Theresa A. Mikhailov

A prospective evaluation of opioid weaning in opioid-dependent pediatric critical care patients.

Critically ill children are treated with opioid medication in an attempt to decrease stress and alleviate pain during prolonged pediatric intensive care. This treatment plan places children at risk for opioid dependency. Once dependent, children need to be weaned or risk development of a withdrawal syndrome on abrupt cessation of medication. We enrolled opioid-dependent children into a prospective, randomized trial of 5- versus 10-day opioid weaning using oral methadone. Children exposed to opioids for an average of 3 wk showed no difference in the number of agitation events requiring opioid rescue (3 consecutive neonatal abstinence scores >8 every 2 h) in either wean group. Most of the events requiring rescue occurred on day 5 and 6 of the wean in both treatment groups. Patients may be able to be weaned successfully in 5 days once converted to oral methadone, with a follow-up period after medication wean to observe for a delayed withdrawal syndrome.

Protecting Fragile Skin: Nursing Interventions to Decrease Development of Pressure Ulcers in Pediatric Intensive Care

BACKGROUND The reported incidence of pressure ulcers in critically ill infants and children is 18% to 27%. Patients at risk for pressure ulcers and nursing interventions to prevent the development of the ulcers have not been established. OBJECTIVES To determine the incidence of pressure ulcers in critically ill children, to compare the characteristics of patients in whom pressure ulcers do and do not develop, and to identify prevention strategies associated with less frequent development of pressure ulcers. METHODS Characteristics of 5346 patients in pediatric intensive care units in whom pressure ulcers did and did not develop were compared. Multiple logistic regression was used to determine which prevention strategies were associated with less frequent development of pressure ulcers. RESULTS The overall incidence of pressure ulcers was 10.2%. Patients at greatest risk were those who were more than 2 years old; who were in the intensive care unit 4 days or longer; or who required mechanical ventilation, noninvasive ventilation, or extracorporeal membrane oxygenation. Strategies associated with less frequent development of pressure ulcers included use of specialty beds, egg crates, foam overlays, gel pads, dry-weave diapers, urinary catheters, disposable under-pads, body lotion, nutrition consultations, change in body position every 2 to 4 hours, blanket rolls, foam wedges, pillows, and draw sheets. CONCLUSIONS The overall incidence of pressure ulcers among critically ill infants and children is greater than 10%. Nursing interventions play an important role in the prevention of pressure ulcers.

Ethnic differences in mortality from insulin-dependent diabetes mellitus among people less than 25 years of age.

Objective. To determine whether the risk of death from type 1 insulin-dependent diabetes mellitus (IDDM) was similar among young non-Hispanic black, non-Hispanic white, and Hispanic patients. Design. Retrospective study of death certificates for Chicago residents between 1 and 24 years of age with any mention of diabetes during 1987 through 1994. Prevalence was estimated by an ongoing incidence registry in the city, the 1990 US Census, and published studies. Autopsy reports and/or medical records were examined to determine more clearly the circumstances of death. Case-fatality rates for IDDM in non-Hispanic black, non-Hispanic white, and Hispanic patients were calculated. Deaths in those with diabetes were compared with the mortality experience of the underlying population using race-specific standardized mortality ratios. Results. A total of 30 diabetes-related deaths occurred in the 8-year interval: 23 among non-Hispanic black, 5 among Hispanic, and 2 among non-Hispanic white paients. The average annual case-fatality rate for all ethnic groups combined was 247.2/105 (95% CI: 166.9–353.5). Race-specific rates were 447.8/105(283.9–671.7) for non-Hispanic black patients, 175.6/105(56.9–409.2) for Hispanic patients, and 48.2/105(5.8–174.0) for non-Hispanic white patients; there were no gender differences in risk. A total of 8 individuals died at the onset of disease (7 non-Hispanic black patients and 1 Hispanic patient). Compared with the underlying population, ethnic-specific standardized mortality ratios were elevated significantly for non-Hispanic black and Hispanic patients but not for non-Hispanic white patients. Conclusions. Short-term mortality is elevated substantially among non-Hispanic black and Hispanic youth with IDDM. The ninefold greater risk of death for non-Hispanic black compared with non-Hispanic white youth with diabetes may indicate gaps in access to comprehensive diabetes care.

Antithrombin Replacement During Extracorporeal Membrane Oxygenation

Heparin remains the predominant anticoagulant during extracorporeal membrane oxygenation (ECMO). Heparin acts by potentiating the anticoagulant effect of antithrombin (ATIII). Acquired ATIII deficiency, common in pediatric patients requiring ECMO, may result in ineffective anticoagulation with heparin. ATIII replacement may result in increased bleeding. Our objective is to determine ATIIIs effect on anticoagulation and blood loss during ECMO. A retrospective chart review was performed of all patients at Childrens Hospital of Wisconsin who received ATIII while supported on ECMO in 2009. ATIII activity levels, heparin drip rate, and activated clotting times (ACT) were compared before, 4, 8, and 24 h after ATIII administration. Chest tube output and packed red blood cell (pRBC) transfusion volume were compared from 24 h before ATIII administration to 24 h after. Twenty-eight patients received ATIII as a bolus dose during the course of 31 separate times on ECMO support. The median age of these patients was 0.3 years (range 1 day-19.5 years). ATIII activity increased significantly at 8 and 24 h after administration. No significant difference was noted in heparin drip rate, ACT levels, chest tube output, or pRBC transfusion volume. ATIII administration resulted in higher ATIII activity levels for 24 h without a significant effect on heparin dose, ACT, or measures of bleeding.

Obesity is not associated with increased mortality and morbidity in critically ill children.

AIM To evaluate the effect of obesity on mortality, length of mechanical ventilation, and length of stay (LOS) in critically ill children. METHODS Retrospective cohort study in 2- to 18-year-olds, admitted to the pediatric intensive care unit (PICU) at the Childrens Hospital of Wisconsin from 2005-2009 who required invasive ventilation. Weight z score was used to categorize patients as normal (-1.89 to 1.04), overweight (1.05-1.65), obese (1.66-2.33), and severely obese (>2.33). Underweight patients were excluded. Age, gender, admission type, Pediatric Index of Mortality 2 score, operative status, trauma status, admission Pediatric Outcome Performance Category, and diagnosis categories were also collected. The outcomes were mortality, total ventilator days, and PICU LOS. Univariate analysis was used to compare the groups, and multivariate logistic regression was used to compare mortality. Total ventilation days and LOS were modeled with linear regression. RESULTS In total, 1030 patients were included in the study, with 753 normal weight, 137 overweight, 76 obese, and 64 severely obese. The risk-adjusted mortality rates in overweight (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.62-1.82), obese (OR, 0.68; 95% CI, 0.31-1.48), and severely obese patients (OR, 1.02; 95% CI, 0.45-2.34) were not significantly different compared with the normal-weight group. Total ventilation days (P = .9628) and PICU LOS (P = .8431) were not significantly different between the groups after adjusting for risk factors. CONCLUSION Critically ill overweight, obese, and severely obese children who require invasive mechanical ventilation have similar mortality, length of stay in the PICU, and ventilator days as compared with normal-weight children.

Altered endothelial function in lambs with pulmonary hypertension and acute lung injury

Acute lung injury produces pulmonary hypertension, altered vascular reactivity, and endothelial injury. To determine whether acute lung injury impairs the endothelium‐dependent regulation of pulmonary vascular tone, 16 lambs were studied during U46619‐induced pulmonary hypertension without acute lung injury, or air embolization‐induced pulmonary hypertension with acute lung injury. The hemodynamic responses to endothelium‐dependent (acetylcholine, ATP, ET‐1, and 4 Ala ET‐1 [an ETb receptor agonist]) and endothelium‐independent (nitroprusside and isoproterenol) vasodilators were compared.

Under pressure: preventing pressure ulcers in critically ill infants

PURPOSE To determine whether a pressure ulcer prevention bundle was associated with a significant reduction in pressure ulcer development in infants in the pediatric intensive care unit. DESIGN AND METHODS Quasi-experimental design involving 399 infants 0 to 3 months of age at a large tertiary care medical center. RESULTS The implementation of the care bundle was associated with a significant drop in pressure ulcer incidence from 18.8 to 6.8%. PRACTICE IMPLICATIONS Pressure ulcers can be prevented in the most vulnerable patients with the consistent implementation of evidence-based interventions and system supports to assist nurses with the change in practice.

Registered Dietitians Making a Difference: Early Medical Record Documentation of Estimated Energy Requirement in Critically Ill Children Is Associated with Higher Daily Energy Intake and with Use of the Enteral Route

BACKGROUND Establishing a caloric requirement or energy target is a recommended part of any nutrition care plan. OBJECTIVE Our objective was to describe early documentation of a caloric requirement in critically ill children, and to determine if this would have any effect on daily energy intake and route of nutrition. DESIGN We used a descriptive chart review of a subgroup of patients included as part of a larger, retrospective multicenter study. Variables of interest included nutritional intake information, as well as presence/absence and amount of a documented caloric requirement within 48 hours of admission. PARTICIPANTS Five of the original 12 study centers collected the required supplementary data. Enrolled patients were those who were admitted to our pediatric intensive care unit (PICU) from January 1, 2007, through December 31, 2008; were between ages 30 days and 18 years; and had a length of stay in the PICU ≥ 96 hours. STATISTICAL ANALYSIS Energy intake among patients with and without a documented caloric requirement was analyzed using Mann-Whitney U tests. The difference of receiving enteral nutrition among patients with and without a caloric requirement was analyzed using a χ(2) test. RESULTS We studied 1,349 patients, of whom 644 (47.7%) had a caloric requirement documented (95.6% of caloric requirements were entered by a registered dietitian) in the medical record; these patients had higher total daily energy intake and were more likely to be fed enterally during the first 4 days of PICU admission than those without a documented caloric requirement (P<0.001 for all comparisons). CONCLUSIONS Less than half of critically ill children studied had a caloric requirement documented in the medical record; when a caloric requirement was documented in the medical record of a critically ill child, a registered dietitian had likely made the note. Having a caloric requirement documented in the medical record is associated with a higher energy intake and the use of the enteral route.

The Need for Evidence Based Nutritional Guidelines for Pediatric Acute Lymphoblastic Leukemia Patients: Acute and Long-Term Following Treatment

High survival rates for pediatric leukemia are very promising. With regard to treatment, children tend to be able to withstand a more aggressive treatment protocol than adults. The differences in both treatment modalities and outcomes between children and adults make extrapolation of adult studies to children inappropriate. The higher success is associated with a significant number of children experiencing nutrition-related adverse effects both in the short and long term after treatment. Specific treatment protocols have been shown to deplete nutrient levels, in particular antioxidants. The optimal nutrition prescription during, after and long-term following cancer treatment is unknown. This review article will provide an overview of the known physiologic processes of pediatric leukemia and how they contribute to the complexity of performing nutritional assessment in this population. It will also discuss known nutrition-related consequences, both short and long term in pediatric leukemia patients. Since specific antioxidants have been shown to be depleted as a consequence of therapy, the role of oxidative stress in the pediatric leukemia population will also be explored. More pediatric studies are needed to develop evidence based therapeutic interventions for nutritional complications of leukemia and its treatment.

Safety of Enteral Feedings in Critically Ill Children Receiving Vasoactive Agents.

BACKGROUND The objective of this retrospective study was to evaluate the safety of enteral feeding in children receiving vasoactive agents (VAs). METHODS Patients aged 1 month to 18 years with a pediatric intensive care unit stay for ≥96 hours during 2007 and 2008 who received any VA (epinephrine, norepinephrine, vasopressin, milrinone, dopamine, and dobutamine) were included and categorized into fed and nonfed groups. Their demographics, clinical characteristics, type and dose of VA, and presence of gastrointestinal (GI) outcomes were obtained. GI outcomes were compared between the groups by the χ(2) test, Mann-Whitney test, and logistic regression. RESULTS In total, 339 patients were included. Of these, 55% were in the fed group and 45% in the nonfed group. Patients in the fed group were younger (median age, 1.05 vs 2.75 years, respectively; P < .001) and tended to have a lower Pediatric Index of Mortality 2 (PIM2) risk of mortality (ROM) than those in the nonfed group (median, 3.33% vs 3.52%, respectively; P = .106). Mortality was lower in the fed group than the nonfed group (6.9% vs 15.9%, respectively; odds ratio [OR], 0.39; 0.18-0.84; P < .01, 95% CI), while GI outcomes did not differ between the groups. The vasoactive-inotropic score (VIS) did not differ between the groups except on day 1 (P = .017). The ROM did not differ between the groups after adjusting for age, PIM2 ROM, and VIS on day 1 (OR, 0.58; 0.26-1.28; P = .18, 95% CI). CONCLUSIONS Enteral feeding in patients receiving VAs is associated with no difference in GI outcomes and a tendency towards lower mortality. Prospective studies are required to confirm the safety of enteral feedings in patients receiving VAs.