Shamel Abd-Allah

Intraosseous access in the setting of pediatric critical care transport.

Objective: To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport. Design: Retrospective chart review. Setting: Pediatric critical care transports to a pediatric intensive care unit. Patients: Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit. Interventions: Intraosseous access placed for emergent vascular access. Measurements and Main Results: During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration. Conclusions: Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.

Intravenous Immunoglobulin as Therapy for Pediatric Guillain-Barré Syndrome

Seven children with Guillain-Barré syndrome were treated with intravenous immunoglobulin. Median patient age was 5.8 years. A standard dosage of 0.4 g/kg/day for 5 days was administered. Clinical improvement occurred on average within 2.4 ± 1.3 days of beginning intravenous immunoglobulin. One child required mechanical ventilation for 7 days. Eight comparable children with Guillain-Barré syndrome at our institution in a prior study treated with plasmapheresis alone had similar clinical results. However, the need for admission to the pediatric intensive care unit and duration of pediatric intensive care unit stay were lower in the intravenous immunoglobulin treated group (P < .05). There were no complications with intravenous immunoglobulin therapy except for a brief episode of hypotension in one patient. Review of the literature identified 74 additional children with Guillain-Barré syndrome successfully receiving intravenous immunoglobulin therapy. We suggest intravenous immunoglobulin as initial therapy for pediatric Guillain-Barré syndrome, because it appears equally as effective as plasmapheresis and is associated with fewer complications. (J Child Neurol 1997;12:376-380).

Helium-oxygen therapy for pediatric acute severe asthma requiring mechanical ventilation.

Objective To illustrate the use of helium-oxygen gas mixtures as therapy for pediatric patients with acute severe asthma requiring conventional mechanical ventilation. Design Retrospective review. Setting Tertiary care children’s teaching hospital. Patients All mechanically ventilated patients with severe asthma admitted to the pediatric intensive care unit from August 1994 to October 2000. Interventions Within 24 hrs of intubation or admission, patients were stabilized on volume ventilation, bronchodilator therapy, corticosteroids, and antibiotics when indicated. Hypercapnia was permitted while maintaining arterial blood gas pH ≥7.25. A helium-oxygen gas mixture then was begun with helium flow set at 5–7 L/min, and oxygen flow was titrated to maintain desired oxygen saturation. Only sedated, chemically paralyzed patients with adequate pre-helium-oxygen and post-helium-oxygen measurements were statistically analyzed. Measurements and Main Results Twenty-eight mechanically ventilated patients with severe asthma placed on helium-oxygen gas mixtures were identified who met study entry criteria. Mean patient age was 8.8 yrs (range, 1.1–14.6). Before helium-oxygen therapy began, mean peak inspiratory pressure was 40.5 ± 4.2 cm H2O, mean arterial blood gas pH was 7.26 ± 0.05, and mean CO2 partial pressure was 58.2 ± 8.5 torr. After patients were placed on helium-oxygen therapy, there was a significant decrease in mean peak inspiratory pressure to 35.3 ± 3.0 cm H2O. Mean pH increased significantly to 7.32 ± 0.06, and mean partial pressure CO2 decreased significantly to 50.5 ± 7.4 torr. Initial mean inspired helium was 57 ± 4% (range, 32–74). Mechanical ventilation days ranged from 1 to 23 days (mean, 5.0). Hospital stay ranged from 4 to 29 days (mean, 10.1), with an average pediatric intensive care unit stay of 6.9 days (range, 2–24). There were two incidences of pneumothorax. Conclusions In the pediatric patient with severe asthma requiring conventional mechanical ventilation, helium-oxygen administration appears to be a safe therapy and may assist in lowering peak inspiratory pressure and improving blood gas pH and partial pressure CO2.

Three-percent saline administration during pediatric critical care transport.

Objectives The purpose of this study was to describe the administration of 3% saline (3%S) during pediatric critical care transport. Methods A retrospective study was performed on pediatric patients who underwent critical transport to Loma Linda University Children’s Hospital from January 1, 2003, to June 30, 2007, and were given 3%S. Patients’ demographics, admission diagnosis, route and amount of 3%S administration, serum electrolytes, vital signs, radiographic data, and Glasgow Coma Scale scores were collected and analyzed. Results A total of 101 children who received 3%S infusions during pediatric critical care transport were identified. Mean patient age was 5.9 years, and mean patient weight was 27.6 kg. The main indications for infusing 3%S were suspected cerebral edema (41%), intracranial bleed with edema (51%), and symptomatic hyponatremia (6%). The amount of 3%S bolus ranged from 1.2 to 24 mL/kg, with a mean of 5.4 mL/kg. Serum electrolytes before and after 3%S infusion demonstrated significant increases in sodium, chloride, and bicarbonate levels (P < 0.05). A significant reduction was also seen in serum urea nitrogen levels and anion gap. Radiographic imaging performed before 3%S infusion demonstrated findings consistent with concerns of increased intracranial pressure such as intracranial bleed and cerebral edema. The route of initial 3%S infusions was mainly through peripheral intravenous lines (96%). No complications related to the 3%S delivery such as local reactions, renal abnormalities, or central pontine myelinolysis were observed. Conclusions It seems 3%S may be administered safely during pediatric critical transport and administration routes can include peripheral lines. With the importance of initiating therapy early to improve patient outcomes, the use of 3%S may benefit transported children with brain injury and suspected intracranial hypertension.

Effect of high-dose continuous albuterol nebulization on clinical variables in children with status asthmaticus.

Objectives: Continuous albuterol nebulization is generally administered at 2.5–20 mg/hr at most centers. We examined the effect of high-dose (75 or 150 mg/hr) albuterol on clinical variables in children with status asthmaticus. Design: Retrospective analysis of inpatient medical records and prospectively collected computerized PICU respiratory therapy database. Setting: Twenty-five-bed multidisciplinary PICU in a tertiary care children’s hospital. Patients: Children admitted to the PICU between January 2006 and December 2007 with status asthmaticus receiving high-dose continuous albuterol nebulization. (Those with cerebral palsy, cardiac pathology, and ventilator dependence were excluded.) Interventions: Chart review for PICU length of stay, albuterol dose, duration of nebulization, occurrence of chest pain, vomiting, tremors, hypokalemia (serum potassium < 3.0 mEq/L), and cardiac arrhythmia. Maximal heart rate, lowest diastolic blood pressure, and mean arterial pressure were compared to the variables at initiation of therapy and at hospital discharge. Measurements and Main Results: Forty-two patients (22 boys and 20 girls) received high-dose continuous albuterol nebulization. Twenty-three received 75 mg/hr and 19 received 150 mg/hr (3.7 mg/kg/hr [interquartile range, 2.4–5.8 mg/kg/hr]) for a duration of 22.3 hours (interquartile range, 6.6–31.7 hr). Heart rate increased and diastolic blood pressure and mean arterial pressure were significantly lower during nebulization compared to initiation of therapy or at hospital discharge (p < 0.05). No patient required fluid resuscitation or inotropic support, and one had self-limited premature ventricular contractions. Hypokalemia occurred in five of 33 patients who had serum electrolytes measured but did not require supplementation. One patient required endotracheal intubation after initiation of nebulization, and seven patients (16.7%) received noninvasive ventilation. PICU length of stay was 2.3 ± 1.7 days; there were no deaths. Conclusions: High-dose continuous albuterol nebulization is associated with a low rate of subsequent mechanical ventilation and fairly short PICU length of stay without significant toxicity. Prospective studies comparing conventional and high-dose albuterol nebulization are needed to determine the optimum dose providing maximum efficacy with the least adverse effects.

Oral, jaw, and neck injury in infants and children: from abusive trauma or intubation?

Objectives The objective of this study was to identify the incidence of oral, jaw, and neck injury secondary to endotracheal intubation in young children. Methods This prospective observational study was conducted in the pediatric intensive care unit at a level 1 trauma center. From October 1998 to January 1999 and November 2007 to April 2008, all intubated patients younger than 3 years with no prior oral procedures were examined within 24 hours of intubation. A standardized form was used to record injuries. Separately, medical records were reviewed for prior injuries. Chi-square/Fisher exact test was used for statistical analysis. Results Of 105 patients included in the study, 12 had oral, jaw, or neck injury. One patient had a hard palate injury from a pen cap in his mouth during a seizure. Another broke a tooth biting the laryngoscope blade (the only injury directly attributable to intubation). The remaining 10 patients were determined to be those who experienced abusive trauma. The overall incidence of injury directly from intubation was 0.9%. Oral, jaw, and neck injuries were all significantly associated with abusive trauma (P < 0.001). Eleven patients had difficult intubations: 9 had no injuries, 1 experienced abusive trauma and the second was the patient who broke his tooth during intubation. Conclusions Oral, jaw, or neck injury in young children is rarely caused by endotracheal intubation, regardless of difficulty during the procedure.

909: A STUDY COMPARING THE ACCURACY OF CGM DEVICE TO FSBG LEVELS AMONG PICU PATIENTS IN DKA

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) care. Ventilated patients were twice as likely to not have delirium assessment completed (242/974 opportunities {25%} vs. 1474/2903 opportunities {51%}). Conclusions: This is the first known non-research setting description of barriers to pCAM-ICU implementation. Our low rates of delirium may be related to missing patients most at risk. Use of a QI tool such as the FMEA can identify and prevent factors likely to interfere with a successful process. Health care management system support such as assessment reminders or efficient documentation procedures may positively impact practice changes.