ResearchPad - intensive-care https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Study protocol for a multicentre longitudinal mixed methods study to explore the Outcomes of ChildrEn and fAmilies in the first year after paediatric Intensive Care: the OCEANIC study]]> https://www.researchpad.co/article/elastic_article_12542 Annually in the UK, 20 000 children become very ill or injured and need specialist care within a paediatric intensive care unit (PICU). Most children survive. However, some children and their families may experience problems after they have left the PICU including physical, functional and/or emotional problems. It is unknown which children and families experience such problems, when these occur or what causes them. The aim of this mixed-method longitudinal cohort study is to understand the physical, functional, emotional and social impact of children surviving PICU (aged: 1 month–17 years), their parents and siblings, during the first year after a PICU admission.Methods and analysisA quantitative study involving 300 child survivors of PICU; 300 parents; and 150–300 siblings will collect data (using self-completion questionnaires) at baseline, PICU discharge, 1, 3, 6 and 12 months post-PICU discharge. Questionnaires will comprise validated and reliable instruments. Demographic data, PICU admission and treatment data, health-related quality of life, functional status, strengths and difficulties behaviour and post-traumatic stress symptoms will be collected from the child. Parent and sibling data will be collected on the impact of paediatric health conditions on the family’s functioning capabilities, levels of anxiety and social impact of the child’s PICU admission. Data will be analysed using descriptive and inferential statistics. Concurrently, an embedded qualitative study involving semistructured interviews with 24 enrolled families at 3 months and 9 months post-PICU discharge will be undertaken. Framework analysis will be used to analyse the qualitative data.Ethics and disseminationThe study has received ethical approval from the National Health Services Research Ethics Committee (Ref: 19/WM/0290) and full governance clearance. This will be the first UK study to comprehensively investigate physical, functional, emotional and social consequences of PICU survival in the first-year postdischarge.Clinical Trials Registration Number: ISRCTN28072812 [Pre-results] ]]> <![CDATA[Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review]]> https://www.researchpad.co/article/elastic_article_9123 The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.ParticipantsCritically ill adult patients who developed NOAF during admission.Primary and secondary outcomesPrimary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events.MethodsWe searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale.ResultsOf 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies).ConclusionThe reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group. ]]> <![CDATA[Prevalence, Severity and Mortality associated with COPD and Smoking in patients with COVID-19: A Rapid Systematic Review and Meta-Analysis]]> https://www.researchpad.co/article/elastic_article_7662 Coronavirus disease 2019 (COVID-19) is an evolving infectious disease that dramatically spread all over the world in the early part of 2020. No studies have yet summarized the potential severity and mortality risks caused by COVID-19 in patients with chronic obstructive pulmonary disease (COPD), and we update information in smokers.MethodsWe systematically searched electronic databases from inception to March 24, 2020. Data were extracted by two independent authors in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale. We synthesized a narrative from eligible studies and conducted a meta-analysis using a random-effects model to calculate pooled prevalence rates and 95% confidence intervals (95%CI).ResultsIn total, 123 abstracts were screened and 61 full-text manuscripts were reviewed. A total of 15 studies met the inclusion criteria, which included a total of 2473 confirmed COVID-19 patients. All studies were included in the meta-analysis. The crude case fatality rate of COVID-19 was 7.4%. The pooled prevalence rates of COPD patients and smokers in COVID-19 cases were 2% (95% CI, 1%–3%) and 9% (95% CI, 4%–14%) respectively. COPD patients were at a higher risk of more severe disease (risk of severity = 63%, (22/35) compared to patients without COPD 33.4% (409/1224) [calculated RR, 1.88 (95% CI, 1.4–2.4)]. This was associated with higher mortality (60%). Our results showed that 22% (31/139) of current smokers and 46% (13/28) of ex-smokers had severe complications. The calculated RR showed that current smokers were 1.45 times more likely [95% CI: 1.03–2.04] to have severe complications compared to former and never smokers. Current smokers also had a higher mortality rate of 38.5%.ConclusionAlthough COPD prevalence in COVID-19 cases was low in current reports, COVID-19 infection was associated with substantial severity and mortality rates in COPD. Compared to former and never smokers, current smokers were at greater risk of severe complications and higher mortality rate. Effective preventive measures are required to reduce COVID-19 risk in COPD patients and current smokers. ]]> <![CDATA[What is the daily practice of mechanical ventilation in pediatric intensive care units? A multicenter study]]> https://www.researchpad.co/article/N018f0261-03b1-4f33-b563-87e6180c4217

Objective

To describe the daily practice of mechanical ventilation (MV), and secondarily, its outcome in pediatric intensive care units (PICUs).

Design

Prospective cohort of infants and children who received MV for at least 12 h.

Setting

Thirty-six medical surgical PICUs.

Patients

All consecutive patients admitted to the PICUs during 2-month period.

Measurements and main results

Of the 1893 patients admitted, 659 (35%) received MV for a median time of 4 days (25th percentile, 75%: 2, 6). Median of age was 13 months (25th percentile, 75%: 5, 48). Common indications for MV were acute respiratory failure (ARF) in 72% of the patients, altered mental status in 14% of the patients, and ARF on chronic pulmonary disease in 10% of the patients. Median length of stay in the PICUs was 8 days (25th percentile, 75%: 5, 13). Overall mortality rate in the PICUs was 15% (confidence interval 95%: 13–18) for the entire population, 50% (95% CI: 25–74) in patients who received MV because of acute respiratory distress syndrome, 24% (95% CI: 16–35) in patients who received MV for altered mental status and 16% (95% CI: 9–29) in patients who received MV for ARF on chronic pulmonary disease.

Conclusion

One in every 3 patients admitted to the PICUs requires ventilatory support.. The ARF was the most common reason for MV, and survival of unselected infants and children receiving MV for more than 12 h was 85%.

Electronic Supplementary Material

Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00134-004-2225-5

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<![CDATA[Acute hypoxemic respiratory failure in children: case mix and the utility of respiratory severity indices]]> https://www.researchpad.co/article/N310061c2-e9e1-4aad-a425-ac9ef0d95d76

Objective: Acute hypoxemic respiratory failure (AHRF) is a common reason for emergency pediatric intensive care. An objective assessment of disease severity from acute physiological parameters would be of value in clinical practice and in the design of clinical trials. We hypothesised that there was a difference in the best early respiratory indices in those who died compared with those who survived.

Design: A prospective observational study of 118 consecutive AHRF admissions with data analysis incorporating all blood gases.

Setting: A pediatric intensive care unit in a national children’s hospital.

Interventions: None.

Results: Mortality was 26/118,22% (95% confidence interval 18–26%). There were no significant differences in the best alveolar-arterial oxygen tension gradient (A-aDO2, torr), oxygenation index (OI), ventilation index (VI), or PaO2/FIO2 during the first 2 days of intensive care between the survivors and non-survivors. Only the mean airway pressure (MAP, cm H2O) used for supportive care was significantly different on days 0 and 1 (p≤0.05) with higher pressure being used in non-survivors. Multiple logistic regression analysis did not identify any gas exchange or ventilator parameter independently associated with mortality. Rather, all deaths were associated with coincident pathology or multi-organ system failure, or perceived treatment futility due to pre-existing diagnoses instead of unsupportable respiratory failure. When using previously published predictors of outcome (VI>40 and OI>40; A-aDO2>450 for 24 h; A-aDO2>470 or MAP>23; or A-aDO2>420) the risk of mortality was overestimated significantly in the current population.

Conclusion: The original hypothesis was refuted. It appears that the outcome of AHRF in present day pediatric critical care is principally related to the severity of associated pathology and now no longer solely to the severity of respiratory failure. Further studies in larger series are needed to confirm these findings.

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<![CDATA[“Less is More” in mechanical ventilation]]> https://www.researchpad.co/article/N71949069-0a84-412e-91bc-159a0db7c053 ]]> <![CDATA[Adjuvant therapies in critical care: steroids in community-acquired pneumonia]]> https://www.researchpad.co/article/N0646805c-5353-4b34-b0cb-9ee188d6a486 ]]> <![CDATA[What’s new in invasive pulmonary aspergillosis in the critically ill]]> https://www.researchpad.co/article/N522ea00b-eeea-462e-b295-098f01bc945b ]]> <![CDATA[How safe is non-bronchoscopic bronchoalveolar lavage in critically ill mechanically ventilated children?]]> https://www.researchpad.co/article/N867a8c54-9344-41d0-b109-607c0d9ebad6

Objective: To assess the safety of non-bronchoscopic bronchoalveolar lavage (NB-BAL) in critically ill mechanically ventilated children. Setting: Paediatric intensive care unit in a tertiary children's hospital. Methods: The data from 60 consecutive critically ill mechanically ventilated children who underwent NB-BAL was reviewed from November 1997 to December 1999. PRISM score prior to NB-BAL, observations at the time of NB-BAL and arterial blood gases, oxygenation index (OI), ventilator settings, haemodynamic variables and temperature taken at 1 h before, and 1 and 6 h after NB-BAL, were retrieved from the archived computerised database. Results: Median age was 7 months (IQR 2.8–43 months) and median weight was 5.5 kg (IQR 4–14 kg). Four (7%) patients exhibited significant immediate complications, requiring escalation of respiratory or haemodynamic support. Forty-two (70%) patients had complete data for calculation of OI; there was no significant change in median OI at 1 and 6 h after NB-BAL. However 5 (12%) of these patients experienced an increase in OI of between 10 and 45 at 1 h post NB-BAL, which returned to baseline at 6 h post NB-BAL. Complications did not correlate with any of the available variables: baseline OI, PRISM score or with deterioration at the time of the procedure, although it was observed that four out of the six patients with baseline OIs of greater than 20 experienced complications. Conclusion: Non-bronchoscopic bronchoalveolar lavage in critically ill mechanically ventilated neonates and children is generally a well-tolerated procedure, but for some patients, in whom it was not possible to elucidate predictive factors, complications developed. All patients, particularly those with OIs of greater than 20, require careful monitoring during and after the procedure.

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<![CDATA[Effect of inhaled nitric oxide on respiratory mechanics in ventilated infants with RSV bronchiolitis]]> https://www.researchpad.co/article/N2b23e84b-4569-494f-90b3-26e8fc5a73d7

Objective: To evaluate the bronchodilator effect of inhaled nitric oxide (NO) in infants with respiratory failure caused by respiratory syncytial virus (RSV) bronchiolitis and to compare the effect with the one obtained by salbutamol. Design: Prospective study. Setting: Pediatric intensive care unit of a university children's hospital. Patients: Twelve acutely ill, intubated infants (mean age 4.5 months, mean weight 4.9 kg) with respiratory failure due to documented RSV bronchiolitis. Interventions: Total respiratory system resistance (Rrs) was measured by single breath occlusion at the baseline and after inhaling NO at 20, 40 and 60 ppm for 1 h, and after inhalation of a standard β 2-agonist, salbutamol. Arterial blood gas analysis was performed at each study level on 6 of the 12 patients. Results: The baseline mean Rrs (SE) was 0.29 (0.04) cm H2O/ml per s. At each dose of NO, the mean Rrs (SE) was 0.28 (0.04) cm H2O/ml per s. With salbutamol, the mean Rrs (SE) was 0.21 (0.03) cm H2O/ml per s. These values were not significantly different from each other (by ANOVA). Inhaled NO produced a significant decrease in Rrs of greater than 4 times the coefficient of variation of the baseline measurement in 3 of 12 patients. Seven of 12 patients had no significant change while two patients had a significant increase in Rrs. Inhaled salbutamol produced a significant decrease in Rrs in 5 of 11 patients, while 6 showed no change in Rrs. Conclusion: Inhaled NO has no apparent bronchodilator effect in the majority of acutely ill infants with RSV bronchiolitis and does not appear to provide any additional benefit over the use of salbutamol. The clinical benefit of inhaled NO as a bronchodilator is questionable under these conditions.

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<![CDATA[Kaposi’s sarcoma: a reversible cause of ARDS in HIV-infected patient]]> https://www.researchpad.co/article/N18f92cfa-c691-483c-a4b8-d80c83294ee2 ]]> <![CDATA[Mechanical ventilation alters the immune response in children without lung pathology]]> https://www.researchpad.co/article/N20f84536-a220-4c9b-ab49-7391e0be62ff

Abstract.

Objective: This study was undertaken to examine the hypothesis that mechanical ventilation in association with anesthesia would alter the cytokine profile in infants without preexisting lung pathology. Design and setting: Prospective observational study in pediatric intensive care unit in a university hospital. Patients: Twelve infants who were subjected to an uncomplicated diagnostic cardiac catheterization procedure were studied. All subjects were ventilated with a volume control mode, 0.3 FIO2, 4 cmH2O PEEP, and 10 ml/kg tidal volume. Volatile (servoflurane) anesthetics were given. Measurements and results: Tracheal aspirates and blood samples were obtained before and after 2 h of mechanical ventilation. In tracheal aspirates and in supernatants of stimulated whole-blood cultures cytokine concentrations were measured. In the tracheal aspirates the immune balance was characterized by a proinflammatory response pattern, with a significant increase in TNF-α and IL-6 concentrations; concentrations of anti-inflammatory mediators remained very low. The functional capacity of peripheral blood leukocytes to produce INF-γ, TNF-α, and IL-6 in vitro was significantly decreased. This was accompanied by a significant decrease in the killing activity of natural killer cells. Conclusions: Two hours of servoflurane and mechanical ventilation using a tidal volume of 10 ml/kg is associated with remarkable changes in the immune response in infants without preexisting lung pathology undergoing cardiac catheterization. In the lungs the immune balance favors a proinflammatory response pattern without detectable concentrations of anti-inflammatory mediators. The Th1 immune response by peripheral blood leukocytes was decreased. The observed change in Th1/Th2 balance in favor of Th2 cytokine activity may be a systemic adaptation to the proinflammatory milieu in the lung.

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<![CDATA[Surfactant adjunctive therapy forPneumocystis carinii pneumonitis in an infant with acute lymphoblastic leukaemia]]> https://www.researchpad.co/article/N88e02d23-e641-4474-88ad-0501a1932d30

We report successful treatment of adult respiratory distress syndrome (ARDS) with artificial surfactant (40mg/kg, Colfosceril Palmitate, ‘Exosurf’, Wellcome) in an infant with severePneumocystis carinii pneumonitis.

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<![CDATA[Treatment with bovine surfactant in severe acute respiratory distress syndrome in children: a randomized multicenter study]]> https://www.researchpad.co/article/Nf9390599-2cb9-4127-8dca-1701428ffad4

Objective

To determine whether bovine surfactant given in cases of severe pediatric acute respiratory distress syndrome (ARDS) improves oxygenation.

Design

Single-center study with 19 patients, followed by a multicenter randomized comparison of surfactant with a standardized treatment algorithm. Primary endpoint PaO2/FIO2 at 48 h, secondary endpoints: PaO2/FIO2 at 2, 4, 12, and 24 h, survival, survival without rescue, days on ventilator, subgroups analyzed by analysis of variance to identify patients who might benefit from surfactant

Setting

Multicenter study in 19 reference centers for ARDS.

Patients

Children after the 44th postconceptional week and under 14 years old, admitted for at least 4 h, ventilated for 12–120 h, and without heart failure or chronic lung disease. In the multicenter study 35 patients were recruited; 20 were randomized to the surfactant group and 15 to the nonsurfactant group. Decreasing recruitment of patients led to a preliminary end of this study.

Interventions

Administration of 100 mg/kg bovine surfactant intratracheally under continuous ventilation and PEEP, as soon as the PaO2/FIO2 ratio dropped to less than 100 for 2 h (in the pilot study increments of 50 mg/kg as long as the PaO2/FIO2 did not increase by 20%). A second equivalent dose within 48 h was permitted.

Results

In the pilot study the PaO2/FIO2 increased by a mean of 100 at 48 h (n=19). A higher PaO2/FIO2 ratio was observed in the surfactant group 2 h after the first dose (58 from baseline vs. 9), at 48 h there was a trend towards a higher ratio (38 from baseline vs. 22). The rate of rescue therapy was significantly lower in the surfactant group. Outcome criteria were not affected by a second surfactant dose (n=11). A significant difference in PaO2/FIO2 in favor of surfactant at 48 h was found in the subgroup with an initial PaO2/FIO2 ratio higher than 65 and in patients without pneumonia.

Conclusions

Surfactant therapy in severe ARDS improves oxygenation immediately after administration. This improvement is sustained only in the subgroup of patients without pneumonia and that with an initial PaO2/FIO2 ratio higher than 65

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<![CDATA[What’s new in severe community-acquired pneumonia? Corticosteroids as adjunctive treatment to antibiotics]]> https://www.researchpad.co/article/Nd73185e7-a5c3-41b4-adff-66ed84b0c4e3 ]]> <![CDATA[Is this critically ill patient immunocompromised?]]> https://www.researchpad.co/article/Ned96fef0-7490-45cc-90cc-7004234bf2b3 ]]> <![CDATA[Research in community-acquired pneumonia: the next steps]]> https://www.researchpad.co/article/Nf2bd1c83-d94a-4211-8a10-a3ed87e3461d ]]> <![CDATA[Current management and outcome of tracheobronchial malacia and stenosis presenting to the paediatric intensive care unit]]> https://www.researchpad.co/article/N40dc25c4-05e5-4096-9ddc-45e15bcd78e4

Objective: To identify factors associated with mortality and prolonged ventilatory requirements in patients admitted to our paediatric intensive care unit (PICU) with tracheobronchial malacia and stenosis diagnosed by dynamic contrast bronchograms. Design: Retrospective review. Setting: Tertiary paediatric intensive care unit. Patients: Forty-eight cases admitted to our PICU over a 5-year period in whom a diagnosis of tracheobronchial malacia or stenosis was made by dynamic contrast bronchography (1994–1999). Interventions: Conservative management, tracheostomy and long-term ventilation, surgical correction, internal or external airway stenting. Measurements and results: Recording of clinical details, length of invasive ventilation and appearance at contrast bronchography. Five groups of patients were defined: isolated primary airway pathology (n=7), ex-premature infants (n=11), vascular rings (n=9), complex cardiac and/or syndromic pathology (n=17) and tracheo-oesophageal fistulae (n=4). The overall mortality was 29%. Median length of invasive ventilation in survivors was 38 days and in patients who died 45. Mortality was highest in the patients with complex cardiac and/or syndromic pathology (p=0.039 Cox regression analysis) but was not related to any other factor. Patients with stenosis required a significantly longer period of ventilatory support (median length of ventilation 59 days) than patients with malacia (39 days). Conclusions: Length of ventilation and bronchographic diagnosis did not predict survival. The only factor found to contribute significantly to mortality was the presence of complex cardiac and/or syndromic pathology. However, patients with stenosis required longer ventilatory support than patients with malacia.

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<![CDATA[Inability to predict outcome of acute respiratory distress syndrome in children when using high frequency oscillation]]> https://www.researchpad.co/article/N690b839f-df6e-46f6-aff8-845d5c24305d

Objective

To (a) describe the experience with high-frequency oscillation (HFO) in children with acute respiratory distress syndrome (ARDS) unresponsive to conventional ventilation; (b) compare observed survival to that predicted by pediatric mortality scores and (c) determine if oxygenation index changes during HFO can predict survival.

Design

Retrospective, observational study.

Setting

A university hospital pediatric intensive care unit.

Patients

Nineteen children with ARDS (PaO2/FIO2<200) unresponsive to conventional ventilation treated with HFO from January 1995 to September 1996.

Interventions

None.

Measurements and results

The following were recorded: demographic, arterial blood gas and ventilator variables at the time points 0, 6, 12 and 24 h after the start of HFO; PRISM in the first 24 h of admission and pediatric respiratory failure and multiple organ system failure scores on the day of starting HFO. The mortality rate was 26% (5/19). The survival was better than predicted by the Pediatric Respiratory Failure score (p<0.01). None of the scores differentiated survivors from non-survivors (p>0.25). There was no significant change in oxygenation index over the first 24 h (p>0.18). Of patients with an initial oxygenation index higher than 20 who did not have at least a 20% reduction in oxygenation index by the time 6 h, 6/9 (67%) survived (sensitivity 75%, specificity 57%).

Conclusions

Survival in pediatric ARDS patients treated with HFO could not be predicted using several outcome scores or the oxygenation index (in the first 24 h). Survival was significantly better than predicted by the Pediatric Respiratory Failure score. A prospective randomized controlled trial of HFO in ARDS is warranted.

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<![CDATA[Use of permissive hypercapnia in the ventilation of infants with respiratory syncytial virus infection]]> https://www.researchpad.co/article/N30b0390c-e39b-44a6-9256-7cd9c72a4efe

We wished to retrospectively evaluate the effects of permissive hypercapnia (PHY) on barotrauma, mortality and length of stay when applied to ventilated infants with respiratory syncytial virus (RSV) bronchiolitis. Nineteen control infants with RSV induced respiratory failure were treated with conventional ventilation (April 1991–January 1994), after which time PHY was adopted as unit policy. A further 28 infants were then treated with PHY (January 1994–April 1996). Demographic and physiological data were collected from admission, and outcome variables including length of stay, barotrauma and mortality were recorded. The PHY group showed a significantly higher mean pCO2 (7.6 vs 5.2 kPa), a lower mean pH (7.34 vs 7.40), and a reduction in maximal peak inspiratory pressures (25 vs 30 cmH2O). Mortality, barotrauma, use of neuromuscular blockade and nosocomial infection did not differ between groups. There was a trend towards increased length of ventilation in the PHY group (median 7 vs 5 days).

Conclusion Based on this retrospective data we can show no benefit for the use of permissive hypercapnia as a ventilatory strategy in this patient group. A prospective randomised controlled trial is warranted to accurately assess the outcome variables and cost implications of this strategy.

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