Toni Petrillo-Albarano

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.

Experience with use of extracorporeal life support for severe refractory status asthmaticus in children

IntroductionSevere status asthmaticus (SA) in children may require intubation and mechanical ventilation with a subsequent increased risk of death. In the patient with SA and refractory hypercapnoeic respiratory failure, use of extracorporeal life support (ECLS) has been anecdotally reported for carbon dioxide removal and respiratory support. We aimed to review the experience of a single paediatric centre with the use of ECLS in children with severe refractory SA, and to compare this with international experience from the Extracorporeal Life Support Organization (ELSO) registry.MethodsAll paediatric patients (aged from 1 to 17 years) with primary International Classification of Diseases (ICD)-9 diagnoses of SA receiving ECLS for respiratory failure from both the Childrens Healthcare of Atlanta at Egleston (Childrens at Egleston) database and the ELSO registry were reviewed.ResultsThirteen children received ECLS for refractory SA at the Childrens at Egleston from 1986 to 2007. The median age of the children was 10 years (range 1 to 16 years). Patients generally received aggressive use of medical and anaesthetic therapies for SA before cannulation with a median partial pressure of arterial carbon dioxide (PaCO2) of 130 mmHg (range 102 to 186 mmHg) and serum pH 6.89 (range 6.75 to 7.03). The median time of ECLS support was 95 hours (range 42 to 395 hours). All 13 children survived without neurological sequelae. An ELSO registry review found 64 children with SA receiving ECLS during the same time period (51 excluding the Childrens at Egleston cohort). Median age, pre-ECLS PaCO2 and pH were not different in non-Childrens ELSO patients. Overall survival was 60 of 64 (94%) children, including all 13 from the Childrens at Egleston cohort. Survival was not significantly associated with age, pre-ECLS PaCO2, pH, cardiac arrest, mode of cannulation or time on ECLS. Significant neurological complications were noted in 3 of 64 (4%) patients; patients with neurological complications were not significantly more likely to die (P = 0.67).ConclusionsSingle centre and ELSO registry experience provide results of a cohort of children with refractory SA managed with ECLS support. Further study is necessary to determine if use of ECLS in this setting produces better outcomes than careful mechanical ventilation and medical therapy alone.

The use of a modified pediatric early warning score to assess stability of pediatric patients during transport.

Objective Pediatric early warning scores (PEWSs) have been used effectively in limited patient care areas. Children’s Transport, at Children’s Healthcare of Atlanta, transports approximately 5000 children annually. In an effort to consistently assess patient acuity and the impact of our team’s interventions, we instituted a modified “transport PEWS” (TPEWS). Methods The existing PEWS was modified to reflect the transport environment. A retrospective chart review was conducted of 100 consecutive children transported by Children’s Transport in March 2009. Transport PEWS given during triage by the dispatch center (TPEWStri), TPEWS calculated at referring facility by the team (TPEWSref), and final TPEWS at the accepting institution (TPEWSacc) were compared. Results Eighty-six patients were transported by ground. The median age was 50.4 months. Sixty patients (60%) received some intervention from the transport team. Median TPEWSref was 3 (0–9) upon initial assessment, and TPEWSacc was 2 (0–9) on arrival at the accepting facility (P = 0.0001). Seventy-three percent (73/100) of patients were transported to the emergency room; 15 (15%) of 100 to the general inpatient area, and 12 (12%) of 100 to the intensive care unit. In addition, a triage TPEWS (TPEWStri) was calculated from information given from the referring facility in 59 of the 100 patients. A significant difference in TPEWStri and TPEWSref was noted (P = 0.0001). Conclusions In this cohort of pediatric transport patients, TPEWS appears to be a helpful additional assessment tool. Transport PEWS may function as a tool for assessing severity of illness, hence optimizing transport dispatch and patient disposition.

Efficacy and safety of deep sedation by non-anesthesiologists for cardiac MRI in children

BackgroundCardiac MRI has become widespread to characterize cardiac lesions in children. No study has examined the role of deep sedation performed by non-anesthesiologists for this investigation.ObjectiveWe hypothesized that deep sedation provided by non-anesthesiologists can be provided with a similar safety and efficacy profile to general anesthesia provided by anesthesiologists.Materials and methodsThis is a retrospective chart review of children who underwent cardiac MRI over a 5-year period. The following data were collected from the medical records: demographic data, cardiac lesion, American Society of Anesthesiologists (ASA) physical status, sedation type, provider, medications, sedation duration and adverse events or interventions. Image and sedation adequacy were recorded.ResultsOf 1,465 studies identified, 1,197 met inclusion criteria; 43 studies (3.6%) used general anesthesia, 506 (42.3%) had deep sedation and eight (0.7%) required anxiolysis only. The remaining 640 studies (53.5%) were performed without sedation. There were two complications in the general anesthesia group (4.7%) versus 17 in the deep sedation group (3.4%). Sedation was considered inadequate in 22 of the 506 deep sedation patients (4.3%). Adequate images were obtained in 95.3% of general anesthesia patients versus 86.6% of deep sedation patients.ConclusionThere was no difference in the incidence of adverse events or cardiac MRI image adequacy for children receiving general anesthesia by anesthesiologists versus deep sedation by non-anesthesiologists. In summary, this study demonstrates that an appropriately trained sedation provider can provide deep sedation for cardiac MRI without the need for general anesthesia in selected cases.