Russell C. Raphaely

Hospital costs of pediatric intensive care

OBJECTIVE To characterize hospital costs of pediatric intensive care and to determine which demographic and disease characteristics are associated with cost. DESIGN Prospective cohort study. SETTING A 20-bed pediatric intensive care unit (PICU) in an urban university-affiliated teaching childrens hospital. PATIENTS All children (n = 1,376) admitted to the multidisciplinary PICU during the fiscal year 1994. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, diagnoses, organ failure, Pediatric Risk of Mortality score, length of stay (LOS), and outcome were recorded. All hospital charges were obtained. The actual hospital costs were calculated by two separate methods. First, we converted the itemized patient charges into costs, using corresponding cost-to-charge ratios for each charge. In addition, we examined all direct and indirect expenses for the PICU. Univariate and multivariate regression analyses were used to determine the correlates to cost. The study population was similar to that of other studies of pediatric intensive care. The PICU was 86% efficient. The total cost for PICU care was

Management of Severe Pediatric Head Trauma

16,983,323. Average cost per admission was

Pulmonary mechanics in infants after cardiac surgery.

12,342 +/-

An unusual case of button battery-induced traumatic tracheoesophageal fistula.

22,313, and average cost per patient day was

Acute respiratory failure in infants and children.

2,264 +/-

Outcome in severe Reye syndrome with early pentobarbital coma and hypothermia

868. The cost because of the PICU location (room cost) was 52.1% of all costs, and cost of laboratory studies was 18.3%. Respiratory therapy, pharmacy services, and radiology each accounted for between 6% and 8%. Total cost was most closely related to LOS, but severity of illness (Pediatric Risk of Mortality), diagnosis, and organ failure were also significant. Severity of illness was the most important factor in determining the variation in daily costs. Increased severity of illness was associated with higher laboratory and diagnostic study costs. We found little difference in the PICU room cost when calculated by adding direct and indirect expenses, compared with that obtained by using the cost-to-charge ratio. CONCLUSIONS The maintenance of the specialty location and its personnel is the most costly component of pediatric intensive care. The strongest correlate with total cost for pediatric intensive care is LOS, but if costs are normalized for LOS, severity of illness best explains cost variation among patients. These data may serve as the basis for additional studies of resource allocation and consumption in the future.

Optimum levels of CPAP for tracheal extubation of newborn infants

Except for prevention, nothing can alter the primary damage to the central nervous system tissues and blood vessels caused by the impact of traumatic forces over a few milli-seconds. However, damage to nervous system tissues secondary to transient reversible brain dysfunction may occur and lead to failure of respiration and circulation. Brain swelling and intracranial hypertension can develop and interfere with oxygen delivery and cellular metabolism of vital central nervous structures. A team approach with simultaneous treatment of the various disorders and recurrent evaluation is the hallmark of successful management.

Consensus Statement on the Triage of Critically III Patients

ObjectiveTo determine pulmonary mechanical characteristics in neonates after cardiac surgery. DesignA prospective study. SettingA 23-bed, pediatric ICU in a 280-bed childrens hospital. PatientsTwenty-six infants on the first post-operative day after cardiac surgery. MethodsPulmonary mechanics measurements were made during spontaneous breathing, using the esophageal balloon technique and a pneumotachometer. The least mean square method of analysis was used to calculate mechanics. Infants who tolerated withdrawal of mechanical ventilation (group 1) were compared with those infants with respiratory failure (group 2). ResultsSpontaneous respiratory rate, tidal volume, and minute ventilation were similar in groups 1 and 2. Lung compliance was decreased, with no difference between groups. Total lung resistance (34.3 ± 21.6 cm H2O/L·sec in group 1 vs. 136.8 ± 105.8 cm H2O/L·sec in group 2, p = .002) and resistive work of breathing (33.4 ± 29.9 g·cm/kg in group 1 vs. 212.9 ± 173.8 g·cm/kg in group 2, p = .001) were significantly higher in group 2. All infants with a total lung resistance >75 cm H2O/L·sec exhibited respiratory failure (resistance >75 cm H2O/L·sec correlated with respiratory failure, r2 = .73, odds ratio of 70 [confidence interval, 4.4 to 3240], p < .001). ConclusionsIncreased lung resistance identifies neonates with respiratory failure after cardiac surgery. Pulmonary mechanics testing may be useful in timing withdrawal of mechanical ventilation. (Crit Care Med 1992; 20:22)

Pediatric Intensive Care

Background: Much of pediatric medicine is focused on prevention of disease and injury. Although accidental ingestions of various household chemicals and medicines are well described and the treatment is supported by local poison control hotlines, the ingestion of button batteries by children is less publicized, and the dangers are less understood by both parents and health care providers. Methods: We describe a case report of a 17-month-old girl with no significant medical history who presented with respiratory distress, cough, and fever and subsequently was discovered to have ingested a button battery. Results: The formation of a traumatic tracheoesophageal fistula required intensive management that escalated to cardiopulmonary bypass and eventual pericardial patch closure of the tracheal defect after the failure of conventional mechanical ventilation. Conclusions: Esophageal button battery impaction places the patient at high risk for full-thickness damage to the esophagus and tracheal structures with fistula formation in as little as a few hours. The key to successful therapy is prompt diagnosis and removal, but in nonverbal pediatric patients, this often is not achievable. Because of the complications associated with this disease (tracheoesophageal fistula) and subsequent difficulties associated with oxygenation and ventilation, these patients should be managed at an institution with the skilled capability of providing cardiopulmonary bypass quickly as a potentially lifesaving therapy.

What Difference Does Pulse Oximetry Make

Lack of published data on morbidity in relation to the treatment of respiratory failure in the pediatric age group, points up the need for agreement upon certain criteria for the diagnosis of acute respiratory failure in this age group and for a multi-institutional assessment of the effectiveness of intensive respiratory care in reducing the morbidity and mortality associated with respiratory failure.