pediatric in-flight fatalities are rare, but death occurs most commonly in infants and in subjects with a preexisting medical condition. The number of fatalities involving seemingly previously healthy children under the age of 2 years (lap infants) is intriguing and could indicate a vulnerable population at increased risk of death related to in-flight environmental factors, sleeping arrangements, or yet another unrecognized factor.

Tratamento atual de crianças com asma crítica e quase fatal

Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.A asma e a mais comum das doencas da infância. Embora a maioria das criancas com exacerbacoes agudas de asma nao demanda cuidados criticos, algumas delas nao respondem ao tratamento padrao e necessitam de cuidados mais intensos. Criancas com asma critica ou quase fatal precisam de monitoramento estrito quanto a deterioracao e podem requerer estrategias terapeuticas agressivas. Esta revisao examinou as evidencias disponiveis que dao suporte a terapias para asma critica e quase fatal, e resumiu o cuidado clinico atual para essas criancas. O tratamento tipico inclui uso parenteral de corticosteroides e farmacos beta-agonistas, por via inalatoria ou intravenosa. Para criancas com resposta inadequada ao tratamento padrao, pode-se lancar mao do uso inalatorio de brometo de ipratropio ou intravenoso de sulfato de magnesio, metilxantinas e misturas gasosas com helio, alem de suporte ventilatorio mecânico nao invasivo. Pacientes com insuficiencia respiratoria progressiva se beneficiam de ventilacao mecânica com uma estrategia que emprega grandes volumes correntes e baixas frequencias do ventilador, para minimizar a hiperinsuflacao dinâmica, o barotrauma e a hipotensao. Sedativos, analgesicos e bloqueadores neuromusculares sao frequentemente necessarios na fase inicial do tratamento para facilitar um estado de hipoventilacao controlada e hipercapnia permissiva. Pacientes que nao conseguem melhorar com a ventilacao mecânica podem ser considerados para abordagens menos comuns, como inalacao de anestesicos, broncoscopia e suporte extracorporeo a vida. Esta abordagem atual resultou em taxas de mortalidade extremamente baixas, mesmo em criancas com necessidade de suporte mecânico.

Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures.

PURPOSE The implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit (ICU) is described. METHODS This retrospective study compared the use of i.v. chlorothiazide and i.v. ethacrynic acid in pediatric cardiovascular surgery patients before and after implementation of a diuretic stewardship program. All pediatric patients admitted to the pediatric cardiovascular service were included. The cardiovascular surgery service was educated on formal indications for specific diuretic agents, and the diuretic stewardship program was implemented on January 1, 2013. Under the stewardship program, i.v. ethacrynic acid was indicated in patients with a sulfonamide allergy, and i.v. chlorothiazide was considered appropriate in patients receiving maximized i.v. loop diuretic doses. A detailed review of the pharmacy database and medical records was performed for each patient to determine i.v. chlorothiazide and i.v. ethacrynic acid use and expenditures, appropriateness of use, days using a ventilator, and cardiovascular ICU length of stay. RESULTS After implementation of diuretic stewardship, the use of i.v. chlorothiazide decreased by 74% (531 fewer doses) while i.v. ethacrynic acid use decreased by 92% (47 fewer doses), resulting in a total reduction of

Validation of a pediatric bedside tool to predict time to death after withdrawal of life support.

91,398 in expenditures on these diuretics over the six-month study period and an estimated annual saving of over

Resposta para: Tratamento atual de crianças com asma crítica e quase fatal

182,000. The median number of days using a ventilator and the length of ICU stay did not differ significantly during the study period. CONCLUSION Implementation of a diuretic stewardship program reduced the use of i.v. chlorothiazide and i.v. ethacrynic acid without adversely affecting clinical outcomes such as ventilator days and length of stay in a pediatric cardiovascular ICU.

Corticosteroid Therapy During Acute Bronchiolitis in Patients Who Later Develop Asthma

AIM To evaluate the accuracy of a tool developed to predict timing of death following withdrawal of life support in children. METHODS Pertinent variables for all pediatric deaths (age ≤ 21 years) from 1/2009 to 6/2014 in our pediatric intensive care unit (PICU) were extracted through a detailed review of the medical records. As originally described, a recently developed tool that predicts timing of death in children following withdrawal of life support (dallas predictor tool [DPT]) was used to calculate individual scores for each patient. Individual scores were calculated for prediction of death within 30 min (DPT30) and within 60 min (DPT60). For various resulting DPT30 and DPT60 scores, sensitivity, specificity and area under the receiver operating characteristic curve were calculated. RESULTS There were 8829 PICU admissions resulting in 132 (1.5%) deaths. Death followed withdrawal of life support in 70 patients (53%). After excluding subjects with insufficient data to calculate DPT scores, 62 subjects were analyzed. Average age of patients was 5.3 years (SD: 6.9), median time to death after withdrawal of life support was 25 min (range; 7 min to 16 h 54 min). Respiratory failure, shock and sepsis were the most common diagnoses. Thirty-seven patients (59.6%) died within 30 min of withdrawal of life support and 52 (83.8%) died within 60 min. DPT30 scores ranged from -17 to 16. A DPT30 score ≥ -3 was most predictive of death within that time period, with sensitivity = 0.76, specificity = 0.52, AUC = 0.69 and an overall classification accuracy = 66.1%. DPT60 scores ranged from -21 to 28. A DPT60 score ≥ -9 was most predictive of death within that time period, with sensitivity = 0.75, specificity = 0.80, AUC = 0.85 and an overall classification accuracy = 75.8%. CONCLUSION In this external cohort, the DPT is clinically relevant in predicting time from withdrawal of life support to death. In our patients, the DPT is more useful in predicting death within 60 min of withdrawal of life support than within 30 min. Furthermore, our analysis suggests optimal cut-off scores. Additional calibration and modifications of this important tool could help guide the intensive care team and families considering DCD.

646: WHAT ARE WE DOING? CHANGES IN THE WAY BRONCHIOLITIS IS TREATED IN THE ICU

We thank Drs. Colleti Jr and Carvalho for their interest in our recent publication in Revista Brasileira de Terapia Intensiva.(1) We agree that avoidance of mechanical ventilation (MV) is preferable in pediatric intensive care unit (PICU) patients with critical asthma, but primarily to avoid MV-associated morbidity, as MV-associated mortality is exceptionally rare in the current era. Newth recently reported a mortality rate of 4.3% for children with near-fatal asthma in United States PICUs, which is lower than the 9.4% mortality rate among adults hospitalized nearly 2 decades ago with near-fatal asthma that was reported in the paper cited by Colleti Jr and Carvalho.(2,3) Moreover, 10 of the 11 children who died in the recent PICU study had suffered cardiac arrest prior to the PICU admission and neurologic injury was the cause of death in nearly all of them, not intractable pulmonary disease.(2) Still, our practice is to avoid MV whenever possible in children with critical asthma. High-flow nasal cannula (HFNC) has been associated with favorable outcomes in many patient groups, including premature neonates, young children with bronchiolitis, and adults with acute hypoxemic respiratory failure.(4-6) HFNC primarily improves gas exchange by washing out dead space, and also causes positive pharyngeal pressures that may be transmitted somewhat to the distal airways and cause a low-level of positive end-expiratory pressure (PEEP). Positive airway pressure effects of HFNC are extremely dependent on patient size, cannula diameter, and HFNC flow rate. Pharyngeal pressures of 5 to 7cmH2O have been generated at 5 to 8L/minute in premature neonates weighing ~1 to 4kg, but flows of 50L/minute are needed to generate similar pressures in adult-sized patients.(7,8) It is unclear how much of that pharyngeal pressure is actually transmitted to the alveoli, but it is thought to be clinically insignificant under usual flows and in the range of ~1cmH2O, thus too low to fully explain the observed clinical benefits.(9) Furthermore, generation of single-level PEEP (as opposed to BiPAP) in asthma may worsen hyperinflation without assisting inspiratory work, leading some to suggest that HFNC should be avoided in asthma.(10) While we do not believe that HFNC is contraindicated in asthma since dead space washout may be helpful and generation of PEEP is likely trivial at typical flow rates, there are insufficient data reporting use of HFNC in PICU patients with critical asthma for us to have included it in our review. Hopefully, now that devices are available that allow for concurrent use of HFNC and continuous nebulized albuterol without the introduction of unconditioned bias flow to the circuit (i.e., Aerogen nebulizer), literature describing its use in pediatric critical asthma will likely become available. Resposta para: Tratamento atual de crianças com asma crítica e quase fatal