Robert Pettignano

Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit.

Objective: To evaluate the effects of instituting a feeding protocol with inclusive bowel regimen on tolerance and time to accomplish goal feeding in the pediatric intensive care unit. Design: Retrospective comparison chart review before and after the initiation of a feeding protocol. Patients: A total of 91 patients in the year 2000, before the initiation of the protocol, who received nasogastric feedings and 93 patients in year 2002 after the protocol was initiated. Measures and Main Results: Patients were selected for review if they received nasogastric tube feedings while in the pediatric intensive care unit. The data were reviewed from time of admission in the pediatric intensive care unit through 7 days of goal feedings or discharge from the pediatric intensive care unit. Data examined included: days in the pediatric intensive care unit and hospital, time to goal feedings, concomitant use of cardiovascular medications, sedation, analgesia, episodes of feedings held, vomiting, diarrhea, and constipation. The protocol group achieved goal nutrition in an average of 18.5 hrs and a median of 14 hrs. The retrospective group achieved goal feedings at an average of 57.8 hrs and a median of 32 hrs (p < .0001). Also noted were a reduction in the percentage of patients vomiting from 20% to 11% and a reduction in constipation from 51% to 33%. Conclusion: This comparison study suggests that the institution of a feeding protocol will not only achieve goal feedings at a substantially reduced time but also improve tolerance of enteral feedings in patients admitted to the pediatric intensive care unit.

Evaluation of an opiate-weaning protocol using methadone in pediatric intensive care unit patients.

Objective To evaluate the efficacy of a standardized opiate-weaning protocol using methadone compared with methadone weaning before protocol development. Design Time series, prospective study with comparison to historical controls. Setting Twenty-bed medical-surgical intensive care unit in an academic children’s hospital. Patients Ten children, aged 6 months to 18 yrs, who received methadone for weaning from continuous opiate infusions for ≥7 days compared with ten patients undergoing weaning by standardized protocol. Interventions Institution of standardized opiate-weaning protocol. Measurements and Main Results Patient age, gender, and diagnosis were similar in both nonprotocol (NP) and protocol (P) groups (p = NS). Days of opiate use were also similar between groups. Nine of ten NP and seven of ten P patients were on continuous fentanyl infusions, and the remainder were on continuous morphine infusions. P patients were weaned significantly faster than NP patients (median, 9 days and 20 days, respectively;p < .001). P patients requiring short-term opiate use also weaned significantly faster than short-term NP patients (median, 5 days and 21.5 days, respectively;p < .001). Withdrawal complications were seen in three NP patients with weaning delayed in two. Two P patients had withdrawal complications with no delay in weaning (p = NS). Significant methadone calculation discrepancy occurred in one NP patient but in no P patients. Conclusions Pediatric intensive care unit patients requiring prolonged opiate use can be weaned by using methadone with minimal signs of withdrawal. Use of a standardized weaning protocol decreased time for weaning without increasing the frequency rate of withdrawal symptoms.

Total enteral nutrition versus total parenteral nutrition during pediatric extracorporeal membrane oxygenation

Abstract Objective: To evaluate the adequacy, tolerance, and complications of enteral nutrition, compared with parenteral nutrition, in pediatric patients requiring extracorporeal membrane oxygenation (ECMO). Design: A retrospective chart review of all patients placed on extracorporeal life support from January 1991 through December 1995. Setting: Medical/surgical pediatric intensive care unit at Egleston Childrens Hospital, a tertiary care pediatric center. Patients: Twenty‐nine consecutive pediatric patients who required ECMO and were provided nutritional support, either enterally or parenterally. Group A consisted of 14 patients who were provided nutritional support using total parenteral nutrition. Group B consisted of 15 patients. Two patients were excluded from group B because their ECMO run was <36 hrs, leaving insufficient data for analysis. The remaining 13 patients were provided total enteral nutrition during ECMO. Interventions: None. Measurements and Main Results: Both groups were similar in age, weight, pre‐ECMO oxygenation index, alveolar‐arterial oxygen difference, type, and duration of ECMO (p = NS). Comparison of percent ideal body weight on admission did not show a statistical difference between groups A and B (p = .883). There was no difference between the two groups in the time needed to achieve caloric goal (p = .536) from the initiation of ECMO. No complications were associated with the utilization of enteral feedings. Savings for the nutritional supplement was estimated to be

Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure.

170 per day for the enterally fed group. The percentage of patients surviving was higher in the enterally fed patients compared with the parenterally fed group (79% vs. 100%), although this difference was not statistically significant (p = .47). Conclusions: Enteral nutrition in patients receiving either venoarterial or venovenous ECMO is well tolerated, provides adequate nutrition, is cost effective, and is without complications, as compared with parenteral nutrition. These data suggest that total enteral nutrition can be safely administered for nutritional support in pediatric patients undergoing either venoarterial or venovenous ECMO. (Crit Care Med 1998; 26:358‐363) Extracorporeal membrane oxygenation (ECMO) is recognized as an advanced therapy for use in pediatric respiratory and/or cardiac failure [1,2]. Although ECMO is frequently applied to the pediatric population, the most experience with this technique has come from neonates with respiratory failure [3,4]. Concerns regarding necrotizing enterocolitis and the possible effect of hypoxia on the gut have led to the use of total parenteral nutrition as the main source of nutritional support in the neonatal population [5]. Approximately 90% of neonates who develop necrotizing enterocolitis were enterally fed and were born at <36 wks gestational age [6]. Although gestational age is not an issue when considering pediatric ECMO, the effect of a prior hypoxic/ischemic insult on the gut must be considered. Typically, pediatric patients placed on ECMO have not been enterally fed because of the theoretical concerns associated with prior hypoxic/ischemic insults, potentially resulting in intestinal ischemia. Additional concerns regarding the initiation of enteral feedings have centered around the use of vasopressors and their contribution to intestinal ischemia. Withholding intestinal feedings while providing nutritional support using total parenteral nutrition results in hypoplasia of the intestinal villi, reduction of intestinal absorptive function, increased bacterial translocation, and total parenteral nutrition‐associated cholestasis[7‐14]. Conversely, the reported advantages of total enteral nutrition include improved gastrointestinal immunologic function, a reduction of sepsis‐associated morbidity, decreased frequency of total parenteral nutrition cholestasis, and reduced cost [15‐18]. In 1994, based on the evidence supporting the advantages of enteral feedings, we began a concerted effort to enterally feed all critically ill patients in the pediatric intensive care unit at our institution. This change in practice was expanded to include patients placed on ECMO, a population that had typically received parenteral nutrition alone. The purpose of this study was to evaluate and report our experience with enteral nutrition in pediatric patients requiring ECMO.

Medical-Legal Partnership: Impact on Patients With Sickle Cell Disease

Objectives To describe a single center’s experience with the primary use of venovenous cannulation for supporting pediatric acute respiratory failure patients with extracorporeal membrane oxygenation (ECMO). Design Retrospective chart review of all patients receiving extracorporeal life support at a single institution. Setting Pediatric intensive care unit at a tertiary care children’s hospital. Patients Eighty-two patients between the ages of 2 wks and 18 yrs with severe acute respiratory failure. Interventions ECMO for acute respiratory failure. Measurements and Main Results From January 1991 until April 2002, 82 pediatric patients with acute respiratory failure were cannulated for ECMO support. Median duration of ventilation before ECMO was 5 days (range, 1–17 days). Sixty-eight of these patients (82%) initially were placed on venovenous ECMO. Fourteen patients were initiated and remained on venoarterial support, including six in whom venovenous cannulae could not be placed. One patient was converted from venovenous to venoarterial support due to inadequate oxygenation. Venoarterial patients had significantly greater alveolar-arterial oxygen gradients and lower Pao2/Fio2 ratios than venovenous patients (p < .03). Fifty-five of 81 venovenous patients received additional drainage cannulae (46 of 55 with an internal jugular cephalad catheter). Thirty-five percent of venovenous patients and 36% of venoarterial patients required at least one vasopressor infusion at time of cannulation (p = nonsignificant); vasopressor dependence decreased over the course of ECMO in both groups. Median duration on venovenous ECMO for acute hypoxemic respiratory failure was 218 hrs (range, 24–921). Venovenous ECMO survivors remained cannulated for significantly shorter time than nonsurvivors did (median, 212 vs. 350 hrs; p = .04). Sixty-three of 82 ECMO (77%) patients survived to discharge—56 of 68 venovenous ECMO (81%) and nine of 14 venoarterial ECMO (64%). Conclusions Venovenous ECMO can effectively provide adequate oxygenation for pediatric patients with severe acute respiratory failure receiving ECMO support. Additional cannulae placed at the initiation of venovenous ECMO could be beneficial in achieving flow rates necessary for adequate oxygenation and lung rest.

The health law partnership: adding a lawyer to the health care team reduces system costs and improves provider satisfaction.

OBJECTIVE: To determine the types of legal problems addressed by the Health Law Partnership (HeLP) and the impact of the legal interventions in pediatric patients with sickle cell disease (SCD) or its variants. We hypothesized that an interdisciplinary team that includes lawyers would positively affect the social determinants of health that affect patients with SCD. METHODS: The HeLP database was retrospectively queried for all patients with the diagnosis of SCD or 1 of its variants who had been seen by the lawyers of HeLP between April 2004 and September 2010. Data collected in this cohort of patients included income level of the patient/client, the initial presenting problems, any patient/parent/guardian problems identified during the legal checkup, and the type of legal assistance provided. Estimated annualized financial outcomes were calculated. RESULTS: From April 2004 through September 2010, 71 parents/guardians with 76 children with SCD were referred to the HeLP for legal intervention. Of the 71 parents/guardians, 33 were at <100% of the federal poverty level. There were 106 initial case problems identified in the 71 parents/guardians; 51 of 106 problems were directly related to the child. An additional 93 issues were identified during the legal checkup. Of 106 cases, 99 were closed with 21 resulting in a measurable gain of benefits. CONCLUSIONS: In a cohort of families of children with SCD, incorporating access to legal services as part of the care plan resulted in a positive impact on these patients/parents/guardians. The impact was directly attributable to the intervention of the HeLP.

Life-threatening bradyarrhythmia after massive azithromycin overdose.

Addressing the legal issues of patients of low socioeconomic status can be useful in increasing organizational reimbursements, reducing costs and improving access to care. Medical-legal partnership is an addition to the health care armamentarium that directly addresses this goal. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a law school or legal aid society that addresses barriers to access to care and limitations to well-being experienced by patients of low socioeconomic status. The Health Law Partnership is one such medical legal partnership that provides a holistic, interdisciplinary approach to health care. An evaluation of the legal and educational services provided by Health Law Partnership showed that Health Law Partnership secured otherwise unreimbursed Medicaid payments for services over a 4-year period from 2006 to 2010, increased physician satisfaction, and saved hospital employers approximately

Can Access to a Medical-Legal Partnership Benefit Patients with Asthma Who Live in an Urban Community?

10 000 in continuing education costs annually.

The Health Law Partnership: A Medical-Legal Partnership Strategically Designed to Provide a Coordinated Approach to Public Health Legal Services, Education, Advocacy, Evaluation, Research, and Scholarship

A 9‐month‐old infant was inadvertently administered azithromycin 50 mg/kg, taken from floor stock, instead of the prescribed ceftriaxone. Shortly thereafter, she became unresponsive and pulseless. The initial heart rhythm observed when cardiopulmonary resuscitation was started was a wide‐complex bradycardia, with a prolonged rate‐corrected QT interval and complete heart block. The baby was resuscitated with epinephrine and atropine, but she suffered severe anoxic encephalopathy. Torsade de pointes and QT‐interval prolongation have been reported after administration of macrolide antibiotics, including azithromycin, both intravenously and orally. This has occurred especially in the context of coadministered drugs that inhibit the cytochrome P450 (CYP) 3A4 isoenzyme, such as ketoconazole and astemizole. However, bradycardia with complete heart block has not, to our knowledge, been reported specifically with intravenous administration of azithromycin alone, either with therapeutic doses or overdose. Clinicians should be alerted about the potential of azithromycin to cause life‐threatening bradycardia, and pharmacy systems should be implemented to ensure special care in the safe administration of this drug, especially when dispensed from a point‐of‐care source.

Interprofessional Medical-legal Education of Medical Students: Assessing the Benefits for Addressing Social Determinants of Health.

Approximately one in 10 children in the U.S. has a diagnosis of asthma. African American and low-income children are more likely to be diagnosed with asthma. They are more likely to suffer the worse outcomes because of low socioeconomic status and environmental exposures. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a lawyer, law school, or legal aid society created to address barriers to health care access and limitations to well-being. Addressing the legal concerns of these patients can improve access to medical services, reduce family stress, and address legal concerns that contribute to poor health. The Health Law Partnership (HeLP) is one such medical-legal partnership that provides a holistic, interdisciplinary approach to health care. During the seven-year study period we found both financial (