ORCID Profile
0000-0003-3543-1014
Current Organisations
Monash University
,
Cabrini Hospital
,
Murdoch Children’s Research Institute
,
Royal Children’s Hospital
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Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2011
Publisher: Jornal de Pediatria
Date: 15-02-2012
DOI: 10.2223/JPED.2165
Publisher: Wiley
Date: 08-2009
DOI: 10.5694/J.1326-5377.2009.TB02735.X
Abstract: Extracorporeal membrane oxygenation (ECMO) is a technique that involves oxygenation of blood outside the body, and provides support to selected patients with severe respiratory or cardiac failure. The two major ECMO modalities are venoarterial and venovenous. Data from several randomised trials support the use of ECMO in neonatal respiratory failure, and a recent randomised controlled trial of ECMO in adults has produced encouraging results. The evidence base for ECMO use in cardiac disease is developing, but progress has been slowed by considerations of clinical equipoise and evolving indications for ECMO. Advancing ECMO technology and increasing experience with ECMO techniques have improved patient outcomes, reduced complications and expanded the potential applications of ECMO. Awareness of the indications and implications of ECMO among doctors managing patients with severe but potentially reversible respiratory or cardiac failure may help facilitate better communication between health care teams and improve patient recovery.
Publisher: Wiley
Date: 10-1990
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2015
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.1016/J.THROMRES.2008.07.009
Abstract: Unfractionated Heparin (UFH) is used widely in paediatrics. Paediatric specific recommendations for UFH therapy are few, with the majority of recommendations being extrapolated from adult practice. In vitro studies have shown that this practice may be suboptimal. This study aimed to improve the understanding of the impact of age upon UFH response in vivo. This prospective, observational study, conducted in the Paediatric Intensive Care Unit (PICU), included: patients 16 years or younger treated with UFH of at least 10 U/Kg/hr. Laboratory analysis included: Antithrombin, APTT, Anti-Xa, Anti-IIa and thrombin generation expressed as the Endogenous Thrombin Potential. Results were grouped according to patient age (i.e. <1, 1-5, 6-10 and 11-16 years). 85 patients received an equivalent mean UFH dose with a median duration of 3 days. Antithrombin levels were decreased compared to age-related norms in children up to 11 years of age. APTT results were comparable across the age-groups. The Anti-Xa results using two different assays showed a trend for lower values in younger children. All children less than one year old recorded Anti-Xa values outside the therapeutic range for heparin therapy, for both assays. There was a trend for decreased Anti-IIa activity in younger children. Endogenous Thrombin Potential showed a significant trend for increased inhibition in older children. In vitro Antithrombin supplementation did not change the Anti-Xa or thrombin generation. This study confirms that, in vivo, for the same dose of UFH, the anti Xa and anti IIa effect, as well as the inhibition of endogenous thrombin potential is age dependent and that these differences are not purely AT dependent. The implication is that the anticoagulant and antithrombotic effect of a given dose of UFH differs with age. Clinical outcome studies to determine the optimal dosing for each age group are warranted.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1995
Publisher: BMJ
Date: 08-1990
DOI: 10.1136/ADC.65.8.896
Abstract: Five children who developed diabetes insipidus as a manifestation of severe brain injury received continuous intravenous treatment with a solution containing both aqueous vasopressin and appropriate crystalloid replacement. Polyuria, hypernatraemia, and decreased urine osmolalities were safely corrected in all patients within eight to 28 hours.
Publisher: Springer Science and Business Media LLC
Date: 22-07-1999
Abstract: To evaluate the outcome of children 1 and 5 years after severe brain injury (Glasgow Coma Score < 8) using a functional measure [Glasgow Outcome Scale (GOS)] and a health status measure (the Torrance Health State (HUI:1)) and to determine the ability of somatosensory evoked potentials (SEPs) to predict these long-term outcomes. Prospective study. A 16-bed paediatric intensive care unit in a tertiary children's hospital. 105 children with severe brain injury. SEPs were recorded once in the first week after admission. Outcome was assessed 1 and 5 years after injury using the GOS and at 5 years after injury using HUI:1. At 5 years, using the GOS, 46 (43.8%) children had a good outcome, 10 (9.5%) were moderately disabled, 2 (1.9%) severely disabled, 3 (2.9%) vegetative and 44 (41.9%) had died. At 5 years, 17 of 40 (42.5%) survivors from 1 year had changed outcomes: 12 had improved, 3 had worsened and 2 had died. For a normal SEP, positive predictive power was 85.4%, sensitivity 62.5%, specificity 87.8%, negative predictive power 67.2% and the positive likelihood ratio was 5.1. For bilaterally absent responses, positive predictive power was 90.9%, sensitivity 61.2%, specificity 94.6% negative predictive power 73.6% and the positive likelihood ratio was 11.4. Outcomes using HUI:1 were: 30 (28.6%) had a good quality of life, 21 (20.0%) had a moderate quality of life, 7 (6.7%) a poor quality, 44 died (41.9%) and 3 (2.9%) survived in a state deemed worse than death. For a normal SEP, positive predictive power was 85.4%, sensitivity 68.6%, specificity 88.9%, negative predictive power 75.0% and the positive likelihood ratio was 6.2. For bilaterally absent responses, positive predictive power was 93.9%, sensitivity 57.4%, specificity 96.1%, negative predictive power 68.1% and the positive likelihood ratio was 14.6. The outcome for children with severe brain injury should be assessed 5 years after injury because important changes occur between 1 year and 5 years. Differences exist between outcomes assessed using the GOS and HUI:1 as they measure slightly different aspects of function. Consideration should therefore be given to using both measures. SEPs are excellent predictors of long-term outcome measured by either the GOS or the HUI:1.
Publisher: Elsevier BV
Date: 10-2017
Publisher: Elsevier BV
Date: 12-2019
DOI: 10.1016/J.HLC.2018.11.003
Abstract: Reported incidence of in hospital cardiac arrest (IHCA) after paediatric cardiac surgery varies between 3-4% in high income countries and this risk may have changed over time. We sought to examine this trend in detail. A retrospective observational study of 3,781 children who underwent 4,938 cardiac surgeries between 1 January 2007 and 31 December 2016 in a tertiary children's hospital. IHCA was defined as cessation of cardiac mechanical activity requiring cardiac massage for ≥1minute. Surgical complexity was categorised using risk adjusted congenital heart surgery (RACHS-1) category. Poisson regression was used to analyse trends for every two-year period. There were a total of 211 (4.3%) IHCA events after surgery. These patients were younger, more likely to have had a premature birth, have a chromosomal or genetic syndrome association and have a high surgical complexity. Overall, there was a 52% reduction in IHCA rate over 10 years: reducing from 5.4 /100 surgeries in 2007-08 to 2.6/100 surgeries in 2015-16 (p-trend=<0.001). The reduction was mainly seen in low-to-moderate risk categories (RACHS-1 categories 1-4) and not in high risk categories (RACHS-1 category 5-6). Children in high risk categories were 13.6 times more likely to experience an IHCA (compared to low risk categories). Overall hospital mortality for children suffering IHCA decreased from 42.5/100 patients in 2007-08 to 11.1/100 patients in 2015-16 (p-trend=0.037). The IHCA rate following cardiac surgery has more than halved over the last decade children who experience IHCA also have lower mortality than in previous years. High risk procedures still have a substantial rate of IHCA and efforts are needed to minimise the burden further in this population.
Publisher: Elsevier BV
Date: 06-2019
Publisher: Elsevier BV
Date: 11-1994
DOI: 10.1016/0022-3468(94)90140-6
Abstract: Over the past decade, the survival rate of infants with congenital diaphragmatic hernia (CDH) treated in the intensive care unit of the Royal Children's Hospital, Melbourne, has remained unchanged at 56% +/- 6%. Newer forms of treatment, such as extracorporeal membrane oxygenation (ECMO), high-frequency oscillation, and surfactant and nitric oxide therapy, are now available. The exact role of these therapies in the management of infants with CDH has not been determined. This study examines five clinical parameters derived from an infant's best preoperative ventilatory and blood gas data in the first 24 hours of life. One hundred twenty-five CDH infants were admitted to the intensive care unit between January 1, 1981 and December 31, 1991. Criteria for inclusion in the study were (1) CDH diagnosed within 6 hours of delivery, (2) ventilation before repair, and (3) no associated lethal congenital abnormality. Of the 90 cases studied in detail, there were 38 deaths (42% mortality rate). All five parameters were analyzed by receiver operating curve analysis to determine the optimum value of each parameter in predicting survival. An oxygenation index (MAP x FIO2/PaO2) of less than 0.08 predicted a 94% chance of survival, with a sensitivity of 96% and a specificity of 95%. Similarly, a modified ventilation index (PIP x RR x CO2/1,000) of less than 40 predicted a 91% chance of survival, with a sensitivity of 94% and a specificity of 86%. By stratifying each criterion according to outcome, three groups of infants were identified according to their response to conventional therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-1993
Publisher: Elsevier BV
Date: 08-1992
Publisher: SAGE Publications
Date: 07-01-2021
Abstract: COVID results in a variety of pathophysiology that causes cardiorespiratory and the need for ECMO. These include hypoxic respiratory failure, cardiogenic shock, cardiac arrest, multisystem inflammatory disease, and vascular thrombosis with pulmonary embolism. A variety of cannulation strategies are required and the “hyperinflammation” and consequent coagulation abnormalities mandate new strategies to provide optimal ECMO support.
Publisher: BMJ
Date: 29-09-2018
DOI: 10.1136/ARCHDISCHILD-2016-312429
Abstract: To describe the effect of extracorporeal membrane oxygenation (ECMO) on survival and cardiac outcome of neonates with myocardial failure secondary to severe enterovirus (EV) myocarditis. Retrospective case series. A 15-bed cardiac paediatric intensive care unit (ICU). We describe the clinical presentations, cardiac findings, ECMO characteristics and outcome of seven neonates with severe EV myocarditis. Additionally, 35 previously reported cases of EV myocarditis supported with ECMO are presented. Extracorporeal membrane oxygenation. Seven neonates presented with cardiovascular collapse within the first 10 days after birth and required ECMO support. Echocardiography showed left ventricular dysfunction in all and additional right ventricular dysfunction in four patients. ECG showing widespread ST changes as well as elevated troponin I indicated myocardial damage. All patients were cannulated onto ECMO shortly after ICU admission. None of the patients suffered cardiac arrest prior to ECMO initiation. Four patients survived ECMO and three survived to hospital discharge. All three survivors showed complete cardiac recovery after a median follow-up of 34 months. The survival rate in 35 previously reported cases was 34% (12/35) and including our seven cases 36% (15/42). In this case series, ECMO initiation prevented further deterioration and cardiac arrest in neonates with severe EV myocarditis and not responding to conventional medical therapies. Moreover, complete cardiac recovery occurred in survivors. However, these neonates may need long ECMO runs and are at increased risk for mechanical complications. Furthermore, mortality remains high due to greater disease severity.
Publisher: Elsevier BV
Date: 12-2006
DOI: 10.1016/J.INJURY.2006.07.011
Abstract: Assessing outcomes in the paediatric trauma population is important. Identifying suitable instruments can be problematic. This article highlights the commonly used outcome measures for assessing functional status and health related quality of life in paediatric trauma patients. Child specific characteristics which impact upon instrument development and selection are reviewed. An electronic database search was conducted to identify suitable English language measures used for outcome assessment in paediatric trauma patients from 1966 to present. Nine suitable instruments were identified, the child health questionnaire (CHQ), Glasgow outcome scale (GOS), paediatric overall performance category (POPC), PedsQL 4.0 generic core scales, paediatric evaluation of disability inventory (PEDI), functional independence measure (FIM), WeeFIM and an unnamed paediatric trauma specific measure [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995 :977-84]. Each instrument was found to have advantages and disadvantages for assessing outcomes in a paediatric trauma population. The PedsQL 4.0 generic core scale could be feasible for administration as a routine outcome measure for paediatric trauma groups. For very young children an additional measure such as that proposed by Gofin et al. [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995 :977-84] may be indicated. Future use of these instruments in the paediatric population would benefit from further psychometric evaluation.
Publisher: Wiley
Date: 08-1989
DOI: 10.1111/J.1440-1754.1989.TB01466.X
Abstract: A 6 year old child is described with infection due to herpes simplex virus type 1 causing brain stem encephalitis. The diagnosis was established by enzyme immunosorbent assays of the cerebrospinal fluid and serum which demonstrated antibody responses to herpes simplex virus. Recovery occurred and the importance of early use of acyclovir in achieving a good outcome is emphasized.
Publisher: Oxford University Press (OUP)
Date: 10-2010
DOI: 10.1510/ICVTS.2010.239210
Abstract: This study aims to evaluate the impact of a change in extracorporeal membrane oxygenation (ECMO) technology on patient and circuit outcomes. A retrospective single-centre study of all ECMO runs from 1988 to 2006 was performed. Predictors of survival to hospital discharge (primary outcome measure) were evaluated in the entire cohort by univariate and multivariate analysis. A detailed subgroup univariate and multivariate analysis was performed in the cardiac and respiratory groups to identify predictors of survival to hospital discharge. A total of 275 patients underwent 294 extracorporeal support runs at a median (interquartile range) age of 40 (3-639) days and weight of 4.0 (3.1-10) kg. The primary indications for support were respiratory (41.8%), cardiac (45.6%) and sepsis (12.6%). Between the initial (Era 1) and most recent era (Era 3), cardiac support became the predominant ECMO indication (26 of 127 vs. 59 of 107 P<0.001). Survival to decannulation, intensive care and hospital discharge for the entire cohort and Era 3 patients were 50.0%, 48.9%, 44.4% and 71.7%, 55.6%, 52.6% (P<0.003), respectively. Treatment in Era 3 was associated with increased survival to intensive care discharge (P=0.02) for all ECMO patients. Cardiac survival was associated with treatment in Era 3 (P=0.04) and a lower complexity score (P<0.001). There was a significant reduction in mechanical circuit complications in the respiratory ECMO subgroup. A significant improvement in patient survival outcomes and reduction in mechanical circuit complications was noted in the current era. This improvement was associated with a change in ECMO technology.
Publisher: SAGE Publications
Date: 12-2005
DOI: 10.1177/0310057X0703500623
Abstract: Pupillary responses are a simple test commonly used as a predictor of outcome after severe brain injury. It is also common for clinicians to associate bilaterally absent pupillary responses with very poor prognosis. We report a series of cases of severely brain injured children with bilaterally absent pupillary responses who had favourable outcomes. From a group of 89 patients with brain injury, 32 had bilaterally absent pupillary responses and six (four with traumatic brain injury and two with infective brain injury) subsequently had favourable outcomes. This represents 18.8% of patients and should be a reminder to clinicians that the clinical sign of bilaterally absent pupillary responses is not always associated with a hopeless outcome.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-09-2020
DOI: 10.1097/CCM.0000000000004622
Abstract: Milrinone is an inodilator widely used in the postoperative management of children undergoing cardiac surgery. The literature supporting its inotropic effect is sparse. We sought to study the effect of milrinone on the vasculature and its effects on the ventricular function using wave intensity analysis. We also intended to evaluate the feasibility of using wave intensity analysis by the bedside. prospective single-center observational study. PICU of a tertiary children’s hospital. Children ( 18 yr) admitted to PICU following cardiac surgery who required to be commenced on a milrinone infusion. Echocardiography and Doppler ultrasound assessments for wave intensity analysis were performed prior to commencing milrinone and 4–6 hours after milrinone infusion. Wave intensity analysis was successfully performed and analyzed in 15 of 16 patients (94%). We identified three waves—a forward compression wave, backward compression wave, and forward decompression wave. The waves were described with their cumulative intensity and wave-related pressure change. There was a 26% reduction in backward compression wave cumulative intensity following the introduction of milrinone. Other variables (backward compression wave cumulative intensity/forward compression wave cumulative intensity ratio, backward compression wave wave-related pressure change, backward compression wave wave-related pressure change/forward compression wave wave-related pressure change ratio) consistent with vasodilation also decreased after milrinone. It also decreased the vascular wavespeed by 7.1% and increased the distensibility of the vessels by 14.6%. However, it did not increase forward compression wave cumulative intensity, a variable indicating the systolic force generated by the ventricle. Forward decompression wave cumulative intensity indicating ventricular early diastolic relaxation also did not change. In a cohort of children recovering in PICU after having undergone cardiac surgery, we found that milrinone acted as a vasodilator but did not demonstrate an improvement in the contractility or an improved relaxation of the left ventricle as assessed by wave intensity analysis. We were able to demonstrate the feasibility and utility of wave intensity analysis to further understand ventriculo-vascular interactions in an intensive care setting.
Publisher: Elsevier BV
Date: 03-1985
DOI: 10.1016/S0022-3476(85)80684-3
Abstract: Timing of obesity development during childhood and adolescence is unclear, hindering preventive strategies. The primary aim of the present study was to quantify the incidence of overweight and obesity throughout childhood and adolescence in a large contemporary cohort of English children (the Avon Longitudinal Study of Parents and Children, ALSPAC children born 1991-1992). A secondary aim was to examine the persistence of overweight and obesity. Longitudinal data on weight and height were collected annually from age 7-15 years in the entire ALSPAC cohort (n=4283), and from 3 to 15 years in a randomly selected subs le of the cohort (n=549 'Children in Focus' CiF). Incidence of overweight and obesity (BMI (Body mass index) at or above the 85th and 95th centiles relative to U.K. reference data) was calculated. Risk ratios (RR) for overweight and obesity at 15 years based on weight status at 3, 7, and 11 years were also calculated. In the entire cohort, four-year incidence of obesity was higher between ages 7 and 11 years than between 11 and 15 years (5.0% vs. 1.4% respectively). In the CiF sub-s le, four-year incidence of obesity was also highest during mid-childhood (age 7-11years, 6.7%), slightly lower during early childhood (3-7 years, 5.1%) and lowest during adolescence (11-15 years 1.6%). Overweight and obesity at all ages had a strong tendency to persist to age 15 years as indicated by risk ratios (95% CI (Confidence interval)) for overweight and obesity at 15 years from overweight and obesity (relative to healthy weight status) at 3 years (2.4, 1.8-3.1), 7 years (4.6, 3.6-5.8), and 11 years (9.3, 6.5-13.2). Mid-late childhood (around age 7-11 years) may merit greater attention in future obesity prevention interventions.
Publisher: SAGE Publications
Date: 02-2005
DOI: 10.1177/0310057X0503300118
Abstract: A 45-year-old woman presented to the emergency department of a tertiary referral hospital after taking an overdose of verapamil, doxepin, quetiapine, diazepam, temazepam, and clonazepam. She rapidly developed shock refractory to pharmacological support and was placed on percutaneous venoarterial extracorporeal membrane oxygenation (ECMO). She had a severe metabolic acidosis from a combination of shock and drug intoxication that improved with continuous venovenous haemodialysis. Forty-eight hours after presentation, while still on ECMO, the patient had complete cardiac standstill for three and a half hours, attributable to slow-release verapamil, that resolved after the commencement of plasmapheresis. The role of plasmapheresis in verapamil overdose requires further study.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
Publisher: Wiley
Date: 20-10-2014
DOI: 10.1111/AOR.12390
Abstract: We aimed to determine the effect of elective left heart decompression at the time of initiation of central venoarterial extracorporeal membrane oxygenation (VA ECMO) on VA ECMO duration and clinical outcomes in children in a single tertiary ECMO referral center with a large pediatric population from a national referral center for pediatric cardiac surgery. We studied 51 episodes of VA ECMO in a historical cohort of 49 pediatric patients treated between the years 1990 and 2013 in the Paediatric Intensive Care Unit (PICU) of the Royal Children's Hospital, Melbourne. The cases had a variety of diagnoses including congenital cardiac abnormalities, sepsis, myocarditis, and cardiomyopathy. Left heart decompression as an elective treatment or an emergency intervention for left heart distension was effectively achieved by a number of methods, including left atrial venting, blade atrial septostomy, and left ventricular cannulation. Elective left heart decompression was associated with a reduction in time on ECMO (128 h) when compared with emergency decompression (236 h) (P = 0.013). Subgroup analysis showed that ECMO duration was greatest in noncardiac patients (elective 138 h, emergency 295 h P = 0.02) and in patients who died despite both emergency decompression and ECMO (elective 133 h, emergency 354 h P = 0.002). As the emergency cases had a lower pH, a higher PaCO2 , and a lower oxygenation index and were treated with a higher mean airway pressure, positive end-expiratory pressure, and respiratory rate prior to receiving VA ECMO, we undertook multivariate linear regression modeling to show that only PaCO2 and the timing of left heart decompression were associated with ECMO duration. However, elective left heart decompression was not associated with a reduction in length of PICU stay, duration of mechanical ventilation, or duration of oxygen therapy. Elective left heart decompression was not associated with improved ECMO survival or survival to PICU discharge. Elective left heart decompression may reduce ECMO duration and has therefore the potential to reduce ECMO-related complications. A prospective, randomized controlled trial is indicated to study this intervention further.
Publisher: Springer Science and Business Media LLC
Date: 27-04-2021
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.ATHORACSUR.2011.04.007
Abstract: After weaning from mechanical circulatory support with extracorporeal membrane oxygenation or ventricular assist devices, patients may recurrently deteriorate and require reinstitution of support. Potential benefits of this desperate strategy are not well documented. We reviewed the hospital records of all patients in whom second-run mechanical circulatory support was instituted from May 1988 to August 2010. Second-run support was instigated in 26 (4.6%) of 567 patients who underwent short-term mechanical circulatory support. Underlying pathologies requiring support were cardiac in 20 patients (76.9%) and noncardiac in 6 patients (23.1%).The majority of patients were younger than 1 year old (73.1%, n=19). Fifteen patients (57.7%) survived second-run support, but only 7 patients (26.9%) survived to discharge from the hospital. After a median follow-up of 42.5 months (range, 16 to 66 months), 4 patients (15.4%) were alive, but 3 of them had various degrees of developmental delay. Selection of patients who can benefit from second-run support is a complex process with unpredictable results. Survival after second-run mechanical circulatory support in children is worse compared with single-run patients. Long-term prospects for survivors are so grim that this strategy should probably not be recommended.
Publisher: Springer Science and Business Media LLC
Date: 30-09-2016
DOI: 10.1007/S00134-016-4420-6
Abstract: Cardiopulmonary bypass induces an ischaemia-reperfusion injury and systemic inflammatory response, which contributes to low cardiac output syndrome following cardiac surgery. Exogenous nitric oxide during cardiopulmonary bypass has shown potential to ameliorate such injury. We undertook a large randomised controlled trial to investigate the clinical effects of administering nitric oxide to the cardiopulmonary bypass circuit in children. After written informed consent, children were randomised to receive 20 ppm nitric oxide to the gas inflow of the cardiopulmonary bypass oxygenator, or standard conduct of bypass. 101 children received nitric oxide and developed low cardiac output syndrome less frequently (15 vs. 31 %, p = 0.007) than the 97 children who did not receive nitric oxide. This effect was most marked in children aged less than 6 weeks of age (20 vs. 52 %, p = 0.012) and in those aged 6 weeks to 2 years (6 vs. 24 %, p = 0.026), who also had significantly reduced ICU length of stay (43 vs. 84 h, p = 0.031). Low cardiac output syndrome was less frequent following more complex surgeries if nitric oxide was administered (17 vs. 48 %, p = 0.018). ECMO was used less often in the nitric oxide group (1 vs. 8 %, p = 0.014). Delivery of nitric oxide to the oxygenator gas flow during paediatric cardiopulmonary bypass reduced the incidence of low cardiac output syndrome by varying degrees, according to age group and surgery complexity. ACTRN12615001376538.
Publisher: Elsevier BV
Date: 03-2020
DOI: 10.51893/2020.1.SR1
Abstract: Inhaled nitric oxide has been used for 30 years to improve oxygenation and decrease pulmonary vascular resistance. In the past 15 years, there has been increased understanding of the role of endogenous nitric oxide on cell surface receptors, mitochondria, and intracellular processes involving calcium and superoxide radicals. This has led to several animal and human experiments revealing a potential role for administered nitric oxide or nitric oxide donors in patients with systemic inflammatory response syndrome or ischaemia–reperfusion injury, and in patients for whom exposure of blood to artificial surfaces has occurred.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2009
Publisher: Elsevier BV
Date: 12-1997
Publisher: SAGE Publications
Date: 21-07-2018
Abstract: We describe our experience of 30 consecutive children supported with ECMO and receiving 20 ppm of nitric oxide in the oxygenator of the ECMO circuit. Administration of nitric oxide into the ECMO circuit is safe and could potentially mitigate ischaemia reperfusion injury and end-organ dysfunction of children requiring mechanical support.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2017
DOI: 10.1097/PCC.0000000000001334
Abstract: To identify the prevalence, causes, risk factors, and outcomes associated with extubation failure following first stage single ventricle reconstruction surgery. Retrospective cohort analysis of neonates who underwent a first stage single ventricle reconstruction operation. Extubation failure was defined as endotracheal reintubation within 48 hours of first extubation attempt. The Royal Children’s Hospital, Melbourne. Data were collected for all infants who underwent a Norwood or Damus-Kaye-Stansel procedure between 2005 and 2014 at our institution. None. Extubation failure occurred in 23 of 137 neonates (16.8% 95% CI, 11.0–24.1%) who underwent a trial of extubation. Overall, 42 patients (30.7%) were extubated to room air, 88 (64.2%) to nasal continuous positive airway pressure, and seven (5.1%) to high-flow nasal cannulae, though there was no major difference in extubation failure rates between these three groups ( p = 0.37). The median time to reintubation was 16.7 hours (interquartile range, 3.2–35.2), and male infants failed extubation more frequently (63.2% vs 87.0% p = 0.02), although age, gestation, weight, cardiac diagnosis (hypoplastic left heart syndrome vs other single ventricle conditions), shunt type (modified Blalock-Taussig vs right ventricle-pulmonary artery shunt), intraoperative perfusion times, preextubation mechanical ventilation duration, preextubation acid-base status, and postoperative fluid balance were not related to extubation outcome. Infants who failed extubation had a higher intensive care mortality (19.4% vs 3.5% p = 0.03) and in-hospital mortality (30.4% vs 6.1% p 0.001). There is a high prevalence of extubation failure following first stage single ventricle reconstruction, and this is associated with considerably worse patient outcomes. The high prevalence and also the wide variation in rates of extubation failure in reported literature provide with an opportunity for implementation of quality assurance activities to minimize this complication and improve outcomes.
Publisher: Wiley
Date: 2010
DOI: 10.1002/NAU.20870
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2020
DOI: 10.1097/PCC.0000000000002305
Abstract: To examine the effects of patient and treatment variables on circuit lifespan in critically ill children requiring continuous renal replacement therapy. Retrospective observational study based on a prospective registry. Tertiary referral 30-bed PICU. One hundred sixty-one critically ill children undergoing continuous renal replacement therapy during an 8-year period (2007–2014) were included in the study. Continuous renal replacement therapy. During the study period, 161 patients received a total of 22,190 hours of continuous renal replacement therapy, with a median duration of 74.75 hours (interquartile range, 32–169.5) per patient. Of the 572 filter circuits used, 276 (48.3%) were changed due to circuit clotting and 262 (45.8%) were electively changed. Median circuit life was 24.62 hours (interquartile range, 10.6–55.3) for all filters and significantly longer for those electively removed as compared to those prematurely removed because of clotting (35.50 hr [interquartile range, 16.9–67.6] vs 22.00 hr [interquartile range, 13.8–42.5] p 0.001). Multivariate regression analyses revealed that admission diagnosis ( p 0.001), anticoagulation type ( p 0.001), access type ( p = 0.016), and circuit size ( p = 0.027) were associated with prolonged circuit life, as well as, in patients on heparin anticoagulation, with higher doses of heparin ( p 0.001) and a prolonged activated partial thromboplastin time ( p 0.001). In this study, circuit lifespan in pediatric continuous renal replacement therapy was low and appeared to depend upon the patient’s diagnosis, the type of access and anticoagulation used as well as the size of the circuit used.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2014
Publisher: Cambridge University Press (CUP)
Date: 23-08-2023
DOI: 10.1017/S1047951123003128
Abstract: Necrotising enterocolitis is linked with altered intestinal microbiota, and caesarean birth is associated with imbalance of newborn intestinal microbiome. We aimed to investigate the role of delivery mode (vaginal or caesarean) and gestational age in the development of necrotising enterocolitis among term-born neonates (≥ 37 weeks) with CHD. Case–control study. We studied all newborns with CHD who underwent cardiac surgery during the neonatal (≤ 28 days of age) period, between 2007 and 2017. Totally, 60 cases of necrotising enterocolitis were matched (by year of birth and type of congenital heart lesion) with 180 controls (1:3 ratio). Multivariable conditional logistic regression was used to assess the study question. The overall prevalence of necrotising enterocolitis was 6.3% in term-born newborns with CHD. Neonates with a left-ventricular outflow tract lesion or single ventricle lesion accounted for 55% (n = 33) of cases. 62% (n = 37) cases were in the modified Bell’s stage 2 or more for necrotising enterocolitis classification. In multivariable modelling, gestational age at birth was not associated with the development of necrotising enterocolitis [adjusted odds ratio per week increase, 95% confidence interval: 1.20 (0.90–1.60)]. Birth by caesarean delivery (compared to vaginal) was strongly associated with development of necrotising enterocolitis [adjusted odds ratio (95% confidence interval): 2.64 (1.31–5.29)]. We failed to identify an association between preoperative enteral nutrition and necrotising enterocolitis. This study showed a high risk of necrotising enterocolitis in newborns with critical CHD born via caesarean. This information is important given the high prevalence of planned birth by caesarean in newborns with CHD.
Publisher: Springer Science and Business Media LLC
Date: 24-06-2023
Publisher: SAGE Publications
Date: 22-07-2016
Abstract: In adults requiring extracorporeal membrane oxygenation (ECMO), we wanted to determine i) the frequency of elevated plasma free haemoglobin (PFHb), ii) the reasons for circuit changes and iii) whether elevated PFHb was associated with higher in-hospital mortality. Patients requiring ECMO between January 2010 and August 2014 were identified from a prospectively collected ECMO database. Their scanned medical records and pathology results were reviewed. Relevant patient, biochemical and circuit data were collected on an Excel spreadsheet and analysed using Stata 13 (StataCorp, College Station, TX). The patients were analysed in three groups, depending on their peak PFHb during ECMO: ‘Normal PFHb’ ( .1 g/L), ‘Low level PFHb’ (0.1 – 0.5 g/L), ‘High level PFHb’ ( .5 g/L). There were 184 ECMO runs (56 VV, 128 VA) – 61 ‘Normal PFHb’, 99 ‘Low level PFHb’, 24 ‘High level PFHb’. Circuit thrombosis (pump, oxygenator) or haemolysis requiring exchanges were significantly more common in VV ECMO compared to VA ECMO – 23.21% (13/56) vs. 0.78% (1/128), p .001. Elevated PFHb was associated with a longer duration of haemofiltration (p .001) and ECMO support (p .001). In-hospital mortality rates for the ‘Normal PFHb’, ‘Low level PFHb’ and ‘High level PFHb’ groups were 16.39% (10/61), 30.30% (30/99) and 37.50% (9/24), respectively, p=0.067. Elevated PFHb values during adult ECMO were common. Severe haemolysis or thrombosis requiring circuit changes were uncommon and occurred almost exclusively on VV ECMO. There was a non-statistically significant increase in in-hospital mortality with elevated PFHb and studies of larger registry data may clarify the prognostic value of PFHb in adult patients.
Publisher: Springer Science and Business Media LLC
Date: 12-09-2016
Publisher: Oxford University Press (OUP)
Date: 10-09-2021
Abstract: Levosimendan use is associated with more successful decannulation from veno-arterial extracorporeal membrane oxygenation (VA ECMO) in adults. We sought to determine the role of levosimendan in children who required VA ECMO after cardiac surgery. This observational study compares the outcomes of children who required VA ECMO after cardiac surgery and received levosimendan for weaning with those who did not receive the drug. A doubly robust estimation methodology (inverse probability of treatment weighting with regression adjustment) was used to balance study covariates (age, weight, sex, lactate pre-ECMO, vasoactive-inotropic score pre-ECMO, ECMO indication, ECMO modality, Risk Adjustment for Congenital Heart Surgery-1 category), and the final model was further adjusted for duration of ECMO. Between January 2012 and December 2018, 118 eligible children received 145 ECMO runs [failed weaning from cardiopulmonary bypass, 67/145 (46%) low cardiac output state, 30/145 (21%) extracorporeal cardiopulmonary resuscitation, 47/145 (32%) other reasons in 1]. Levosimendan was administered before decannulation in 54/145 (37%) runs. The median time to start levosimendan after ECMO cannulation was 39 h (interquartile range, 14–83 h). The unadjusted rates of weaning failure in the levosimendan vs control group were 7% (4/54) vs 19% (17/91). In the controlled analysis, levosimendan was associated with decreased risk of weaning failure [adjusted relative risk (95% confidence interval), 0.20 (0.07–0.57)] and decreased risk of in-hospital mortality [adjusted relative risk (95% confidence interval), 0.45 (0.26–0.76)]. Levosimendan administration in children requiring VA ECMO after cardiac surgery was associated with decreased risk of weaning failure and decreased in-hospital mortality.
Publisher: Springer Science and Business Media LLC
Date: 26-05-2023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2007
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2014
Publisher: Elsevier BV
Date: 05-1997
Publisher: Elsevier BV
Date: 09-1995
Abstract: To estimate mortality risk in pediatric patients with acute hypoxemic respiratory failure (AHRF). Retrospective chart review. Forty-one pediatric ICUs. Four hundred seventy children with AHRF. We defined AHRF as mechanical ventilation with positive end-expiratory pressure > or = 6 cm H2O and fraction of inspired oxygen greater than or equal to 0.5 for 12 or more hours. Physiologic and treatment variables were recorded every 12 h for 14 days. Cases were randomly assigned to score development and score validation subsets. Variables were assessed for their association with mortality in the development subset by logistic regression analysis. The analysis generated a series of logistic equations, which we called the Pediatric Respiratory Failure (PeRF) score, to estimate mortality risk at 12-h intervals over the first 7 days of treatment for AHRF. The predictive ability of the score was assessed in the validation subset by receiver operating characteristic curve area and goodness-of-fit chi 2. Mortality of the collected cases was 43%. The PeRF score included age, operative status, Pediatric Risk of Mortality score, fraction of inspired oxygen, respiratory rate, peak inspiratory pressure, positive end-expiratory pressure, PaO2, and PaCO2. Area under the receiver operating characteristic curve was 0.769 at entry and increased to greater than 0.8 after 36 h. When the score was applied to the validation subset of patients, goodness-of-fit chi 2 showed no significant difference between estimated and actual mortality between 0 and 96 h. The PeRF Score accurately estimated mortality risk in this retrospectively s led group of high-risk pediatric patients with AHRF. This score may be useful in studies of newer therapies for pediatric AHRF, though prospective validation is necessary before it could be used to make clinical decisions.
Publisher: Springer Science and Business Media LLC
Date: 06-06-2021
DOI: 10.1186/S13054-021-03620-7
Abstract: There is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use. We performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010–December 2019. Patients were ided in pre-intervention era (2010–2014) and post-intervention era (2015–2019). 1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7–4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1–4.2) and 1.7 (0.9–3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3–4.9) and 2.1 (1.2–4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49–0.83, p = 0.001) with the predicted reduction of PICU length of stay being − 10.6 h (95% confidential interval − 16.9 to − 4.3 h), and decreased respiratory support use (− 25.1 h, 95% confidential interval − 47.9 to − 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport. The implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.
Publisher: Springer Science and Business Media LLC
Date: 28-09-2012
DOI: 10.1007/S00134-012-2718-6
Abstract: Hypovitaminosis D is an independent risk factor for cardiovascular disease, muscle weakness, impaired metabolism, immune dysfunction, and compromised lung function. Hypovitaminosis D is common in critically ill adults and has been associated with adverse outcomes. The prevalence of hypovitaminosis D and its significance in critically ill children are unclear. We performed a prospective study to determine the prevalence of hypovitaminosis D in 316 critically ill children, and examined its association with physiological and biochemical variables, length of pediatric intensive care unit (PICU) stay, and hospital mortality. The prevalence of hypovitaminosis D [25(OH)D(3) <50 nmol/L] was 34.5 %. Hypovitaminosis D was more common in postoperative cardiac patients than in general medical ICU patients (40.5 versus 22.6 %, p = 0.002), and the cardiac patients had a higher inotrope score [2.5 (1.9-3.3) versus 1.4 (1.1-1.9), p = 0.006]. Additionally, ionized calcium within the first 24 h was lower in patients with 25(OH)D(3) <50 nmol/L [1.07 (0.99-1.14) mmol/L] compared with patients with normal vitamin D(3) [1.17 (1.14-1.19) mmol/L, p = 0.02]. Hypovitaminosis D was not associated with longer PICU stay or increased hospital mortality. Hypovitaminosis D is common in critically ill children, and is associated with higher inotropes in the postoperative cardiac population, but not with PICU length of stay or hospital survival.
Publisher: Wiley
Date: 08-1995
DOI: 10.1111/J.1440-1754.1995.TB00814.X
Abstract: To report ventilation strategies, survival and complications in 39 outborn infants treated with high frequency oscillatory ventilation (HFOV). Data were collected prospectively between 1 May 1992 and 31 December 1993 on all infants treated with HFOV who had severe respiratory failure despite optimal conventional ventilation. Twenty-eight out of 39 (72%) survived. Of the 15 infants with birthweights 1500 g with hyaline membrane disease (8/8), and meconium aspiration syndrome (7/7). Three infants deteriorated while on HFOV and required extracorporeal membrane oxygenation. Complications were: (i) development of pulmonary interstitial emphysema (1) (ii) recurrence of pneumothorax (3) (iii) hypotension (2) and (iv) bronchopulmonary dysplasia (9). One of the eight infants weighing < 1500 g who received HFOV in the first week of life developed periventricular haemorrhage. The initial results of HFOV for severe failure were encouraging although a learning curve was encountered with its introduction.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2014
Publisher: Springer Science and Business Media LLC
Date: 06-1992
DOI: 10.1007/BF01694369
Publisher: American Medical Association (AMA)
Date: 11-05-2022
Publisher: Springer Science and Business Media LLC
Date: 09-1998
Publisher: American Medical Association (AMA)
Date: 08-07-2022
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2018
DOI: 10.1097/CCM.0000000000003192
Abstract: Little is known about platelet transfusions in pediatric critical illness. We sought to describe the epidemiology, indications, and outcomes of platelet transfusions among critically ill children. Prospective cohort study. Multicenter (82 PICUs), international (16 countries) from September 2016 to April 2017. Children ages 3 days to 16 years prescribed a platelet transfusion in the ICU during screening days. None. Over 6 weeks, 16,934 patients were eligible, and 559 received at least one platelet transfusion (prevalence, 3.3%). The indications for transfusion included prophylaxis (67%), minor bleeding (21%), and major bleeding (12%). Thirty-four percent of prophylactic platelet transfusions were prescribed when the platelet count was greater than or equal to 50 × 10 9 cells/L. The median (interquartile range) change in platelet count post transfusion was 48 × 10 9 cells/L (17–82 × 10 9 cells/L) for major bleeding, 42 × 10 9 cells/L (16–80 × 10 9 cells/L) for prophylactic transfusions to meet a defined threshold, 38 × 10 9 cells/L (17–72 × 10 9 cells/L) for minor bleeding, and 25 × 10 9 cells/L (10–47 × 10 9 cells/L) for prophylaxis in patients at risk of bleeding from a device. Overall ICU mortality was 25% but varied from 18% to 35% based on indication for transfusion. Upon adjusted analysis, total administered platelet dose was independently associated with increased ICU mortality (odds ratio for each additional 1 mL/kg platelets transfused, 1.002 95% CI, 1.001–1.003 p = 0.005). The majority of platelet transfusions are given as prophylaxis to nonbleeding children, and significant variation in platelet thresholds exists. Studies are needed to clarify appropriate indications, with focus on prophylactic transfusions.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2001
DOI: 10.1097/00003246-200101000-00036
Abstract: Review the predictive powers of somatosensory evoked potentials (SEPs) in severe brain injury. Publications in the scientific literature, manual review of article bibliographies, and questioning workers in the field. Studies addressing the prediction of outcome after severe brain injury using SEPs. To determine the outcome of patients with either normal or bilaterally absent SEPs as categorized using the Glasgow Outcome Scale into favorable outcomes (good or moderate disability) or unfavorable outcomes (severe disability, vegetative, or dead). Studies were included if they were in English and allowed the determination of outcomes for all patients with normal or bilaterally absent SEPs. Papers were not considered if subjects were neonates, consisted of abstracts where all necessary details were unavailable, were case reports or duplications of other published studies, or dealt only with brain dead subjects. For all studies (n = 44), positive likelihood ratio, positive predictive value, and sensitivity were 4.04, 71.2%, and 59.0%, respectively, for normal SEPs (predicting favorable outcome) and 11.41, 98.5%, and 46.2%, respectively, for bilaterally absent SEPs (predicting unfavorable outcome). Summary receiver operating characteristic curve analysis detected a cut-off criterion effect for only blinded studies of bilaterally absent SEPs. Twelve patients (12/777) were identified with bilaterally absent SEPs who had favorable outcomes. These false positives are typically pediatric patients or have suffered traumatic brain injuries. We suggest criteria for the use of bilaterally absent SEPs in the prediction of poor outcome, which include absence of focal lesions, subdural or extradural fluid collections, and no decompressive craniotomy in previous 48 hrs. Using these criteria the data suggest that the false-positive rate is <0.5% for bilaterally absent SEPs. SEPs are powerful predictors of outcome, particularly poor outcome, if patients with focal lesions, subdural effusions, and those who have had recent decompressive craniotomies are excluded.
Publisher: Frontiers Media SA
Date: 16-02-2023
DOI: 10.3389/FMED.2023.1043041
Abstract: Effective leadership is crucial to team performance within the intensive care unit. This novel study aimed to explore how staff members from an intensive care unit conceptualize leadership and what facilitators and barriers to leadership exist within a simulated workplace. It also aimed to identify factors that intersect with their perceptions of leadership. This study was underpinned by interpretivism, and video-reflexive ethnography was chosen as the methodology for the study. The use of both video recording (to capture the complex interactions occurring in the ICU) and team reflexivity allowed repeated analysis of those interactions by the research team. Purposive s ling was used to recruit participants from an ICU in a large tertiary and private hospital in Australia. Simulation groups were designed to replicate the typical clinical teams involved in airway management within the intensive care unit. Twenty staff participated in the four simulation activities (five staff per simulation group). Each group simulated the intubations of three patients with hypoxia and respiratory distress due to severe COVID-19. All 20 participants who completed the study simulations were invited to attend video-reflexivity sessions with their respective group. Twelve of the 20 participants (60%) from the simulations took part in the reflexive sessions. Video-reflexivity sessions (142 min) were transcribed verbatim. Transcripts were then imported into NVivo software for analysis. The five stages of framework analysis were used to conduct thematic analysis of the video-reflexivity focus group sessions, including the development of a coding framework. All transcripts were coded in NVivo. NVivo queries were conducted to explore patterns in the coding. The following key themes regarding participants’ conceptualizations of leadership within the intensive care were identified: (1) leadership is both a group/shared process and in idualistic/hierarchical (2) leadership is communication and (3) gender is a key leadership dimension. Key facilitators identified were: (1) role allocation (2) trust, respect and staff familiarity and (3) the use of checklists. Key barriers identified were: (1) noise and (2) personal protective equipment. The impact of socio-materiality on leadership within the intensive care unit is also identified.
Publisher: Wiley
Date: 12-1990
DOI: 10.1111/J.1440-1754.1990.TB02449.X
Abstract: In the 7 years from 1982 to 1988, 10,639 children with acute asthma were admitted to the Royal Children's Hospital, Melbourne. Of these, 262 children (2%) were treated in the Intensive Care Unit. Twenty-seven required mechanical ventilation on 34 occasions, being 0.3% of hospital asthma admissions. Five patients died, four due to brain death following respiratory arrest prior to intubation. The main complications were (i) barotrauma, which occurred in five patients on seven occasions (20%) (ii) a reversible myopathy which occurred in three patients treated with high dose corticosteroids and muscle relaxants. Follow-up of patients ventilated in intensive care revealed that all but one of the initial survivors was alive 1-5 years later, all patients required subsequent readmission to hospital for treatment of acute asthma and 78% had persistent rather than episodic asthma. Although uncommon, an episode of ventilation has a major impact on the family's understanding and future management of acute asthma.
Publisher: F1000 Research Ltd
Date: 26-04-2016
DOI: 10.12688/F1000RESEARCH.8320.1
Abstract: The use of extracorporeal membrane oxygenation (ECMO) is an important issue for intensivists, critical care nurses, surgeons, cardiologists, and many others. There has been a continued increase in the number of centres performing ECMO. This review examines novel applications and recent trends in the use of ECMO over the last 2 years. These include ECMO to facilitate the safe use of other treatments, changing the timing of initiation, newer equipment and better biocompatibility, and the ability of ECMO programs to essentially choose which cluster of potential complications they are prepared to accept. ECMO continues to evolve, ersify in its applications, and improve in safety.
Publisher: Springer Science and Business Media LLC
Date: 06-10-2016
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.INJURY.2011.08.032
Abstract: The aim of this study was to establish the profile and outcomes of paediatric major trauma care (PTMC) within an integrated inclusive regionalised trauma system. Prospectively collected data from July 2001 to June 2009 from the Victorian State Trauma Registry of patients aged 2) was the most frequent injury (n=950, 58%). Surgery was required in 39% (n=637) of all cases 437 patients in the 10-17 year old group and 200 patients in the 0-9 year old group the mortality was 6.6%. There were 530 patients (32.4%) ventilated in ICU these had a median ISS (IQR) of 25 (17-34) and mortality of 7.4%. Improvements in risk-adjusted mortality have occurred as the years have progressed [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a Level 1 trauma centre was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)]. The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of major trauma requiring surgery in the 0-9 year old age group is notable, creating a challenging environment for maintaining skills and institutional preparedness.
Publisher: Springer Science and Business Media LLC
Date: 31-01-2009
DOI: 10.1007/S00134-009-1425-4
Abstract: Continuous renal replacement therapy (CRRT) is an invaluable means of supporting critically ill children with many illnesses, including acute renal failure, drug intoxication, inborn errors of metabolism, and multiorgan failure. However, the ideal method of applying the technique is unknown. The indications for initiation of CRRT, mode, dose, and means of anticoagulating the circuit to prolong filter life are all subjects of controversy. The formation of a prospective, multicentre paediatric CRRT registry has been a major step forward but large, randomised trials of the sort that exist in adult medicine are lacking. This review describes the basic technique of CRRT, highlights the differences between adult and paediatric prescription, and elaborates on the main controversies in the application of CRRT in children. Current evidence suggests that early initiation of CRRT before the onset of substantial fluid overload, considering continuous haemofiltration in disease states such as respiratory failure following stem cell transplantation, and the use of continuous haemodialysis and citrate anticoagulation to prolong circuit life may be associated with improved outcomes.
Publisher: Elsevier BV
Date: 10-2016
DOI: 10.1016/J.JTCVS.2016.05.006
Abstract: Children who require prolonged intensive care after cardiac surgery are at risk of high mortality. The long-term survival and functional outcome of these children have not been studied in detail. Children who stayed in intensive care for >28 days after cardiac surgery from 1997 to 2012 were studied in a single institution. A total of 116 patients were identified 107 (92%) were <1 year of age and 63 (54%) had univentricular physiology. The incidence of children requiring prolonged intensive care increased from 1.01/100 undergoing cardiac surgery in 1997 to 2000 to 2.66/100 in 2009 to 2012 (P trend = .002). This increase coincided with an increase in the number of children with hypoplastic left heart syndrome having prolonged intensive care during the same period (0.13/100 in 1997-2000 to 1.0/100 in 2009-2012 P trend = .001). Survival to pediatric intensive care unit (PICU) discharge was 74% (95% confidence interval [CI], 65-82) and 51% (95% CI, 41-59) at 3 years. Factors associated with mortality were univentricular repair (hazard ratio [HR], 2.12 95% CI, 1.21-3.70 P = .008) and acute renal failure (HR, 3.01 95% CI, 1.77-5.12 P < .001), but era did not influence mortality (1997-2005 vs 2006-2012 log-rank P = .66). Among PICU survivors, 3-year survival in those who did not need early reoperation was 81% (95% CI, 66-90), compared with 58% (95% CI, 42-71) in those who required early reoperation (log-rank P = .01). Among survivors, 36% had either moderate or severe disability and 13% had poor quality of life. The incidence of children requiring prolonged intensive care after cardiac surgery has increased in our institution. Our data suggest that the long-term outcome for most of these children is poor, especially after univentricular repair.
Publisher: Springer Science and Business Media LLC
Date: 09-06-2021
DOI: 10.1186/S13054-021-03518-4
Abstract: Heterogeneous respiratory system static compliance ( C RS ) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous small-case series or studies conducted at a national level. We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe C RS —calculated as: tidal volume/[airway plateau pressure-positive end-expiratory pressure (PEEP)]—and its association with ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide. We studied 745 patients from 22 countries, who required admission to the ICU and MV from January 14 to December 31, 2020, and presented at least one value of C RS within the first seven days of MV. Median (IQR) age was 62 (52–71), patients were predominantly males (68%) and from Europe/North and South America (88%). C RS , within 48 h from endotracheal intubation, was available in 649 patients and was neither associated with the duration from onset of symptoms to commencement of MV ( p = 0.417) nor with PaO 2 /FiO 2 ( p = 0.100). Females presented lower C RS than males (95% CI of C RS difference between females-males: − 11.8 to − 7.4 mL/cmH 2 O p 0.001), and although females presented higher body mass index (BMI), association of BMI with C RS was marginal ( p = 0.139). Ventilatory management varied across C RS range, resulting in a significant association between C RS and driving pressure (estimated decrease − 0.31 cmH 2 O/L per mL/cmH 2 0 of C RS , 95% CI − 0.48 to − 0.14, p 0.001). Overall, 28-day ICU mortality, accounting for the competing risk of being discharged within the period, was 35.6% (SE 1.7). Cox proportional hazard analysis demonstrated that C RS (+ 10 mL/cm H 2 O) was only associated with being discharge from the ICU within 28 days (HR 1.14, 95% CI 1.02–1.28, p = 0.018). This multicentre report provides a comprehensive account of C RS in COVID-19 patients on MV. C RS measured within 48 h from commencement of MV has marginal predictive value for 28-day mortality, but was associated with being discharged from ICU within the same period. Trial documentation: Available at tudy . Trial registration : ACTRN12620000421932.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2019
DOI: 10.1097/PCC.0000000000001793
Abstract: Early peritoneal dialysis may have a role in modulating the inflammatory response after cardiopulmonary bypass. This study sought to test the effect of early peritoneal dialysis on major adverse events after pediatric cardiac surgery involving cardiopulmonary bypass. In this observational study, the outcomes in infants post cardiac surgery who received early peritoneal dialysis (within 6 hr of completing cardiopulmonary bypass) were compared with those who received late peritoneal dialysis. The primary outcome was a composite of one or more of cardiac arrest, emergency chest reopening, requirement for extracorporeal membrane oxygenation, or death. Secondary outcomes included duration of mechanical ventilation, length of intensive care, and hospital stay. A propensity score methodology utilizing inverse probability of treatment weighting was used to minimize selection bias due to timing of peritoneal dialysis. Cardiac ICU, The Royal Children’s Hospital, Melbourne, VIC, Australia. From 2012 to 2015, infants who were commenced on peritoneal dialysis after cardiac surgery were included. Among 239 eligible infants, 56 (23%) were commenced on early peritoneal dialysis and 183 (77%) on late peritoneal dialysis. At 90 days, early peritoneal dialysis as compared with late peritoneal dialysis was associated with a decreased risk of primary outcome (relative risk, 0.16 95% CI, 0.05–0.47 p 0.001 and absolute risk difference, –18.1% 95% CI, –25.1 to –11.1 p 0.001). Early peritoneal dialysis was also associated with a decrease in duration of mechanical ventilation and intensive care stay. Among infants with a cardiopulmonary bypass greater than 150 minutes, early peritoneal dialysis was also associated with a survival advantage (relative risk, 0.14 95% CI, 0.03–0.84 p = 0.03 and absolute risk difference, –7.8 95% CI, –13.6 to –2 p = 0.008). Early peritoneal dialysis in infants post cardiac surgery is associated with a decrease in the rate of major adverse events. The role of early peritoneal dialysis warrants the conduct of randomized trials both in high and low-to-middle income countries any beneficial effects if confirmed have the potential to strongly influence outcomes for children born with congenital heart disease.
Publisher: Cambridge University Press (CUP)
Date: 17-12-2015
DOI: 10.1017/S1047951113002011
Abstract: Objective: There are limited data on the outcomes of children receiving delayed (≥7 days) extracorporeal membrane oxygenation after cardiac surgery. The primary aim of this project is to identify the aetiology and outcomes of extracorporeal membrane oxygenation in children receiving delayed (≥7 days) extracorporeal membrane oxygenation after cardiac surgery. Patients and methods: We conducted a retrospective review of all children ≤18 years supported with delayed extracorporeal membrane oxygenation after cardiac surgery between the period January, 2001 and March, 2012 at the Arkansas Children’s Hospital, United States of America, and Royal Children’s Hospital, Australia. The data collected in our study included patient demographic information, diagnoses, extracorporeal membrane oxygenation indication, extracorporeal membrane oxygenation support details, medical and surgical history, laboratory, microbiological, and radiographic data, information on organ dysfunction, complications, and patient outcomes. The outcome variables evaluated in this report included: survival to hospital discharge and current survival with emphasis on neurological, renal, pulmonary, and other end-organ function. Results: During the study period, 423 patients undergoing cardiac surgery were supported with extracorporeal membrane oxygenation at two institutions, with a survival of 232 patients (55%). Of these, 371 patients received extracorporeal membrane oxygenation days after cardiac surgery, with a survival of 205 (55%) patients, and 52 patients received extracorporeal membrane oxygenation ≥7 days after cardiac surgery, with a survival of 27 (52%) patients. The median duration of extracorporeal membrane oxygenation run for the study cohort was 5 days (interquartile range: 3, 10). In all, 14 patients (25%) received extracorporeal membrane oxygenation during active cardiopulmonary resuscitation with chest compressions. There were 24 patients (44%) who received dialysis while being on extracorporeal membrane oxygenation. There were eight patients (15%) who had positive blood cultures and four patients (7%) who had positive urine cultures while being on extracorporeal membrane oxygenation. There were nine patients (16%) who had bleeding complications associated with extracorporeal membrane oxygenation runs. There were 10 patients (18%) who had cerebrovascular thromboembolic events associated with extracorporeal membrane oxygenation runs. Of these, 19 patients are still alive with significant comorbidities. Conclusions: This study demonstrates that mortality outcomes are comparable among children receiving extracorporeal membrane oxygenation ≥7 days and days after cardiac surgery. The proportion of patients receiving extracorporeal membrane oxygenation ≥7 days is small and the aetiology erse.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 29-08-2022
DOI: 10.1097/PCC.0000000000003055
Abstract: To identify a PICU Core Outcome Measurement Set (PICU COMS), a set of measures that can be used to evaluate the PICU Core Outcome Set (PICU COS) domains in PICU patients and their families. A modified Delphi consensus process. Four webinars attended by PICU physicians and nurses, pediatric surgeons, rehabilitation physicians, and scientists with expertise in PICU clinical care or research ( n = 35). Attendees were from eight countries and convened from the Pediatric Acute Lung Injury and Sepsis Investigators Pediatric Outcomes STudies after PICU Investigators and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network PICU COS Investigators. Measures to assess outcome domains of the PICU COS are as follows: cognitive, emotional, overall (including health-related quality of life), physical, and family health. Measures evaluating social health were also considered. None. Measures were classified as general or additional based on generalizability across PICU populations, feasibility, and relevance to specific COS domains. Measures with high consensus, defined as 80% agreement for inclusion, were selected for the PICU COMS. Among 140 candidate measures, 24 were delineated as general (broadly applicable) and, of these, 10 achieved consensus for inclusion in the COMS (7 patient-oriented and 3 family-oriented). Six of the seven patient measures were applicable to the broadest range of patients, diagnoses, and developmental abilities. All were validated in pediatric populations and have normative pediatric data. Twenty additional measures focusing on specific populations or in-depth evaluation of a COS subdomain also met consensus for inclusion as COMS additional measures. The PICU COMS delineates measures to evaluate domains in the PICU COS and facilitates comparability across future research studies to characterize PICU survivorship and enable interventional studies to target long-term outcomes after critical illness.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
Publisher: Springer Science and Business Media LLC
Date: 28-04-2012
DOI: 10.1007/S00134-012-2581-5
Abstract: To review the use of extracorporeal membrane oxygenation (ECMO) in severe paediatric pneumonia and evaluate factors that may affect efficacy of this treatment. Retrospective study of the ECMO database of a tertiary paediatric intensive care unit and chart review of all patients who were managed with ECMO during their treatment for severe pneumonia over a 23-year period. The main outcome measures were survival to hospital discharge, and ICU and hospital length of stay. We compared the groups of culture-positive versus culture-negative pneumonia, venoarterial (VA) versus venovenous (VV) ECMO, community- versus hospital-acquired cases, and cases before and after 2005. Fifty patients had 52 cases of pneumonia managed with ECMO. Community-acquired cases were sicker with higher oxygenation index (41.5 ± 20.5 versus 26.8 ± 17.8 p = 0.031) and higher inotrope score [20 (5-37.5) versus 7.5 (0-18.8) p = 0.07]. Use of VA compared with VV ECMO was associated with higher inotrope scores [20 (10-50) versus 5 (0-20) p = 0.012]. There was a trend towards improved survival in the VV ECMO group (82.4 versus 62.9 % p = 0.15). Since 2005, patients have been older [4.7 (1-8) versus 1.25 (0.15-2.8) years p = 0.008] and survival has improved (88.2 versus 60.0 % p = 0.039). Survival in children with pneumonia requiring ECMO has improved over time and is now 90 % in the modern era. Risk factors for death include performing a circuit change [odds ratio (OR) 5.0 95 % confidence interval (CI) 1.02-24.41 p = 0.047] and use of continuous renal replacement therapy (OR 4.2 95 % CI 1.13-15.59 p = 0.032).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2009
Publisher: Elsevier BV
Date: 03-2019
DOI: 10.1016/J.HLC.2018.02.001
Abstract: In 2011 we reported unfavourable outcomes of second-run extracorporeal life support (ECLS) in children. We wanted to investigate whether this previous report affected our strategy and modified our long-term outcomes. Between 1988 and 2015, 31 patients underwent a second-run ECLS. Median age at the time of first support was 9days (0-16 years). Median length of support for the first and second runs were 4.7days (0.1-10) and 3.6days (0.5-8.7) respectively, with an interval of 1.8days (0.1-66) between supports. There was an increasing trend in the number of patients undergoing second-run ECLS after our report: 21 patients between 1988 and mid-2010 (0.9 patients/year) and 10 between mid-2010 and 2015 (two patients/year) (p=0.06). However, among all the patients who underwent ECLS, the proportion of second-run ECLS was not different before and after 2010 (4% vs. 4.2% respectively, p=0.92). While 58% of patients (18/31) survived weaning of support, only 23% (7/31) survived to hospital discharge and 14% (5/31) were still alive after hospital discharge at a median of 6.5 years (1.2-11.6). The three patients who had positive long-term outcomes had the second-run ECLS instituted to allow for major cardiac operations. Compassionate use of second-run ECLS is difficult to refuse but one should be aware that its outcomes are dismal. In our centre, benefits seem to be limited to cases where the second-run ECLS allows for a major cardiac intervention.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 13-10-2020
DOI: 10.1097/CCM.0000000000004660
Abstract: More children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multistakeholder-recommended pediatric critical care core outcome set for inclusion in clinical and research programs. A two-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring greater than 69% “critical” and less than 15% “not important” advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components. Multinational survey. Stakeholder participants from six continents representing clinicians, researchers, and family/advocates. Overall response rates were 75% and 82% for each round. Participants voted on seven Global Domains and 45 Specific Outcomes in round 1, and six Global Domains and 30 Specific Outcomes in round 2. Using overall (three stakeholder groups combined) results, consensus was defined as outcomes scoring greater than 90% “critical” and less than 15% “not important” and were included in the final PICU core outcome set: four Global Domains (Cognitive, Emotional, Physical, and Overall Health) and four Specific Outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families ( n = 21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU core outcome set—extended. The PICU core outcome set and PICU core outcome set—extended are multistakeholder-recommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.
Publisher: Elsevier BV
Date: 05-2016
DOI: 10.1093/BJA/AEW103
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2007
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-09-2022
DOI: 10.1097/PCC.0000000000003047
Abstract: To describe the prevalence, patterns, explanatory variables, and outcomes associated with fluid accumulation (FA) in mechanically ventilated children. Retrospective cohort study. Tertiary PICU. Children mechanically ventilated for greater than or equal to 24 hours. None. Between July 2016 and July 2021, 1,636 children met eligibility criteria. Median age was 5.5 months (interquartile range [IQR], 0.7–46.5 mo), and congenital heart disease was the most common diagnosis. Overall, by day 7 of admission, the median maximum cumulative FA, as a percentage of estimated admission weight, was 7.5% (IQR, 3.3–15.1) occurring at a median of 4 days after admission. Overall, higher FA was associated with greater duration of mechanical ventilation (MV) (mean difference, 1.17 [95% CI, 1.13–1.22] p 0.001]), longer intensive care length of stay (LOS) (mean difference, 1.16 [95% CI, 1.12–1.21] p 0.001]), longer hospital LOS (mean difference, 1.19 [95% CI, 1.13–1.26] p 0.001]), and increased mortality (odds ratio, 1.31 [95% CI, 1.08–1.59] p = 0.005). However, these associations depended on the effects of children with extreme values, and there was no increase in risk up to 20% FA, overall, in children following cardiopulmonary bypass and in children in the general ICU. When excluding children with maximum FA of %, there was no association with duration of MV (mean difference, 0.99 [95% CI, 0.94–1.04] p = 0.64) and intensive care or hospital LOS (mean difference, 1.01 [95% CI, 0.96–1.06] p = 0.70 and 1.01 [95% CI, 0.95–1.08] 0.79, respectively) but an association with reduced mortality 0.71 (95% CI, 0.53–0.97 p = 0.03). In mechanically ventilated critically ill children, greater maximum FA was associated with longer duration of MV, intensive care LOS, hospital LOS, and mortality. However, these findings were driven by extreme values of FA of greater than 20%, and up to 10%, there was reduced mortality and no signal of harm.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2018
DOI: 10.1097/PCC.0000000000001660
Abstract: The role of venoarterial extracorporeal membrane oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial extracorporeal membrane oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or length of ICU and hospital stay when compared with conventional therapy. International multicenter, retrospective cohort study using prospectively collected data of children admitted to intensive care with a diagnosis of severe septic shock between the years 2006 and 2014. Tertiary PICUs in Australia, New Zealand, Netherlands, United Kingdom, and United States. Children greater than 30 days old and less than 18 years old. None. Of 2,452 children with a diagnosis of sepsis or septic shock, 164 patients met the inclusion criteria for severe septic shock. With conventional therapy ( n = 120), survival to hospital discharge was 40%. With venoarterial extracorporeal membrane oxygenation ( n = 44), survival was 50% ( p = 0.25 CI, –0.3 to 0.1). In children who suffered an in-hospital cardiac arrest, survival to hospital discharge was 18% with conventional therapy and 42% with venoarterial extracorporeal membrane oxygenation (Δ = 24% p = 0.02 CI, 2.5–42%). Survival was significantly higher in patients who received high extracorporeal membrane oxygenation flows of greater than 150 mL/kg/min compared with children who received standard extracorporeal membrane oxygenation flows or no extracorporeal membrane oxygenation (82%, 43%, and 48% p = 0.03 CI, 0.1–0.7 and p 0.01 CI, 0.2–0.7, respectively). Lengths of ICU and hospital stay were significantly longer for children who had venoarterial extracorporeal membrane oxygenation. The use of venoarterial extracorporeal membrane oxygenation in severe pediatric sepsis is not by itself associated with improved survival. However, venoarterial extracorporeal membrane oxygenation significantly reduces mortality after cardiac arrest due to septic shock. Venoarterial extracorporeal membrane oxygenation flows greater than 150 mL/kg/min are associated with almost twice the survival rate of conventional therapy or standard-flow extracorporeal membrane oxygenation.
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.INJURY.2018.02.013
Abstract: Prehospital airway management of the paediatric patient with traumatic brain injury (TBI) is controversial. Endotracheal intubation of children in the field requires specific skills and has potential benefits but also carries potentially serious complications. We aimed to compare mortality and functional outcomes after six months between children with TBI who either underwent prehospital rapid sequence intubation (RSI) by trained Intensive Care paramedics (ICP) or received no intubation. We conducted a retrospective study of patients aged ≤14 years with suspected TBI in Victoria, Australia. Patients were either transported via helicopter and received RSI by an ICP (2005-2013) or via road ambulance and received no intubation (2006-2013). Prehospital data was linked to hospital and 6-month follow-up data to assess mortality and functional outcome. A total of 106 patients were included in the study of which 87 received RSI by paramedics and 19 did not receive intubation. Overall, the intubation success rate was 99% (86/87), with a first-pass success rate of 93% (81/87). In total, 67% of patients (n = 41) receiving RSI had a favourable functional outcome, compared with 54% of non-intubated patients (n = 7) (p = 0.36). In the 75 children with major trauma, prehospital RSI was associated with a significant decrease in length of hospital stay (523 h vs. 1939 h, p = 0.03). In the 53 children in this subgroup with available six months data the difference in favourable functional outcome increased to 66% (n = 31)vs. 17% (n = 1) (p = 0.06). Prehospital RSI in paediatric patients with TBI can safely be performed by highly trained paramedics. Overall, we observed more favourable long-term outcomes in patients who received prehospital intubation than those who did not, however our study is not powered to detect a significant difference. Intubation prior to transport might be beneficial for major trauma patients.
Publisher: Springer Science and Business Media LLC
Date: 03-2000
Abstract: Persistent cyanosis after successful balloon valvuloplasty for neonatal critical pulmonary valve stenosis is often related to poor right ventricular compliance and right-to-left shunting at the atrial level. A successful catheter closure of an atrial septal defect was performed with a dramatic increase in systemic oxygen saturation alleviating the need for a surgical systemic-to-pulmonary artery shunt.
Publisher: BMJ
Date: 06-1999
DOI: 10.1136/THX.54.6.511
Abstract: Severe tracheobronchial malacia and stenosis are important causes of morbidity and mortality in children in intensive care, but little is known about how best to diagnose these conditions or determine their prognosis. The records of all 62 children in whom one or both of these conditions had been diagnosed by contrast cinetracheobronchography in our intensive care unit in the period 1986-95 were studied. Seventy four per cent of the 62 children had congenital heart disease none was a preterm baby with airways disease associated with prolonged ventilation. Fifteen of the children had airway stenosis without malacia three died because of the stenosis and two died from other causes. Twenty eight of the 47 children with malacia died only eight children survived without developmental or respiratory handicap. All children needing ventilation for malacia for longer than 14 consecutive days died if their bronchogram showed moderate or severe malacia of either main bronchus (15 cases), or malacia of any severity of both bronchi (three additional cases) all children needing ventilation for malacia for longer than 21 consecutive days died if their bronchogram showed malacia of any severity of the trachea or a main bronchus (three additional cases). These findings were strongly associated with a fatal outcome (p<0.00005) they were present in 21 children (all of whom died) and absent in 26 (of whom seven died, six from non-respiratory causes). They had a positive predictive value for death of 100%, but the lower limit of the 95% confidence interval was 83.9% so up to 16% of patients meeting the criteria might survive. In this series the findings on contrast cinetracheobronchography combined with the duration of ventilation provided a useful guide to the prognosis of children with tracheobronchomalacia. The information provided by bronchoscopy was less useful.
Publisher: Springer London
Date: 18-09-2014
Publisher: Elsevier BV
Date: 11-1999
DOI: 10.1016/S0003-4975(99)01066-8
Abstract: BACKGROUND.:Contact of blood with the surfaces of the cardiopulmonary bypass (CPB) circuit has been implicated as a cause of the inflammatory response. We undertook a prospective randomized trial of 200 pediatric patients, all with a calculated total bypass flow of less than 2.3 L/min (< 0.96 L/m2/min). Patients were randomly assigned to 1 of 4 CPB groups: (1) Nonheparin-bonded circuit with no albumin preprime (2) Nonheparin-bonded circuit with albumin preprime (3) Heparin-bonded circuit with no albumin preprime (4) Heparin-bonded circuit with albumin preprime. Measurements of cytokines, (interleukin [IL]-6, IL-8) and blood cell counts were made prebypass and 6 and 24 hours after institution of cardiopulmonary bypass. Analysis of variance showed no significant difference in any of the clinical or biochemical characteristics of the 4 groups. The interaction between heparin-bonded oxygenators and albumin preprime was not significant. No important differences in IL-6 or IL-8 concentrations were noted after CPB using either heparin or nonheparin-bonded oxygenators with albumin or albumin free preprime using two-way analysis of variance. Albumin preprime and heparin-bonding do not attenuate the inflammatory response component attributable to the concentration of these markers.
Publisher: Springer Science and Business Media LLC
Date: 17-04-2021
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 04-2019
DOI: 10.3171/2018.10.PEDS18374
Abstract: There is no consensus on the optimal timing and specific brain MRI sequences in the evaluation and management of severe pediatric traumatic brain injury (TBI), and information on current practices is lacking. The authors performed a survey of MRI practices among sites participating in a multicenter study of severe pediatric TBI to provide information for designing future clinical trials using MRI to assess brain injury after severe pediatric TBI. Information on current imaging practices and resources was collected from 27 institutions participating in the Approaches and Decisions after Pediatric TBI Trial. Multiple-choice questions addressed the percentage of patients with TBI who have MRI studies, timing of MRI, MRI sequences used to investigate TBI, as well as the magnetic field strength of MR scanners used at the participating institutions and use of standardized MRI protocols for imaging after severe pediatric TBI. Overall, the reported use of MRI in pediatric patients with severe TBI at participating sites was high, with 40% of sites indicating that they obtain MRI studies in 95% of this patient population. Differences were observed in the frequency of MRI use between US and international sites, with the US sites obtaining MRI in a higher proportion of their pediatric patients with severe TBI (94% of US vs 44% of international sites reported MRI in at least 70% of patients with severe TBI). The reported timing and composition of MRI studies was highly variable across sites. Sixty percent of sites reported typically obtaining an MRI study within the first 7 days postinjury, with the remainder of responses distributed throughout the first 30-day postinjury period. Responses indicated that MRI sequences sensitive for diffuse axonal injury and ischemia are frequently obtained in patients with TBI, whereas perfusion imaging and spectroscopy techniques are less common. Results from this survey suggest that despite the lack of consensus or guidelines, MRI is commonly obtained during the acute clinical setting after severe pediatric TBI. The variation in MRI practices highlights the need for additional studies to determine the utility, optimal timing, and composition of clinical MRI studies after TBI. The information in this survey describes current clinical MRI practices in children with severe TBI and identifies important challenges and objectives that should be considered when designing future studies.
Publisher: Informa UK Limited
Date: 10-2000
Publisher: Elsevier BV
Date: 08-1986
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2019
DOI: 10.1097/PCC.0000000000001779
Abstract: To determine if transfusing ABO compatible platelets has a greater effect on incremental change in platelet count as compared to ABO incompatible platelets in critically ill children. Secondary analysis of a prospective, observational study. Transfusions were classified as either ABO compatible, major incompatibility, or minor incompatibility. The primary outcome was the incremental change in platelet count. Transfusion reactions were analyzed as a secondary outcome. Eighty-two PICUs in 16 countries. Children (3 d to 16 yr old) were enrolled if they received a platelet transfusion during one of the predefined screening weeks. None. Five-hundred three children were enrolled and had complete ABO information for both donor and recipient, as well as laboratory data. Three-hundred forty-two (68%) received ABO-identical platelets, 133 (26%) received platelets with major incompatibility, and 28 (6%) received platelets with minor incompatibility. Age, weight, proportion with mechanical ventilation or underlying oncologic diagnosis did not differ between the groups. After adjustment for transfusion dose, there was no difference in the incremental change in platelet count between the groups the median (interquartile range) change for ABO-identical transfusions was 28 × 10 9 cells/L (8–68 × 10 9 cells/L), for transfusions with major incompatibility 26 × 10 9 cells/L (7–74 × 10 9 cells/L), and for transfusions with minor incompatibility 54 × 10 9 cells/L (14–81 × 10 9 cells/L) ( p = 0.37). No differences in count increment between the groups were noted for bleeding ( p = 0.92) and nonbleeding patients ( p = 0.29). There were also no differences observed between the groups for any transfusion reaction ( p = 0.07). No differences were seen in the incremental change in platelet count nor in transfusion reactions when comparing major ABO incompatible platelet transfusions with ABO compatible transfusions in a large study of critically ill children. Studies in larger, prospectively enrolled cohorts should be performed to validate whether ABO matching for platelet transfusions in critically ill children is necessary.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2018
DOI: 10.1097/PCC.0000000000001659
Abstract: Causes of major adverse event after systemic-to-pulmonary shunt procedure are usually shunt occlusion or over-shunting. Outcomes categorized on the basis of these causes will be helpful both for quality improvement and prognostication. Retrospective cohort analysis of children who underwent a systemic-to-pulmonary shunt after excluding those who had it for Norwood or Damus-Kaye-Stansel procedure. The Royal Children’s Hospital, Melbourne, VIC, Australia. From 2008 to 2015, 201 children who had a systemic-to-pulmonary shunt were included. Major adverse event is defined as one or more of cardiac arrest, chest reopening, or requirement for extracorporeal membrane oxygenation. Study outcome is a “composite poor outcome,” defined as one or more of acute kidney injury, necrotizing enterocolitis, brain injury, or in-hospital mortality. Median (interquartile range) age was 12 days (6–38 d) and median (interquartile range) time to major adverse event was 5.5 hours (2–17 hr) after admission. Overall, 36 (18%) experienced a major adverse event, and reasons were over-shunting ( n = 17), blocked shunt ( n = 13), or other ( n = 6). Fifteen (88%) in over-shunting group suffered a cardiac arrest compared with two (15%) in the blocked shunt group ( p 0.001). The composite poor outcome was seen in 15 (88%) in over-shunting group, four (31%) in the blocked shunt group, and 56 (34%) in those who did not experience a major adverse event ( p 0.001). By multivariable analysis, predictors for composite poor outcome were major adverse event due to over-shunting (no major adverse event—reference over-shunting odds ratio, 18.60 95% CI, 3.87–89.4 and shunt-block odds ratio, 1.57 95% CI, 0.46–5.35), single ventricle physiology (odds ratio, 4.70 95% CI, 2.34–9.45), and gestation (odds ratio, 0.84/wk increase 95% CI, 0.74–0.96). Infants who suffer major adverse event due to over-shunting experience considerably poorer outcomes than those who experience events due to shunt block. A mainly hypoxic event with maintenance of systemic perfusion (as often seen in a blocked shunt) is less likely to result in poorer outcomes than those after a hypoxic-ischemic event (commonly seen in over-shunting).
Publisher: Elsevier BV
Date: 10-2020
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-01-2023
DOI: 10.1097/PCC.0000000000003152
Abstract: To investigate changes in von Willebrand factor (VWF) concentration, function, and multimers during pediatric extracorporeal membrane oxygenation (ECMO) and determine whether routine monitoring of VWF during ECMO would be useful in predicting bleeding. Prospective observational study of pediatric ECMO patients from April 2017 to May 2019. The PICU in a large, tertiary referral pediatric ECMO center. Twenty-five neonates and children ( 18 yr) supported by venoarterial ECMO. None. Arterial blood s les were collected within 24 hours pre-ECMO, daily for the first 5 days of ECMO, every second day until decannulation, and 24 hours post-ECMO. The STA R Max analyzer was used to measure VWF antigen (VWF:Ag) and ristocetin cofactor (VWF:RCo) activity. VWF collagen binding (VWF:CB) was measured using an enzyme-linked immunosorbent assay. VWF multimers were measured using the semi-automated Hydragel 11 VWF Multimer assay. Corresponding clinical data for each patient was also recorded. A total of 25 venoarterial ECMO patients were recruited (median age, 73 d interquartile range [IQR], 3 d to 1 yr). The median ECMO duration was 4 days (IQR, 3–8 d) and 15 patients had at least one major bleed during ECMO. The percentage of high molecular weight multimers (HMWM) decreased and intermediate molecular weight multimers increased while patients were on ECMO, irrespective of a bleeding status. VWF:Ag increased and the VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios decreased while patients were on ECMO compared with the baseline pre-ECMO s les and healthy children. Neonates and children on ECMO exhibited a loss of HMWM and lower VWF:CB/VWF:Ag and VWF:RCo/VWF:Ag ratios compared with healthy children, irrespective of major bleeding occurring. Therefore, monitoring VWF during ECMO would not be useful in predicting bleeding in these patients and changes to other hemostatic factors should be investigated to further understand bleeding during ECMO.
Publisher: SAGE Publications
Date: 07-2020
Abstract: An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a s le of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses (b) leadership experiences (c) facilitators and/or barriers to leadership and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal in idual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit.
Publisher: Informa UK Limited
Date: 15-06-2022
Publisher: Springer Science and Business Media LLC
Date: 04-2005
DOI: 10.1007/S00134-005-2620-6
Abstract: Veno-venous extracorporeal membrane oxygenation (ECMO) is an established therapy for the treatment of respiratory failure. Traditionally ECMO has been used to support patients with an acute, reversible disease process, with a predictable outcome. We report the successful use of veno-venous ECMO for an unusual indication. A 10-year old girl was admitted to intensive care with severe, hypoxic respiratory failure on the background of a 2-month history of worsening respiratory symptoms. She required high levels of conventional positive pressure ventilation, and high frequency oscillation. Lung biopsy confirmed a non-specific interstitial pneumonia, and the patient was commenced on immune suppressive therapy. Her clinical course was further complicated by pulmonary haemorrhage and severe air leak. On day 20 after admission the patient was placed on veno-venous ECMO for lung rest while awaiting a response to continued medical treatment. She required ECMO for 20 days, during which time sedation was reduced, and she was able to interact with those around her. The patient's ventilatory requirements after decannulation were minimal, and she subsequently made a steady clinical recovery. ECMO was safely and successfully used to provide a period of lung rest and time for medical therapy to take effect in a child with an unusual indication for support: a rare disease with an uncertain outcome on the background of prolonged mechanical ventilation.
Publisher: SAGE Publications
Date: 06-2012
Abstract: A 9-month-old infant presented with transposition of the great arteries and intact ventricular septum. His left ventricle was thin and deconditioned. He underwent an arterial switch operation and was electively supported with a left ventricular assist device for 8 days. He subsequently made a full recovery. Elective use of left ventricular support allows an extension of the age limit for the arterial switch operation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2010
Publisher: Springer Science and Business Media LLC
Date: 17-05-2022
DOI: 10.1186/S13054-022-03983-5
Abstract: The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis. We analyzed a convenience s le of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression. Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28 days, VFD were 16 (IQR 0–25) and 25 (IQR 7–26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0–87) and 87 (IQR 0–88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07 p = 0.177). In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.
Publisher: Elsevier BV
Date: 11-2020
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1053/J.JVCA.2021.05.018
Abstract: During episodes of low cardiac output, sympathetic neurohumoral responses with peripheral vasoconstriction result in an increase in the core-peripheral temperature gradient (CPTG). However, assessment of CPTG as a surrogate of low cardiac output and a predictor of outcomes in pediatric cardiac patients rarely has been performed. In this retrospective study, the authors assessed the prognostic abilities of CPTG, skin temperature, and serum lactate level for predicting clinical outcomes. A retrospective single-center study. Referral high-volume pediatric center. Patients younger than four months of age with congenital heart disease who underwent cardiac surgery with cardiopulmonary bypass. None. The primary outcome was a composite of one or more of the following major adverse events (MAEs) that occurred within seven days after surgery: death from any cause, cardiac arrest, emergency chest reopening, and requirement for extracorporeal membrane oxygenation. A total of 661 patients were included in the study. Univariate logistic regression analyses showed no significant difference in the odds for MAEs with CPTG at admission and at six hours after surgery and in the odds for MAEs with skin temperature at admission. On the other hand, the odds for MAEs increased significantly with increase in serum lactate level at admission (odds ratio [OR]: 1.54, 95% confidence interval [CI]: 1.26-1.87, p < 0.001) and at six hours after surgery (OR: 1.94, 95% CI: 1.50-2.51, p < 0.001). Areas under the receiver operating curve at admission for predicting MAEs were 0.531 for CPTG, 0.557 for skin temperature, and 0.713 for serum lactate. Multivariate logistic regression analysis showed neither CPTG nor skin temperature at any time point was significantly associated with MAEs. Both CPTG and skin temperature had low performance for prediction of MAEs in children after cardiac surgery. Either of those markers, especially at admission, should not be used as a single marker for assessing the condition of a patient.
Publisher: Springer Science and Business Media LLC
Date: 03-03-2011
DOI: 10.1007/S00134-011-2168-6
Abstract: Survival outcomes in children with heart disease after use of either non-emergent extracorporeal membrane oxygenation (ECMO) or cardiopulmonary resuscitation (CPR) onto ECMO (ECPR) are comparable. Concerns remain regarding the impact of CPR duration on survival and neurological outcome. Children with cardiac disease requiring ECMO were identified from our database. Demographic, operative and ECMO details were evaluated with respect to survival. In addition, resuscitation details were extracted for the recent subgroup requiring ECPR these details were evaluated with respect to survival and neurological outcomes at midterm follow-up by univariate analysis and multivariable logistic regression. There were 126 ECMO runs in 116 children 61 (53%) received ECPR. Forty-eight (41%) children survived to discharge survival in the most recent era was 48%. Thirty-seven children underwent ECPR in the most recent era with 14 (38%) surviving to discharge. Duration of cardiopulmonary resuscitation differed significantly between survivors and nonsurvivors (15 vs. 40 min, p = 0.009) children requiring ≥30 min of CPR had 79% reduced odds of hospital survival (OR = 0.21, 95% CI = 0.05-0.96, p = 0.04). Two children died after hospital discharge with 33% having paediatric cerebral performance category scores ≤2. Poor neurological outcome was associated with longer duration of CPR (32 vs. 17.5 min, p = 0.03). Despite comparable survival outcomes between ECPR and non-emergent ECMO in children with cardiac disease a significant association between CPR duration and outcome (survival and neurological) was noted in this population.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-1991
DOI: 10.1097/00003246-199102000-00029
Abstract: Novel aluminum(III)- and zirconium(IV)-tetraphenylporhyrin (TPP) derivatives are examined as fluoride-selective ionophores for preparing polymer membrane-based ion-selective electrodes (ISEs). The influence of t-butyl- or dichloro-phenyl ring substituents as well as the nature of the metal ion center (Al(III) versus Zr(IV)) on the anion complexation constants of TPP derivative ionophores are reported. The anion binding stability constants of the ionophores are characterized by the so-called "sandwich membrane" method. All of the metalloporphyrins examined form their strongest anion complexes with fluoride. The influence of plasticizer as well as the type of lipophilic ionic site additive and their amounts in the sensing membrane are discussed. It is shown that membrane electrodes formulated with the metalloporphyrin derivatives and appropriate anionic or cationic additives exhibit enhanced potentiometric response toward fluoride over all other anions tested. Since selectivity toward fluoride is enhanced in the presence of both anionic and cationic additives, the metalloporphyrins can function as either charged or neutral carriers within the organic membrane phase. In contrast to previously reported fluoride-selective polymeric membrane electrodes based on metalloporphyrins, nernstian or near-nernstian (-51.2 to -60.1 mV decade(-1)) as well as rapid (t < 80 s) and fully reversible potentiometric fluoride responses are observed. Moreover, use of aluminum(III)-t-butyltetraphenylporphyrin as the ionophore provides fluoride sensors with prolonged (7 months) functional lifetime.
Publisher: Elsevier BV
Date: 03-2016
Publisher: SAGE Publications
Date: 06-02-2015
DOI: 10.5301/IJAO.5000410
Abstract: Patients with severe portopulmonary hypertension (PoPH) responsive to medical therapy may be considered for liver transplantation. We present a case of extracorporeal membrane oxygenation (ECMO) resuscitation for PoPH crisis in a child following liver transplantation (LT), and review the literature on management of this challenging setting. A 7-year-old girl, with previous Kasai portoenterostomy and subsequent severe PoPH responsive to pulmonary vasodilator therapy, underwent orthotopic LT. Five days following surgery, she had an asystolic arrest with suprasystemic pulmonary hypertension, and was resuscitated with ECMO therapy. Multi-modal strategies included sildenafil, ambrisentan, nitric oxide, intravenous Epoprostenol infusion, levosimendan, and atrial septostomy. Ten days after her LT, exploration for bleeding was necessary following abdominal drain removal. By 10 days of ECMO support, she was reviewed and considered for lung transplantation. Unfortunately, she deteriorated precipitously with abdominal compartment syndrome and multi-organ failure sadly, life support was withdrawn 23 days after transplantation. Patients with severe PoPH may need combined thoracic organ and liver transplantation either at single or serial events. Case reports on ECMO use include resuscitation after massive pulmonary embolism during liver transplantation, bridge until the goal of vasodilatory therapy was reached in worsening PoPH following LT, and bridge to lung or repeat liver transplantation for severe pulmonary hypertension. ECMO resuscitation and support may be deployed as rescue therapy around the period of liver transplantation. We highlight the importance of patient selection and high risk of complications during ECMO therapy as a bridge to PoPH control.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-06-2020
DOI: 10.1097/CCM.0000000000004409
Abstract: Gestational age at birth is declining, probably because more deliveries are being induced. Gestational age is an important modifiable risk factor for neonatal mortality and morbidity. We aimed to investigate the association between gestational age and mortality in hospital for term-born neonates (≥ 37 wk’) admitted to PICUs in Australia and New Zealand. Observational multicenter cohort study. PICUs in Australia and New Zealand. Term-born neonates (≥ 37 wk) admitted to PICUs. None We studied 5,073 infants born with a gestational age greater than or equal to 37 weeks and were less than 28 days old when admitted to a PICU in Australia or New Zealand between 2007 and 2016. The association between gestational age and mortality was estimated using a multivariable logistic regression model, adjusting for age, sex, indigenous status, Pediatric Index of Mortality version 2, and site. The median gestational age was 39.1 weeks (interquartile range, 38.2–40 wk) and mortality in hospital was 6.6%. Risk of mortality declined log-linearly with gestational age. The adjusted analysis showed a 20% (95% CI, 11–28%) relative reduction in mortality for each extra week of gestation beyond 37 weeks. The effect of gestation was stronger among those who received extracorporeal life support: each extra week of gestation was associated with a 44% (95% CI, 25–57%) relative reduction in mortality. Longer gestation was also associated with reduced length of stay in hospital: each week increase in gestation, the average length of stay decreased by 4% (95% CI, 2–6%). Among neonates born at “term” who are admitted to a PICU, increasing gestational age at birth is associated with a substantial reduction in the risk of dying in hospital. The maturational influence on outcome was more strongly noted in the sickest neonates, such as those requiring extracorporeal life support. This information is important in view of the increasing proportion of planned births in both high- and low-/middle-income countries.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2021
Publisher: Springer Science and Business Media LLC
Date: 22-08-2008
DOI: 10.1007/S00381-007-0461-Z
Abstract: To determine the predictive powers of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) amongst severely brain injured children. ICP and CPP were recorded from thirty-five severely brain injured children who were prospectively recruited after admission to paediatric intensive care. Twenty-five suffered traumatic brain injury (TBI) and ten suffered non-TBI. Peak ICP and minimum CPP recorded for each patient during their admission were related to 5 year Glasgow Outcome Scale outcome. Receiver operator characteristic curves determined that the optimum threshold for unfavourable outcome prediction was >or=40 mmHg for ICP and <or=49 mmHg for CPP. At these thresholds the sensitivity/specificity pairs for the prediction of unfavourable outcome were 33.3/100% and 55.6/100% for ICP and CPP, respectively, amongst patients suffering TBI and were 46.2/100% and 66.2/100% for ICP and CPP, respectively, amongst all patients. ICP and CPP are accurate predictors of unfavourable outcome.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2018
DOI: 10.1097/PCC.0000000000001400
Abstract: To characterize the clinical indications, procedural safety, and outcome of critically ill children requiring therapeutic plasma exchange. Retrospective observational study based on a prospective registry. Tertiary and quaternary referral 30-bed PICU. Forty-eight critically ill children who received therapeutic plasma exchange during an 8-year period (2007–2014) were included in the study. Therapeutic plasma exchange. A total of 48 patients underwent 244 therapeutic plasma exchange sessions. Of those, therapeutic plasma exchange was performed as sole procedure in 193 (79%), in combination with continuous renal replacement therapy in 40 (16.4%) and additional extracorporeal membrane oxygenation in 11 (4.6%) sessions. The most common admission diagnoses were hematologic disorders (30%), solid organ transplantation (20%), neurologic disorders (20%), and rheumatologic disorders (15%). Complications associated with the procedure occurred in 50 (21.2%) therapeutic plasma exchange sessions. Overall, patient survival from ICU was 82%. Although patients requiring therapeutic plasma exchange alone ( n = 31 64%) had a survival rate of 97%, those with additional continuous renal replacement therapy ( n = 13 27%) and extracorporeal membrane oxygenation ( n = 4 8%) had survival rates of 69% and 50%, respectively. Factors associated with increased mortality were lower Pediatric Index of Mortality 2 score, need for mechanical ventilation, higher number of failed organs, and longer ICU stay. Our results indicate that, in specialized centers, therapeutic plasma exchange can be performed relatively safely in critically ill children, alone or in combination with continuous renal replacement therapy and extracorporeal membrane oxygenation. Outcome in children requiring therapeutic plasma exchange alone is excellent. However, survival decreases with the number of failed organs and the need for continuous renal replacement therapy and extracorporeal membrane oxygenation.
Publisher: Elsevier BV
Date: 06-1991
DOI: 10.1016/S0022-3476(05)82198-5
Abstract: Continuous venovenous hemofiltration was used to treat two neonates, one with maple syrup urine disease and the other with an inborn error of long-chain fatty acid oxidation. The latter infant had hypoglycemia, hyperammonemia and lactic acidosis. In both cases, acceptable biochemical control was achieved within 8 hours. This therapy offers the potential to overcome acute crises rapidly in a wide range of inborn errors of intermediary metabolism.
Publisher: Elsevier BV
Date: 10-1984
Publisher: Cambridge University Press (CUP)
Date: 18-01-2013
DOI: 10.1017/S1047951112002181
Abstract: The objective of the study was to identify incidence, aetiology, and outcomes of extubation failure in infants with shunt-dependent pulmonary blood flow at a single tertiary care, academic children's hospital. The second objective of this study was to determine the haemodynamic effects of transition of positive pressure ventilation to spontaneous breathing in infants with extubation failure. Extubation failure for our study was defined as the need for positive pressure ventilation within 96 hours after extubation. We collected demographics, pre-operative, intra-operative, post-operative, and peri-extubation data in a retrospective, observational format in patients who underwent a modified Blalock–Taussig shunt between January, 2005 and March, 2011. Infants undergoing Norwood operation or Damus–Kaye–Stansel with modified Blalock–Taussig shunt were excluded from the study. The cardiorespiratory variables collected before extubation and immediately after extubation included heart rate, respiratory rate, mean arterial blood pressure, central venous pressures, near infrared spectroscopy, oxygen saturations, and lactate levels. Clinical outcomes evaluated included the success or failure of extubation, cardiovascular intensive care unit length of stay, hospital length of stay, and mortality. Descriptive and univariate statistics were utilised to compare groups with extubation failure and extubation success. Of the 55 eligible patients during the study period, extubation failure occurred in 27% (15/55) of the patients. Of the 15 patients with extubation failure, 10 patients needed reintubation and five patients received continuous positive pressure ventilation without getting reintubated. There were three patients who had extubation failure in the first 2 hours after extubation, nine patients in the 2–24-hour period, and three patients in the 24–96-hour period. In all, eight patients were extubated in the second attempt after the first extubation failure, with a median duration of mechanical ventilation of 2 days (1 day, 6 days). The median age of patients at extubation was 19 days (12 days, 22 days) and median weight of patients was 3.6 kg (3.02 kg, 4.26 kg). In all, 38% (21/55) of the patients were intubated before surgery. The most common risk factors for failed extubation were lung disease in 46% (7/15), cardiac dysfunction in 26% (4/15), diaphragmatic paralysis in 13% (2/15), airway oedema in 6% (1/15), and vocal cord paralysis in 6% (1/15). The median duration of mechanical ventilation was 4 days (1 day, 10.5 days), median cardiovascular intensive care unit length of stay was 11 days (6.5 days, 23.5 days), and the median hospital length of stay was 30 days (14 days, 48 days). The overall mortality at the time of hospital discharge was 7%. Extubation failure in infants with shunt-dependent pulmonary blood flow and univentricular physiology is high and aetiology is erse. Cardiopulmonary effects of removal of positive pressure ventilation are more pronounced in children with extubation failure and include escalation in the need for oxygen requirement and increase in mean arterial blood pressure. The majority of extubation failures in this select patient population occurs in the first 24 hours. Extubation failure in these patients is not associated with increased hospital length of stay or mortality.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2017
Publisher: Springer Science and Business Media LLC
Date: 23-02-2001
Abstract: The object of our study was to determine, in children with traumatic brain injury and sustained intracranial hypertension, whether very early decompressive craniectomy improves control of intracranial hypertension and longterm function and quality of life. All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomized to standardized management alone or standardized management plus cerebral decompression. A decompressive bitemporal craniectomy was performed at a median of 19.2 h (range 7.3-29.3 h) from the time of injury. ICP was recorded hourly via an intraventricular catheter. Compared with the ICP before randomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomization in the control group, and 8.98 mmHg lower in the 48 hours after craniectomy in the decompression group (P=0.057). Outcome was assessed 6 months after injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the control group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracranial hypertension are treated with a combination of very early decompressive craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, and functional outcome and quality of life may be better than in children treated with medical management alone (P=0.046 owing to multiple significance testing P <0.0221 is required for statistical significance). This pilot study suggests that very early decompressive craniectomy may be indicated in the treatment of traumatic brain injury.
Publisher: Wiley
Date: 05-1986
DOI: 10.1111/J.1440-1754.1986.TB00201.X
Abstract: Newborn infants with impaired myocardial performance may not respond to inotropic drugs and volume loading. Vasodilator therapy was tried in 10 such patients and in most there was improvement in peripheral perfusion, blood pH, arterial oxygenation, blood pressure and urine output. No complications of these drugs were detected. Vasodilator therapy has a role in the management of the acutely sick newborn infant with clinical signs of low cardiac output.
Publisher: Wiley
Date: 08-1989
Publisher: Elsevier BV
Date: 07-2023
Publisher: Elsevier BV
Date: 02-1997
DOI: 10.1016/S0140-6736(96)12106-1
Abstract: Meningococcal disease is still associated with considerable mortality, despite the use of early antibiotics and management in specialised intensive care units, due principally to early refractory myocardial depression and hypotension as well as severe acute respiratory distress syndrome. Extracorporeal membrane oxygenation (ECMO) is a complex technology that uses a modified "heart-lung" machine to provide temporary cardiac and respiratory support. We reviewed the UK and Australian experience of the use of ECMO in patients with refractory cardiorespiratory failure due to meningococcal disease. The records from all 12 known patients supported with ECMO for meningococcal disease in the UK and Australia since 1989 were reviewed. 12 patients (aged 4 months to 18 years, median 26 months) with meningococcal disease received ECMO over 8 years. In seven patients, ECMO was required early for cardiac support for intractable shock within 36 h of admission to intensive care. In the other five patients, ECMO was indicated for respiratory failure due to severe adult respiratory distress syndrome, which tended to occur later in the disease. The paediatric risk of mortality score ranged from 13 to 40 (median 29, median predicted risk of mortality 72%). Six of the 12 patients required cardiopulmonary resuscitation before ECMO and the other six were deteriorating despite maximal conventional therapy. Overall, eight of the 12 patients survived, with six leading functionally normal lives at a median of 1 year (range 4 months to 4 years) of follow-up. ECMO might be considered to support patients with intractable cardiorespiratory failure due to meningococcal disease who are not responding to conventional treatment.
Publisher: Faculty Opinions Ltd
Date: 03-12-2013
DOI: 10.12703/P5-55
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 20-10-2021
DOI: 10.1097/PCC.0000000000002607
Abstract: To describe the hemodynamic response to fluid boluses for hypotension in children in a cardiac ICU. A prospective, observational study. Single-centered cardiac ICU. Children in a cardiac ICU with hypotension. Clinician prescribed fluid bolus. Sixty-four fluid boluses were administered to 52 children. Fluid composition was 4% albumin in 36/64 (56%), 0.9% saline in 18/64 (28%), and cardiopulmonary bypass pump blood in 10/64 (16%). The median volume and duration were 5.0 mL/kg (interquartile range, 4.8–5.4) and 8 minutes (interquartile range, 4–19), respectively. Hypovolemia/low filling pressures was the most common additional indication (25/102 [25%]). Mean arterial pressure response, defined as a 10% increase from baseline, occurred in 42/64 (66%) of all fluid boluses at a median time of 6 minutes (interquartile range, 4–11). Mean arterial pressure responders had a median peak increase in the mean arterial pressure of 15 mm Hg (43 mm Hg [interquartile range, 29–50 mm Hg] to 58 mm Hg [interquartile range, 49–65 mm Hg]) at 17 minutes (interquartile range, 14–24 min) compared with 4 mm Hg (48 mm Hg [interquartile range, 40–51 mm Hg] to 52 mm Hg [interquartile range, 45–56 mm Hg]) at 10 minutes (interquartile range, 3–18 min) in nonresponders. Dissipation of mean arterial pressure response, when defined as a subsequent decrement in mean arterial pressure below 10%, 5%, and 2% increases from baseline, occurred in 28/42 (67%), 18/42 (43%), and 13/42 (31%) of mean arterial pressure responders, respectively. Cardiopulmonary bypass pump blood was strongly associated with peak change in mean arterial pressure from baseline (coefficient 11.0 [95% CI, 4.3–17.7] p = 0.02). Fifty out of 64 (78%) were receiving a vasoactive agent. However, change in vasoactive inotrope score was not associated with change in mean arterial pressure (coefficient 2.3 [95% CI, –2.5 to –7.2] p = 0.35). Timing from admission, nor fluid bolus duration, influenced mean arterial pressure response. In children with hypotension in a cardiac ICU, the median dose and duration of fluid boluses were 5 mL/kg and 8 minutes. Peak response occurred shortly following administration and commonly returned to baseline.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2015
Publisher: Springer Science and Business Media LLC
Date: 02-06-2016
Publisher: Elsevier BV
Date: 07-1995
DOI: 10.1016/S0147-9563(05)80074-3
Abstract: To review changes that occur during an 18-hour period in composition and bacterial contamination of blood salvaged from the cardiopulmonary bypass (CPB) circuit of pediatric patients. Prospective, blinded study. Pediatric tertiary multidisciplinary intensive care unit. One hundred and one children who underwent CPB. The degree of bacterial contamination and biochemical and hematologic alterations of blood salvaged from the CPB and any increased blood loss associated with reinfusion of this blood. The salvaged blood from the CPB circuit was collected into 1 L blood transfer packs after CPB. This blood was then stored at room temperature for 18 hours. S ling occurred immediately after CPB and at 6 and 18 hours for biochemic and hematologic assay and for the detection of bacterial organisms. The amount of chest drainage loss was assessed in the first 18 hours after bypass. The type and amount of intravenous fluid infused also was recorded. Bacterial contamination occurred in three s les (two at 6 hours and in one of the preceding at 18 hours) of the 101 units of salvaged blood. All three positive cultures grew a coagulase-negative staphylococcus. Sodium and potassium remained within normal physiologic values. The glucose values declined from 15.8 to 13.4 mmol/L, and the hemoglobin values increased from 0.4 to 0.5 gm/dl. The reinfusion of the salvaged blood (and any other blood or blood products) to 31 of the 101 patients averaged 14.2 ml/kg/24 hr, with a mean chest drainage loss of 4.9 ml/kg/24 hr. The remaining 70 patients received 12.5 ml/kg/hr of either plasma expanders or blood, with a mean chest drainage loss of 6.0 ml/kg/24 hr. The results of this study demonstrate minimal chemical deterioration and limited microbiologic contamination in blood that was salvaged from the CPB circuit and stored at room temperature for an 18-hour period. No increase in postoperative bleeding was noted from the use of this blood. These results suggest it may be safe to reinfuse salvaged blood after CPB in pediatric patients for up to 18 hours however, a prospective clinical trial is needed to validate these findings.
Publisher: Wiley
Date: 29-10-2009
DOI: 10.1111/J.1440-1754.2009.01594.X
Abstract: Paediatric chest trauma is a marker of severe injury and a significant cause of morbidity and mortality. However, current trends in the Australian population are unknown. This study aims to outline the profile and management of major paediatric chest trauma in Victoria. Prospectively collected data of patients from the Victorian State Trauma Registry from July 2001 to June 2007 were retrospectively reviewed. Data on fatalities were obtained from the National Coroners Information System. Descriptive statistics were used to summarise the profiles of major trauma cases and coroners' cases. Overall, 204 cases with serious paediatric chest injuries were reported by the Victorian State Trauma Registry (n = 158) and National Coroners Information System (n = 46) (excluding overlapping cases) in 2001-2007. Paediatric chest trauma was more common in males. The Injury Severity Score ranged from 16 to 25 in most patients. Blunt trauma was responsible for 96% of cases, of which motor vehicle collisions accounted for 75%. Median hospitalisation was 9 days, and 64% of patients were admitted to intensive care. Common injuries included lung contusion (66%), haemo neumothorax (32%) and rib fracture (23%). Multiple organ injury occurred in 99% of cases, with head (62%) and abdominal (50%) injury common. Management was conservative, with only 11 cases (7%) treated surgically. The highest mortality was in the 10-15-year age group. In 52 (79%) fatalities, injury was transport related. Australian paediatric chest trauma trends are similar to international patterns. Serious injury requiring surgical intervention is rare. This limited exposure may lead to difficulty in maintaining surgical expertise in this highly specialised area.
Publisher: Wiley
Date: 18-04-2013
DOI: 10.1111/ANS.12132
Abstract: Severe tracheal stenosis is a rare life-threatening condition that often requires early surgical intervention. The management of this anomaly has been associated with significant mortality and morbidity. We describe our experience with repair of this condition. From 1986 to 2011, 20 patients underwent repair of tracheal stenosis at the Royal Children's Hospital (median age 4.9 months) and were retrospectively reviewed. Tracheal repair techniques used were as follows: patch tracheoplasty (n=8 40%, 8 out of 20), slide tracheoplasty (n=7 35%, 7 out of 20), end-to-end anastomosis (n=5 25%, 5 out of 20). Six patients (30%, 6 out of 20) had coexisting congenital intracardiac anomalies. There were 12 pulmonary artery sling (60%, 12 out of 20) patients. Overall operative mortality was 15% (n=3 3 out of 20). Operative mortality was 20% (n=2 2 out of 10) from 1986 to 2001 and decreased to 10% (n=1 1 out of 10) from 2002 to 2011. All early deaths occurred in patients who had undergone patch tracheoplasty. Since 2004, there were no operative deaths. Seven patients (35%, 7 out of 20) required tracheal reintervention postoperatively. There were three late deaths (17.6%, 3 out of 17) at 8, 9 and 22 months after surgery. At last follow-up (mean 5.3±6.6 years range 1 month to 18 years), all 14 survivors remained asymptomatic. Repair of tracheal stenosis in children has been associated with high morbidity and mortality. Since the introduction of slide tracheoplasty, a multidisciplinary team approach and abandonment of patch tracheoplasty, the mortality has been reduced. Survival beyond 2 years after surgery is associated with an excellent outcome.
Publisher: Springer Science and Business Media LLC
Date: 26-06-1997
Abstract: To assess the markers of perfusion which best discriminate survivors from non-survivors of childhood sepsis and to compare the information derived from gastric tonometry with conventionally measured haemodynamic and laboratory parameters. Prospective clinical study of children with sepsis syndrome or septic shock. Paediatric intensive care unit in a tertiary referral centre. 31 children with sepsis syndrome or septic shock. A tonometer was passed into the stomach via the orogastric route. The following data were recorded at admission, 12, 24 and 48 h: heart rate, mean arterial pressure, arterial pH, base deficit, arterial lactate, gastric intramucosal pH (pHi) and DCO2 (intramucosal carbon dioxide tension minus arterial partial pressure of carbon dioxide). The principal outcome measure was. The secondary outcome measure was the number of organ systems failing at 48 h after admission. There were 10 deaths and 21 survivors. No variable discriminated survival from death at presentation. Blood lactate level was the earliest discriminator of survival. Using univariate logistic regression, lactate discriminated survivors from those who died at 12 and 24 h after admission, but not at 48 h (p = 0.049, 0.044 and 0.062, respectively). The area under the receiver operating characteristic (ROC) curve for lactate was 0.81, 0.88 and 0.89 at 12, 24 and 48 h, respectively. At 12 h after admission, a blood lactate level > 3 mmol/l had a positive predictive value for death of 56% and a lactate level of 3 mmol/l or less had a positive predictive value for survival of 84%. At 24 h a lactate level > 3 mmol/l had a positive predictive value for death of 71% and a level of 3 mmol/l or less had a positive predictive value for survival of 86%. No other variable identified non-survivors from survivors at 12 h. Gastric tonometry could only be done on 19 of the 31 children, of whom 8 died and 11 survived. In these 19 children, DCO2 measured at 24 h, but not at 12 or 48 h, distinguished those who died from those who survived (p = 0.045 and p = 0.20, respectively). The area under the ROC curve for DCO2 measured at 24 h as a predictor of survival was 0.71. Neither the absolute value of pHi nor the trend of change in pHi at any time in the first 48 h identified survivors in this series. The mean arterial pressure distinguished survivors from non-survivors at 24 and 48 h (area under ROC curve = 0.80 and 0.78, respectively). The base deficit and heart rate did not identify non-survivors from survivors at any time in the first 48 h. Blood lactate level was the earliest predictor of outcome in children with sepsis. In this group of patients, gastric tonometry added little to the clinical information that could be derived more simply by other means.
Publisher: Springer Science and Business Media LLC
Date: 28-01-2005
DOI: 10.1007/S00134-004-2539-3
Abstract: To determine the most accurate indirect method of measuring intra-abdominal pressure (IAP) in children. Single-centre, prospective, clinical study in a 23-bed specialist paediatric intensive care unit in Australia. 20 children admitted to paediatric intensive care with a peritoneal dialysis catheter in situ following congenital cardiac surgery. IAP was measured directly via the peritoneal dialysis catheter and by intragastric manometry via an indwelling nasogastric tube, and by intravesical manometry via an indwelling transurethral urinary catheter, using volumes of 0, 1, 3 and 5 ml/kg body weight of sterile saline instilled into the bladder. Across the range of IAPs of 1-8 mmHg the Bland-Altman method for assessing agreement between two methods of clinical measurement showed bladder pressure measured via the urinary catheter with 1 ml/kg body weight of saline instilled to be the most accurate indirect measurement technique, tending to give pressures between 0.07 and 1.23 mmHg higher than the direct measurement (95% CI for bias). Measuring bladder pressure with either no saline instilled or more saline per kilogram body weight instilled was less accurate over the same range of pressures, as was measuring the gastric pressure. The most accurate indirect method of measuring IAP in children over the normal range of IAPs involves measuring bladder pressure via a transurethral urinary catheter with 1 ml/kg body weight of sterile saline instilled into the bladder.
Publisher: Research Square Platform LLC
Date: 31-01-2023
DOI: 10.21203/RS.3.RS-2514464/V1
Abstract: Background In the past decade, molecular diagnostic syndromic arrays incorporating a range of bacterial and viral pathogens have been described. It is unclear how paediatric intensive care unit (PICU) staff diagnose lower respiratory tract infection (LRTI) and integrate diagnostic array results into antimicrobial decision-making. Methods An online survey with eleven questions was distributed throughout paediatric intensive care societies in the UK, continental Europe, and Australasia. Participants were asked to rate the clinical factors and investigations they used when prescribing for LRTI. Semi-structured interviews were undertaken with staff who participated in a single-centre observational study of a 52-pathogen diagnostic array. Results Seventy-two survey responses were received most were from senior doctors. Whilst diagnostic arrays were used less frequently than routine investigations (i.e. microbiological culture), they were of comparable perceived utility when making antimicrobial decisions. Prescribers reported that for arrays to be clinically impactful, they would need to deliver results within six hours for stable patients and within one hour for unstable patients to inform their immediate decision to prescribe antimicrobials. From 16 staff interviews, we identified that arrays were helpful for the diagnosis and screening of bacterial LRTI. Staff reported it could be challenging to interpret results in some cases due to the high sensitivity of the test. Therefore, results were considered within the context of the patient and discussed within the multidisciplinary team. Conclusions Diagnostic arrays were considered of comparable value to microbiological investigations by PICU prescribers. Our findings support the need for further clinical and economic evaluation of diagnostic arrays in a randomised control trial. Trial registration Clinicaltrials.gov, NCT04233268, t2/show/NCT04233268. Registered 18 January 2020.
Publisher: Wiley
Date: 02-1997
DOI: 10.1111/J.1440-1754.1997.TB00986.X
Abstract: To determine the aetiology, symptoms and outcome of extreme sodium derangement in a paediatric inpatient population. A retrospective study of children with extreme disturbance of their plasma sodium (> or = 165 mmol/L or < or = 115 mmol/L) admitted to a tertiary referral centre during a 72-month period. Twenty-seven cases of hypernatraemia and 21 of hyponatraemia were reviewed. Sodium disturbance developed after hospital admission in 27/57 cases (57%). Gastroenteritis was the most common cause of hypernatraemia (8/27 30%), four of 27 (15%) had iatrogenic hypernatraemia. Water overload accounted for 8/21 (38%) cases of hyponatraemia. Neurologic symptoms occurred in 19/24 (79%) with hypernatraemia and in 11/19 (58%) with hyponatraemia. Ten (37%) with hypernatraemia and four (19%) with hyponatraemia died. A deterioration in functional status was seen in two patients with hypernatraemia. There was no apparent deterioration in the survivors with hyponatraemia. Extreme sodium disturbance often develops after admission to hospital and is caused by a variety of diseases and interventions. Neurologic symptoms are common and the mortality rate is high. The outcome in survivors is survivors is most likely to be dependent on the underlying disease process.
Publisher: SAGE Publications
Date: 02-1995
DOI: 10.1177/0310057X9502300110
Abstract: Despite numerous reports about temporal changes in semen quality from all over the world, the debates continue. The latest systemic review has shown an overtime decrease in semen quality worldwide. To assess the temporal changes in the semen quality among Iranian population referred to an infertility center. In this retrospective cross-sectional study, semen parameters including concentration, motility, and morphology were compared between Iranian men reffered to Research and Clinical Center for Infertility, Yazd between 1990 to 1992 (group 1, n = 707) and 2010 to 2012 (group 2, n = 1108). Demographic characteristics and semen analysis were collected from the records. The effect of age on semen parameters was also investigated. Despite the increase in sperm concentration l in group 2, sperm with normal morphology decreased significantly (p This study showed inconsistent temporal changes in the participant semen quality. Significant temporal decline were obtained between various semen parameters, sperm morphology and grade A motility. These results should be further evaluated by larger studies in the future.
Publisher: Wiley
Date: 16-02-2007
DOI: 10.1111/J.1440-1754.2007.01035.X
Abstract: There is a paucity of population-based studies regarding the spectrum of paediatric head injury from mild through serious to fatal paediatric head injury. The aims of the present study were to determine the incidence, demographics and outcome of significant head injury in a state-wide population of children aged 0-15 years. A secondary aim was to determine if any serious head injuries were being missed under the current management protocols of the state-wide trauma system. A retrospective review of significant head injury in all paediatric patients over a period of 2 years was undertaken. Data were collected from the Victorian State Trauma Outcome Registry and Monitoring database, the Victorian Emergency Minimum Dataset and from the Victorian Institute of Forensic Medicine. The incidence of paediatric head injury in Victoria over the 2-year period was 765 per 100000 per year. The incidence of admitted head injuries was 75 per 100000 per year and the incidence of significant head injury was seven per 100000 or 151 children. Forty-one per cent of these injuries required surgical intervention. Mortality was 1.6 children per 100000. All patients who died presented with a Glasgow Coma Score (GCS) of 3 and had multiple other risk factors. There were no deaths in patients discharged from hospital. Demographic and clinical factors associated with higher mortality and morbidity was determined. The incidence of significant paediatric head injury was low. Deaths occurred early and were always associated with significant early clinical features of severe head injury. This highlights the importance of strategies for the prevention of head injuries. There appeared to be no serious head injuries missed during the study period.
Publisher: AMPCo
Date: 10-1985
DOI: 10.5694/J.1326-5377.1985.TB123056.X
Abstract: Some children who snore heavily, have been shown to have periods of apnoea which, if frequent, are known as the obstructive sleep apnoea syndrome (OSA). Twenty patients with OSA, who presented to the Department of Thoracic Medicine, Royal Children's Hospital, Melbourne, over a three-year period, were reviewed. The findings indicated that OSA is more common than is generally supposed and that it can present with a wide range of symptoms. It is important that an early diagnosis of this syndrome is made, to prevent major complications and to allow appropriate therapy.
Publisher: Springer Science and Business Media LLC
Date: 03-03-2016
Publisher: Cambridge University Press (CUP)
Date: 06-2004
DOI: 10.1017/S1047951104003075
Abstract: Objective: To investigate the relationship between dialysate volume, intra-abdominal pressure, and cardio-respiratory function in infants following cardiac surgery. Design: Prospective pilot study. Setting: Paediatric intensive care unit. Patients: Six infants undergoing peritoneal dialysis within 24 h of cardiopulmonary bypass. Interventions: Manipulation of the volume of dialysate at levels of 0, 10, 20, and 30 ml/kg in variable order. Measurements and main results: Intra-abdominal pressure was measured at each volume of dialysate via a pressure transducer connected to the dialysis catheter. Haemodynamic data was collected, including cardiac output, which was measured by thermodilution via a 3.5-French gauge catheter placed in the pulmonary arterial pathway. Respiratory data included PaO 2 , PaCO 2 , and dynamic compliance. Intra-abdominal pressure increased with increasing volume of dialysate (p 0.001), though there was considerable variation between patients in the magnitude of increase. Intra-abdominal pressure remained low even with 30 ml/kg in the abdomen. In three infants, intra-abdominal pressure was re-measured in the absence of muscle relaxants, and was found to be higher in each case. No negative effects on cardiac output, markers of delivery of oxygen, or respiratory function were seen even at volumes of 30 ml/kg. Cardiac index was significantly higher with 10 ml/kg than when the abdomen was empty or contained a larger volume (p 0.05). Conclusions: In this small group of infants, intra-abdominal pressure increased with increasing volumes of dialysate but remained low, even with 30 ml/kg in the abdomen, and was not associated with any deleterious effects on cardio-respiratory performance.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1992
DOI: 10.1097/00003246-199201000-00029
Abstract: To elucidate whether prognosis after acute myocardial infarction can be predicted by measuring plasma adrenomedullin, a novel vasorelaxant peptide. Plasma adrenomedullin concentrations on day 2 after myocardial infarction were measured in 113 patients with myocardial infarction with other clinical and haemodynamic variables related to mortality. During a mean follow up period of 25 months, 16 patients died of cardiac causes. Plasma adrenomedullin concentrations on day 2 increased significantly in patients with myocardial infarction compared with controls (mean (SD), 12.3 (8.8) v 4.9 (1.0) pmol/l, p < 0.001). Plasma adrenomedullin correlated negatively with left ventricular ejection fraction on admission (r = -0.47, p < 0.001), although it did not significantly correlate with any other haemodynamic variable. By univariate Cox proportional hazards analysis, plasma adrenomedullin, age, coronary reperfusion, maximum creatine kinase concentrations, pulmonary congestion, pulmonary capillary wedge pressure, cardiac index, and left ventricular ejection fraction were all significantly related to mortality. Among the non-invasive variables, only plasma adrenomedullin was an independent predictor of mortality after myocardial infarction (p < 0.05). The Kaplan-Meier survival curves based on the median plasma adrenomedullin concentration (10.3 pmol/l) showed that patients with high plasma adrenomedullin had a higher mortality than those with low plasma adrenomedullin (p < 0.01). Plasma adrenomedullin on day 2 after myocardial infarction is strongly associated with long term mortality, and thus may complement standard prognostic indicators.
Publisher: Elsevier BV
Date: 1995
DOI: 10.1016/0887-8994(94)00116-J
Abstract: Somatosensory evoked potentials (SEPs) were recorded from 11 patients receiving venoarterial extracorporeal membrane oxygenation (ECMO). Cortical responses recorded from the right and left hemispheres were compared to those from 2 other groups of children who were not receiving ECMO. One group consisted of 99 brain-injured patients, while the other consisted of a group of 17 neurologically normal controls. SEP responses from each hemisphere were categorized into 3 grades based on the N20 component--normal latency, abnormal (latency increased > 3 S.D.), or absent. For ECMO patients, 15% of tests disclosed a disagreement between the right and left hemispheres, while 27% of tests from the control group revealed a disagreement between the right and left hemispheres. SEPs were normal over the right hemisphere in 9 patients. Central conduction times obtained from the right and left hemispheres were similar in ECMO patients and were not different from those recorded from a group of patients suffering hypoxic-ischemic injuries and a group of normal controls who did not receive ECMO. The results of this pilot study suggest that SEPs may be employed to evaluate ECMO patients as they are in other brain-injured patients.
Publisher: Frontiers Media SA
Date: 21-02-2020
Publisher: Springer Science and Business Media LLC
Date: 10-05-2022
Publisher: Springer Science and Business Media LLC
Date: 05-2003
DOI: 10.1007/S00134-003-1690-6
Abstract: To evaluate the long-term outcome of children following admission to a paediatric intensive care unit. Prospective, long-term follow-up study. Sixteen-bed multi-disciplinary paediatric intensive care unit in a free-standing, university, tertiary, teaching hospital. All children consecutively admitted to the paediatric intensive care unit from 1(st) January, 1995, to 31(st) December, 1995. Outcome was evaluated, by telephone interview, at a median of 3.5 years (range 2.3-6 years) after admission to the intensive care unit using a modification of the Glasgow Outcome Score (GOS) to assess functional outcome and the Health State Utility Index (Mark 1) to assess quality of life. Of the children admitted to the intensive care unit, 83.8% were alive at the time of follow-up. While 10.3% of the survivors had an unfavourable outcome and were likely to live dependent on care, 89.7% had a favourable outcome and were likely to lead an independent existence. Although 16.4% had an unfavourable quality of life, 83.6% of the children survived with a favourable quality of life. At the time of follow-up, 16.2% of the children were dead: 49% died in the intensive care unit, 5% died in hospital and 46% died after discharge from hospital. The majority of children admitted to a paediatric intensive care unit survive with an excellent functional outcome and quality of life. Long-term outcome assessment provides a basis for observing trends in outcome over time within the same institution.
Publisher: Elsevier BV
Date: 12-1985
DOI: 10.1016/S0022-3476(85)80205-5
Abstract: Twelve newborn infants were given morphine intravenously for postoperative analgesia. They received a continuous infusion of 6.2 to 40 micrograms/kg/hr for 9 to 105 hours (mean +/- SEM 59.5 +/- 10.2 hours) in four the infusion was preceded by a loading dose of 50 to 100 micrograms/kg. Morphine plasma concentrations correlated with the rate of infusion, but with large variability. There was a tendency for plasma morphine concentrations to decrease in some patients receiving a constant infusion rate, suggesting improvement in morphine clearance rate. Elimination half-life of morphine (13.9 +/- 6.4 hours) was significantly longer than in older children and adults (about 2 hours). Similarly, morphine concentrations in neonates receiving 20 micrograms/kg/hr for 24 hours were three times higher (52 +/- 31 ng/ml) than in older children receiving the same schedule. Two infants who received 32 and 40 micrograms/kg/hr, respectively, developed generalized seizures. Because of the apparently greater sensitivity to morphine and the lower elimination rate in newborn infants, the infused dose should not exceed 15 micrograms/kg/hr.
Publisher: Wiley
Date: 12-1992
DOI: 10.1111/J.1440-1754.1992.TB02709.X
Abstract: At the Royal Children's Hospital, Melbourne, extracorporeal membrane oxygenation (ECMO) has been used in the treatment of newborn infants with life-threatening respiratory or cardiac failure since May 1989. The main indications for the use of ECMO are that the disease is reversible, the surviving infant is likely to be normal and there is an 80% likelihood of death without ECMO. Sixteen of 22 (73%) newborn infants have survived at least 6 months after ECMO. Fourteen of 16 (87.5%) infants receiving ECMO (who did not have a congenital diaphragmatic hernia) were functionally normal survivors the other two infants died. Two of six infants with congenital diaphragmatic hernia who received ECMO were discharged and survived to have normal neurological and respiratory function at 6 month follow up. These results are similar to results from other centres internationally. It would appear that ECMO is a useful therapy for near-term newborn infants with otherwise fatal cardiorespiratory failure.
Publisher: SAGE Publications
Date: 05-1993
DOI: 10.1177/026765919300800307
Abstract: The use of extracorporeal life support (ECLS) is considered in children who (1) have an acute life-threatening heart or lung disease, (2) are normal before the illness and are likely to be normal if they survive, and (3) have an 80% chance of death. Our use of a constrained vortex pump (CVP) offers a number of potential advantages compared to a roller pump. The circuit is designed to provide the capability of changing over to a new circuit while maintaining full support and is primed to match the biochemistry of the patient as closely as possible. Since May 1989 at the Royal Children's Hospital, Melbourne, Australia, we have provided ECLS to 30 neonates (20 of whom survived) and 22 children (eight of whom survived). ECLS is a useful technique for supporting patients who are unable to be adequately ventilated or oxygenated or who have an inadequate cardiac output.
Publisher: AMPCo
Date: 05-2011
DOI: 10.5694/J.1326-5377.2011.TB03064.X
Abstract: We report a case of compassionate use of a haemoglobin-based oxygen carrier in a severely injured Jehovah's Witness patient, for whom survival was considered unlikely. Severe anaemia and cardiac hypoxia were reversed after slow infusion of this agent. No vasoactive side effects were associated with the treatment, possibly due to the slow infusion, and the patient survived.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2019
DOI: 10.1097/PCC.0000000000001987
Abstract: To describe the epidemiology of platelet transfusions in critically ill children with an underlying oncologic diagnosis and to examine effects of prophylactic versus therapeutic transfusions. Subgroup analysis of a prospective, observational study. Eighty-two PICUs in 16 countries. All children (3 d to 16 yr old) who received a platelet transfusion during one of the six predefined screening weeks and had received chemotherapy in the previous 6 months or had undergone hematopoietic stem cell transplantation in the last year. None. Of the 548 patients enrolled in the parent study, 237 (43%) had an underlying oncologic diagnosis. In this population, 71% (168/237) of transfusions were given prophylactically, and 59% (139/237) of transfusions were given at a total platelet count greater than 20 × 10 9 /L, higher than the current recommendations. Those with an underlying oncologic diagnosis were significantly older, and received less support including less mechanical ventilation, fewer medications that affect platelet function, and less use of extracorporeal life support than those without an underlying oncologic diagnosis. In this subpopulation, there were no statistically significant differences in median (interquartile range) platelet transfusion thresholds when comparing bleeding or nonbleeding patients (50 × 10 9 /L [10–50 × 10 9 /L] and 30 × 10 9 /L [10–50 × 10 9 /L], respectively [ p = 0.166]). The median (interquartile range) interval transfusion increment in children with an underlying oncologic diagnosis was 17 × 10 9 /L (6–52 × 10 9 /L). The presence of an underlying oncologic diagnosis was associated with a poor platelet increment response to platelet transfusion in this cohort (adjusted odds ratio, 0.46 95% CI, 0.22–0.95 p = 0.035). Children with an underlying oncologic diagnosis receive nearly half of platelet transfusions prescribed by pediatric intensivists. Over half of these transfusions are prescribed at total platelet count greater than current recommendations. Studies must be done to clarify appropriate indications for platelet transfusions in this vulnerable population.
Publisher: BMJ
Date: 08-2023
DOI: 10.1136/BMJOPEN-2023-075429
Abstract: Despite growing awareness of neurodevelopmental impairments in children with congenital heart disease (CHD), there is a lack of large, longitudinal, population-based cohorts. Little is known about the contemporary neurodevelopmental profile and the emergence of specific impairments in children with CHD entering school. The performance of standardised screening tools to predict neurodevelopmental outcomes at school age in this high-risk population remains poorly understood. The NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial randomised 1371 children years of age, investigating the effect of gaseous nitric oxide applied into the cardiopulmonary bypass oxygenator during heart surgery. The NITRIC follow-up study will follow this cohort annually until 5 years of age to assess outcomes related to cognition and socioemotional behaviour at school entry, identify risk factors for adverse outcomes and evaluate the performance of screening tools. Approximately 1150 children from the NITRIC trial across five sites in Australia and New Zealand will be eligible. Follow-up assessments will occur in two stages: (1) annual online screening of global neurodevelopment, socioemotional and executive functioning, health-related quality of life and parenting stress at ages 2–5 years and (2) face-to-face assessment at age 5 years assessing intellectual ability, attention, memory and processing speed fine motor skills language and communication and socioemotional outcomes. Cognitive and socioemotional outcomes and trajectories of neurodevelopment will be described and demographic, clinical, genetic and environmental predictors of these outcomes will be explored. Ethical approval has been obtained from the Children’s Health Queensland (HREC/20/QCHQ/70626) and New Zealand Health and Disability (21/NTA/83) Research Ethics Committees. The findings will inform the development of clinical decision tools and improve preventative and intervention strategies in children with CHD. Dissemination of the outcomes of the study is expected via publications in peer-reviewed journals, presentation at conferences, via social media, podcast presentations and medical education resources, and through CHD family partners. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as ‘Gene Expression to Predict Long-Term Neurodevelopmental Outcome in Infants from the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) Study – A Multicentre Prospective Trial’. Trial registration: ACTRN12621000904875.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2014
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-01-2022
DOI: 10.1097/CCM.0000000000005435
Abstract: To investigate platelet pathophysiology associated with pediatric extracorporeal membrane oxygenation (ECMO). Prospective observational study of neonatal and pediatric ECMO patients from September 1, 2016, to December 31, 2019. The PICU in a large tertiary referral pediatric ECMO center. Eighty-seven neonates and children ( 18 yr) supported by ECMO. None. Arterial blood s les were collected on days 1, 2, and 5 of ECMO and were analyzed by whole blood flow cytometry. Corresponding clinical data for each patient was also recorded. A total of 87 patients were recruited (median age, 65 d interquartile range [IQR], 7 d to 4 yr). The median duration of ECMO was 5 days (IQR, 3–8 d) with a median length of stay in PICU and hospital of 18 days (IQR, 10–29 d) and 35 days (IQR, 19–75 d), respectively. Forty-two patients (48%) had at least one major bleed according to a priori determined definitions, and 12 patients (14%) had at least one thrombotic event during ECMO. Platelet fibrinogen receptor expression decreased (median fluorescence intensity [MFI], 29,256 vs 26,544 p = 0.0005), while von Willebrand Factor expression increased (MFI: 7,620 vs 8,829 p = 0.0459) from day 2 to day 5 of ECMO. Platelet response to agonist, Thrombin Receptor Activator Peptide 6, also decreased from day 2 to day 5 of ECMO, as measured by binding with anti-P-selectin, PAC-1 (binds activated GPIIb/IIIa), and anti-CD63 monoclonal antibodies (P-selectin area under the curve [AUC]: 63.46 vs 42.82, respectively, p = 0.0022 PAC-1 AUC: 93.75 vs 74.46, p = 0.0191 CD63 AUC: 55.69 vs 41.76, p = 0.0020). The loss of platelet response over time may contribute to bleeding during ECMO. These novel insights may be useful in understanding mechanisms of bleeding in pediatric ECMO and monitoring platelet markers clinically could allow for prediction or early detection of bleeding and thrombosis.
Publisher: Elsevier BV
Date: 05-2010
DOI: 10.1016/J.THROMRES.2009.07.001
Abstract: Children requiring extracorporeal life support (ECLS) are at significant risk for thrombotic and haemorrhagic complications. Thromboelastography (TEG) is increasingly being used to assist in monitoring the coagulation status of critically ill patients. Its role in heparinised children receiving ECLS is unknown. A retrospective review of TEG in 27 children (mean age 2 years and 8 months) receiving ECLS in a tertiary paediatric intensive care unit between December 2006 and April 2008. Paired TEG (kaolin and heparinase) analysis was performed on 171 occasions. On all occasions activated partial thromboplastin time (APTT) and platelet count were performed within 4 hours of the TEG (mean 6.5 minutes after TEG). On 158 occasions, the activated clotting time (ACT) was measured simultaneously with TEG. The TEG (kaolin) s le was not interpretable due to the heparin effect in 89 (52%) s les. There was a weak correlation between TEG (heparinase) variables and APTT, and between TEG and ACT with a stronger correlation between TEG (Maximum litude) and platelet count. TEG monitoring should always include paired s les in heparinised children on ECLS. In this heterogeneous population, weak, and moderate correlations exist between TEG and standard haematological tests. Prospective studies, with simultaneous s ling for TEG and conventional laboratory tests, must be performed in order to establish its absolute utility as a clinical tool in this population.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2017
Publisher: Springer Science and Business Media LLC
Date: 22-04-2005
DOI: 10.1007/S00134-005-2633-1
Abstract: Many tests have been used to predict outcome following severe brain injury. We compared predictive powers of clinical examination (pupillary responses, motor responses and Glasgow Coma Scale, GCS), electroencephalography (EEG) and computed tomography (CT) to that of somatosensory evoked potentials (SEPs) in a systematic review. Medline (1976-2002) and Embase (1980-2002) were searched, manual review of article reference lists was conducted, and authors were contacted. We selected 25 studies addressing the prediction of outcome after severe brain injury using SEPs and either GCS, EEG, CT, pupillary or motor responses. Outcomes were determined for patients with normal or bilaterally absent SEPs and graded measures of GCS, EEG, CT, pupillary responses or motor responses. For favourable outcome prediction SEPs were superior in sensitivity, specificity and positive and negative predictive values, except for pupillary responses which had superior sensitivity and GCS which had higher specificity. SEPs had superior summary receiver operating characteristic curves, with the exception of motor responses, and superior ratio of odds ratios. For unfavourable outcome prediction SEPs were superior to the other tests in sensitivity, specificity and positive and negative predictive values, except for motor and pupillary responses, GCS and CTs which had superior sensitivity. All SEP summary receiver operating characteristic curves and pooled ratio of odds ratios were superior. Although imperfect, SEPs appear to be the best single overall predictor of outcome. There is sufficient evidence for clinicians to use SEPs in the prediction of outcome after brain injury.
Publisher: Informa UK Limited
Date: 12-1997
Publisher: Wiley
Date: 08-1986
DOI: 10.1111/J.1440-1754.1986.TB00227.X
Abstract: Tolazoline Hydrochloride is a pulmonary vasodilator that is used for the treatment of pulmonary hypertension of the newborn. Two patients who were receiving Tolazoline by infusion developed duodenal ulceration and subsequent intestinal perforation. This undesirable side effect of Tolazoline may be prevented by the concomitant use of antacids to maintain gastric pH greater than 5.
Publisher: Elsevier BV
Date: 10-2012
DOI: 10.1016/J.ATHORACSUR.2012.05.033
Abstract: Identify incidence, etiology, and predictors of extubation failure in neonates and infants who underwent Norwood operation with either a modified Blalock-Taussig shunt (mBTS) or a Sano shunt at a single tertiary care, academic children's hospital. Extubation failure for our study was defined as reintubation within 96 hours after extubation. We collected demographics, preoperative, intraoperative, postoperative, and peri-extubation data in a retrospective, observational format in patients who underwent Norwood operation with either a modified Blalock-Taussig shunt (mBTS) or a Sano shunt between January 2005 and March 2011. Clinical outcomes evaluated included the success or failure of extubation, cardiac intensive care unit (CICU) length of stay (LOS), hospital LOS, and mortality. Descriptive, univariate, and multivariate statistics were utilized to compare groups with extubation failure and extubation success. Of 64 eligible patients during the study period, extubation failure occurred in 22% (14 of 64) of the patients. Eight patients failed extubation in the first 24 hours with an extubation failure rate of 12%. The median age of patients was 18 days (range 13.75 days to 22 days) and median weight of patients was 3.37 kg (range 3.11 kg to 3.86 kg). Twelve patients received a mBTS while 52 patients received a Sano shunt. All extubation failures occurred in patients receiving a Sano shunt. The most common risk factors for failed extubation were lung disease in 29% (4 of 14), cardiac dysfunction in 21% (3 of 14), diaphragmatic paralysis in 14% (2 of 14), airway edema in 14% (2 of 14), vocal cord paralysis in 14% (2 of 14), and laryngotracheomalacia in 7% (1 of 14). Patients with extubation failure had longer CICU LOS and hospital LOS. Overall mortality at the time of hospital discharge was 8%. Independent predictors of extubation failure included use of nitric oxide after surgery, increased days of mechanical ventilation prior to extubation, elevated inotrope score leaving the operating room, and presence of atelectasis prior to extubation. Extubation failure in children after the Norwood operation is a slow and evolving process occurring as late as 96 hours after extubation and is not associated with an increase in in-hospital mortality. Causes of failed extubation are erse. Successful weaning from positive pressure ventilation depends on adequate cardiovascular function, the presence of satisfactory ventilatory reserves, and favorable pulmonary mechanics.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-1987
DOI: 10.1097/00003246-198703000-00010
Abstract: In a prospective randomized controlled trial involving 470 arterial catheters in 470 children, we studied the effect of changing either the concentration or the flow rate of a heparin infusion. Although catheters tended to remain patent longer with a flow rate of 2 ml/h rather than 1 ml/h, the difference was not statistically significant. Increasing the heparin concentration from 1 to 5 U/ml significantly prolonged catheter patency.
Publisher: Wiley
Date: 08-1992
DOI: 10.1111/J.1440-1754.1992.TB02676.X
Abstract: A retrospective study of all neonates with birthweight 2000 g or less undergoing major cardiac surgery at the Royal Children's Hospital, Melbourne over the last 5 years was performed in order to determine outcome and identify subgroups within this population that may have a poor prognosis. The mean length of stay in intensive care following surgery was 32 days, with non-survivors having a significantly longer duration of stay than survivors. Overall mortality was 43%, and for children with congenital heart disease as part of a recognizable syndrome the mortality was 100%. None of the survivors suffered incapacitating cardiac, neurological or respiratory handicap. These children in general have a poor prognosis and utilize significant resources results of cardiac surgery in this group need to be closely followed in the future.
Publisher: Elsevier BV
Date: 1997
Abstract: To assess the role of gastric tonometry in monitoring children receiving extracorporeal life support (ECLS) and to determine if DCO2 or pHi in the weaning phase of ECLS predicts survival. A prospective study of consecutive patients treated with ECLS. A tertiary pediatric ICU that is the ECLS referral center for Australia. Twenty consecutive children receiving ECLS for cardiovascular or respiratory failure. All children were monitored throughout their ECLS course using a tonometer inserted into the stomach via the orogastric route. The PCO2 in the tonometer balloon was measured every 4 to 6 h and the pHi was calculated using the Henderson-Hasselbalch equation. The DCO2, which is the difference between PCO2 in tonometer saline solution and arterial blood, was calculated. We compared the ability of pHi, DCO2, heart rate, mean arterial pressure, arterial pH, base deficit, and blood lactate to predict death or survival during the weaning phase. Measurements were taken on the lowest level of support, which for veno-arterial extracorporeal membrane oxygenation and ventricular assist device was defined as the lowest ECLS pump flows, and on veno-venous extracorporeal membrane oxygenation was defined as the time of lowest ECLS gas flow. Predictive power was assessed using the receivor operating characteristic (ROC) analysis on the data collected at these times. In the weaning phase of ECLS, the pHi was significantly lower in children who died (pHi = 7.21 95% confidence intervals, 7.14 to 7.28) than in those who survived (pHi = 7.38 95% confidence intervals, 7.28 to 7.47). The DCO2 was significantly higher in children who died (23.6 mm Hg 95% confidence intervals, 14.3 to 33.1) compared with survivors (4.7 mm Hg 95% confidence intervals, -0.78 to 10.1). The area under the ROC curve was 0.95 for DCO2 (and 0.88 for pHi). pHi and DCO2 predicted survival better than base deficit (area under ROC curve, 0.82), blood lactate level (0.29), arterial pH (0.65), heart rate (0.62), and mean arterial pressure (0.74). DCO2 is a clinically meaningful measurement in children receiving ECLS. A high DCO2 was a good predictor of death in this series. Gastric tonometry may provide a useful measure of the adequacy of regional perfusion and oxygenation in this group of patients.
Publisher: Springer Science and Business Media LLC
Date: 27-08-2005
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2012
Publisher: Elsevier BV
Date: 06-2001
DOI: 10.1016/S0031-3955(05)70330-8
Abstract: Infection is problematic because it affects many patients (adults and children), is a major cause of death in intensive care units (ICU) worldwide, and uses a large amount of hospital resources. The mortality rate among patients with septic shock varies but approximates 40% in infected patients admitted to ICUs. Because of the large number of adults dying of sepsis, many resources are expended. Children are physiologically different from adults, but nonetheless, many similarities exist with respect to the response to septic shock.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2007
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2018
DOI: 10.1097/PCC.0000000000001611
Abstract: To examine the circumstance of death in the PICU in the setting of ongoing curative or life-prolonging goals. Multidisciplinary author group, international expert opinion, and use of current literature. We describe three common clinical scenarios when curative or life-prolonging goals of care are pursued despite a high likelihood of death. We explore the challenges to providing high-quality end-of-life care in this setting. We describe possible perspectives of families and ICU clinicians facing these circumstances to aid in our understanding of these complex deaths. Finally, we offer suggestions of how PICU clinicians might improve the care of children at the end of life in this setting. Merging curative interventions and optimal end-of-life care is possible, important, and can be enabled when clinicians use creativity, explore possibilities, remain open minded, and maintain flexibility in the provision of critical care medicine. When faced with real and perceived barriers in providing optimal end-of-life care, particularly when curative goals of care are prioritized despite a very poor prognosis, tensions and conflict may arise. Through an intentional exploration of self and others’ perspectives, values, and goals, and working toward finding commonality in order to align with each other, conflict in end-of-life care may lessen, allowing the central focus to remain on providing optimal support for the dying child and their family.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 24-08-2022
DOI: 10.1097/PCC.0000000000002821
Abstract: Therapeutic hypothermia minimizes neuronal injury in animal models of hypoxic-ischemic encephalopathy with greater effect when used sooner after the insult. Clinical trials generally showed limited benefit but are difficult to perform in a timely manner. In this clinical study, we evaluated the association between the use of hypothermia (or not) and health-related quality of life among survivors of pediatric cardiac arrest as well as overall mortality. Single-center, retrospectively identified cohort with prospective assessment of health-related quality of life. PICU of a pediatric hospital. Children with either out-of-hospital or in-hospital cardiac arrest from January 2012 to December 2017. Patients were assigned into two groups: those who received therapeutic hypothermia at less than or equal to 35°C and those who did not receive therapeutic hypothermia but who had normothermia targeted (36–36.5°C). The primary outcome was health-related quality of life assessment and the secondary outcome was PICU mortality. We studied 239 children, 112 (47%) in the therapeutic hypothermia group. The median (interquartile range) of lowest temperature reached in the 48 hours post cardiac arrest in the therapeutic hypothermia group was 33°C (32.6–33.6°C) compared with 35.4°C (34.7–36.2°C) in the no therapeutic hypothermia group ( p 0.001). At follow-up, 152 (64%) were alive and health-related quality of life assessments were completed in 128. Use of therapeutic hypothermia was associated with higher lactate and lower pH at baseline. After regression adjustment, therapeutic hypothermia (as opposed to no therapeutic hypothermia) was associated with higher physical (mean difference, 15.8 95% CI, 3.5–27.9) and psychosocial scores (13.6 [5.8–21.5]). These observations remained even when patients with a temperature greater than 37.5°C were excluded. We failed to find an association between therapeutic hypothermia and lower mortality. Out-of-hospital or in-hospital cardiac arrest treated with therapeutic hypothermia was associated with higher health-related quality of life scores despite having association with higher lactate and lower pH after resuscitation. We failed to identify an association between use of therapeutic hypothermia and lower mortality.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2020
DOI: 10.1097/PCC.0000000000002268
Abstract: To explore relationships between the training background of cardiac critical care attending physicians and self-reported perceived strengths and weaknesses in their ability to provide clinical care. Cross-sectional observational survey sent worldwide to ~550 practicing cardiac ICU attending physicians. Hospitals providing cardiac critical care. Practicing cardiac critical care physicians. None. We received responses from 243 ICU attending physicians from 82 centers (14 countries). The primary training background of the respondents included critical care (62%), dual training in critical care and cardiology (16%), cardiology (14%), and other (8%). We received 49 responses from medical directors in nine countries, who reported that the predominant training background for attending physicians who provide cardiac intensive care at their institutions were critical care (58%), dual trained (18%), cardiology (12%), and other (11%). A greater proportion of physicians trained in either critical care or dual-training reported feeling confident managing multiple organ failure, neurologic conditions, brain death, cardiac arrest, and performing procedures like advanced airway placement and inserting chest- and abdominal-drains. In contrast, physicians with cardiology and dual-training reported feeling more confident managing intractable arrhythmias, understanding cardiopulmonary interactions, and interpreting echocardiogram, electrocardiogram, and cardiac catheterization. Overall, only 57% of the respondents felt comfortable based on their current training background to manage patients with complex cardiac issues without collaboration with other specialists. Our survey demonstrates that intensivists trained in critical care are more comfortable with critical care skills, cardiology-trained intensivists are more comfortable with cardiology skills, and dual-trained physicians are comfortable with both critical care skills and cardiology skills. These findings may help inform future efforts to optimize the educational curriculum and training pathways for future cardiac intensivists. These data may also be used to shape continuing medical education activities for cardiac intensivists who have already completed their training.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2014
Publisher: Springer Science and Business Media LLC
Date: 03-1996
DOI: 10.1007/BF01712247
Abstract: Increasingly, use of the electronic health record (EHR) is interwoven into even the most basic patient care tasks. Accordingly, learning how to utilize the EHR during patient encounters is important for medical students as they develop their clinical skills. Existing EHR curricula have focused primarily on doctor-patient relationship skills. We developed a session for our preclinical students on EHR-related doctor-patient relationship skills as well as on using the EHR to verify data and focus one's history taking. We developed student notes, three training videos, four standardized patient (SP) cases, and a simplified, simulated EHR based on these cases. Students reviewed the notes and videos prior to class. During class, students practiced EHR-related communication and data-collection strategies by interviewing an SP while interacting with the simulated EHR. Following each encounter, students received feedback from a small group of peers and faculty. Two-hundred eighty-nine second-year medical students participated this session in 2019 and 2020, and 27 (19%, 2019) and 40 (28%, 2020) students, respectively, completed the postsession evaluation. Most respondents rated the SP activity as extremely or quite effective for practicing doctor-patient relationship strategies while interacting with the EHR (89%, 2019 83%, 2020) and for practicing verification of EHR data during a patient encounter (81%, 2019 86%, 2020). This training session was effective for introducing preclinical medical students to fundamental concepts and skills related to incorporating the EHR into patient encounters and offers a low-cost approach to teaching early medical students these important skills.
Publisher: Cambridge University Press (CUP)
Date: 04-08-2022
DOI: 10.1017/S1047951122002384
Abstract: In medical research, continuous variables are often categorised into two or more groups before being included in the analysis this practice often comes with a cost, such as loss of power in analysis, less reliable estimates, and can often leave residual confounding in the results. In this research report, we show this by way of estimates from a regression analysis looking at the association between acute kidney injury and post-operative mortality in a s le of 194 neonates who underwent the Norwood operation. Two models were developed, one using a continuous measure of renal function as the main explanatory variable and second using a categorised version of the same variable. A continuous measure of renal function is more likely to yield reliable estimates and also maintains more statistical power in the analysis to detect a relation between the exposure and outcome. It also reveals the true biological relationship between the exposure and outcome. Categorising a continuous variable may not only miss an important message, it can also get it wrong. Additionally, given a non-linear relationship is commonly encountered between the exposure and outcome variable, investigators are advised to retain a predictor with a linear term only when supported by data. All of this is particularly important in small data sets which account for the majority of clinical research studies.
Publisher: SAGE Publications
Date: 09-2017
DOI: 10.1177/0310057X1704500509
Abstract: We assessed the clinical impact of thrombelastography (TEG ® ) results (TEG ® 5000, Haemonetics Corporation, Braintree, MA, USA) by measuring their ability to cause changes in a theoretical treatment plan and contribute to the understanding of haemostasis. We prospectively included paediatric intensive care unit (PICU) patients who had standard tests of haemostasis and TEG ordered and had an arterial catheter or extracorporeal access port in situ. Blood for standard tests and TEG was taken simultaneously. Independent of patient care, general patient information and results of standard laboratory tests were presented to five clinicians who were asked to document their theoretical treatment plan. Clinicians were then shown TEG results and asked if they caused a change in their plan, if they confirmed initial standard laboratory test results, if they enabled a better understanding of haemostasis and if they provided additional information. Inter-rater agreement between the clinicians was determined. Forty-two TEG results were obtained from 34 patients. Overall, the inclusion of TEG results led to a change in treatment plan in 97 of 207 occasions (47%), confirmed standard laboratory test results in 177 of 204 occasions (87%), enabled a better understanding of haemostasis in 140 of 204 occasions (69%) and provided additional information in 131 of 204 occasions (64%). Variation existed between clinicians, seemingly due to in idual differences, with poor inter-rater agreement. We conclude that TEG results led to changes in treatment plans almost half the time, confirmed findings of standard tests and provided a better understanding of haemostasis, but randomised controlled trials are required to determine the role and influence of TEG results on patient outcome.
Publisher: SAGE Publications
Date: 14-07-2010
Abstract: During extracorporeal life support (ECLS), blood is exposed to a myriad of unphysiological factors that can affect outcome. One aspect of this is the sub-atmospheric pressure generated by the ECLS pump and imparted to blood elements along the pump inlet line. This pressure can be measured on the inlet line close to the pump head by adding a connector, or at the venous cannula connection site. We compared the two measurement sites located at both points between the venous cannula-inlet tubing and inlet tubing-pump, with a range of cannulae and flows. We also investigated the effects on inlet pressure from pump afterload and increasing inlet tubing length.
Publisher: Elsevier BV
Date: 2007
DOI: 10.1016/J.JTCVS.2006.09.017
Abstract: Acidosis caused by increased unmeasured anion levels occurs frequently after cardiac surgery, with uncertain significance. We examined the ability of unmeasured anions and lactate to predict major events after cardiac surgery, in addition to lactate/increased unmeasured anion levels during low cardiac output states. In the initial 6 months, all patients admitted after cardiac surgery were enrolled. Arterial s les were taken at 0, 4, 8, 12, 24, and 36 hours postoperatively. The Stewart method was used to calculate excess acid and unmeasured anion levels. Major adverse events were defined as low cardiac output states requiring cardiac massage or mechanical support. In the second 6-month period, data were collected from a further 8 infants during cardiac arrest/extracorporeal membrane oxygenation cannulation. One hundred thirteen patients were analyzed. Major adverse events occurred in 8 (7.1%) of 113 patients. On admission, metabolic acidosis occurred in 94 of 113 s les: lactate alone (n = 25) mixed lactate and unmeasured anions (n = 44) and unmeasured anions alone (n = 25). All of the patients who experienced major adverse events had unmeasured anion levels of greater than 3 mEq/L on admission. Initial unmeasured anion levels were significantly higher in those infants with major adverse events (10.6 mEq/L [standard deviation, 8.2 mEq/L] vs 4.8 mEq/L [standard deviation, 6.6 mEq/L], P = .024). Lactate levels did not differ between the 2 groups. In the 16 patients s led during major adverse events, metabolic acidosis occurred in 15 of 16, with a mean excess acid level of 14.9 mEq/L (standard deviation, 8.3 mEq/L). Although unmeasured anions made a significant contribution, lactate was the predominant acid. After cardiac surgery, unmeasured anion levels were significantly higher in those children with major adverse events. The greatest risk of major adverse events was found in children with both increased lactate levels and increased unmeasured anion levels on admission.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
DOI: 10.1097/PCC.0000000000001170
Abstract: A positive fluid balance after cardiac surgery may be associated with poor outcomes however, previous studies looking at this association have been limited by the number of deaths in the study population. Our primary aim was to determine the relationship between postoperative cumulative fluid balance and mortality in cardiac surgical patients. Secondary aims were to study the association between fluid balance and duration of mechanical ventilation, intensive care and hospital length of stay. Case-control study. A 30-bed multidisciplinary PICU. All patients admitted to the PICU following cardiac surgery from 2010 to 2014. Deaths during PICU admission following cardiac surgery (cases) were matched 1:3 with children who survived to PICU discharge (controls) using the following criteria: age at surgery (within a 20% age range), Risk Adjusted Congenital Heart Surgery (RACHS-1) category, and year of admission. Of 1,996 eligible children, 46 died (2.3%) of whom 45 (98%) were successfully matched. Cumulative fluid balance on days 2 and 7 was not associated with PICU mortality. On multivariable analysis, factors associated with mortality were cardiopulmonary bypass time (per 10-min increase, odds ratio [95% CI], 1.06 [1.00–1.12] p = 0.03), extracorporeal membrane oxygenation requirement within 3 days (46.6 [9.47–230.11] p 0.001), peak serum chloride (mmol/L) in the first 48 hours (1.12 [1.01–1.23]), and time to start peritoneal dialysis after surgery (in comparison to no peritoneal dialysis, odds ratio [95% CI] in those started on early peritoneal dialysis was 1.07 [0.33–3.41] p = 0.90 and in late peritoneal dialysis 3.65 [1.21–10.99] p = 0.02). Children with cumulative fluid balance greater than or equal to 5% by day 2 spent longer on mechanical ventilation (median [interquartile range], 211 hr [97–539] vs 93 hr [34–225] p .001), in PICU (11 d [8–26] vs 6 [3–13] p 0.001) and in hospital (22 d [13–39] vs 14 d [8–30] p = 0.001). Early fluid overload is not associated with mortality. However, it is associated with increased duration of mechanical ventilation and PICU length of stay. Early peritoneal dialysis commencement (compared with late peritoneal dialysis) after surgery was associated with decreased mortality.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2010
Publisher: SAGE Publications
Date: 28-07-2014
Abstract: We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient’s pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient’s evolving needs.
Publisher: Elsevier BV
Date: 06-2021
DOI: 10.51893/2021.2.OA6
Abstract: OBJECTIVE: Most interventions in paediatric critical care lack high grade evidence. We aimed to identify the key research priorities and key clinical outcome measures pertinent to research in paediatric intensive care patients. DESIGN: Modified three-stage Delphi study combining staged online surveys, followed by a face-to-face discussion and final voting. SETTING: Paediatric intensive care units in Australia and New Zealand. PARTICIPANTS: Medical and nursing staff working in intensive care. MAIN OUTCOME MEASUREMENTS: Self-reported priorities for research. RESULTS: 193 respondents provided a total of 267 research questions and 234 outcomes. In Stage 3, the top 56 research questions and 50 outcomes were discussed face to face, which allowed the identification of the top 20 research questions with the Hanlon prioritisation score and the top 20 outcomes. Topics centred on the use of intravenous fluids (restrictive v liberal fluids, use of fluid resuscitation bolus, early inotrope use, type of intravenous fluid, and assessment of fluid responsiveness), and patient- and family-centred outcomes (health-related quality of life, liberation) emerged as priorities. While mortality, length of stay, and organ support/organ dysfunction were considered important and the most feasible outcomes, long term quality of life and neurodevelopmental measures were rated highly in terms of their importance. CONCLUSIONS: Using a modified Delphi method, this study provides guidance towards prioritisation of research topics in paediatric critical care in Australia and New Zealand, and identifies study outcomes of key relevance to clinicians and experts in the field.
Publisher: SAGE Publications
Date: 07-1993
DOI: 10.1177/026765919300800405
Abstract: Calcium is necessary for myocardial muscle contraction. The ionized calcium fraction in blood is the physiologically active component and can be readily measured with calcium-selective electrodes. Cardiopulmonary bypass (CPB) alters the relationship between calcium and related blood constituents, depending on the composition of the pump-prime and the quantity of blood products administered peri-operatively. Serial measurements of total and ionized serum calcium concentrations and related biochemical parameters were made in 115 consecutive children over a 24-hour period before and after CPB. Total and ionized calcium concentrations were consistently elevated in the immediate postoperative period, and though infants may, theoretically, benefit from calcium infusion after CPB, the uncritical use of calcium salts in children after cardiac surgery is not justified.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2006
Publisher: Wiley
Date: 05-2006
DOI: 10.1111/J.1445-2197.2006.03723.X
Abstract: The aim was to study the epidemiology of significant adolescent head injury in a statewide population. A retrospective review of all significant adolescent (12-19 years old) head injuries over a period of 3 years was undertaken and compared with those of children (0-11 years old) and young adults (20-29 years old). The incidence of significant adolescent head injury was 19.2 per 100,000 adolescents per year. This compared to the incidence in children of 12.9 per 100,000 and in young adult of 14.7 per 100,000. Of all significant adolescent head injuries, 63.9% are managed at adult trauma centres. Demographics, pathology, neurosurgical management, length of intensive care unit stay, ventilated hours and length of hospital stay were similar to those of young adults and significantly different from those of children. Prehospital predictors of mortality were similar across all groups. Adolescent discharge destinations were similar to those of young adults and significantly different from those of children. The study emphasizes the incidence of and mortality from adolescent head injury. The pattern of adolescent head injury is different from that of children and supports current practice of treatment of a majority of adolescents in adult trauma centres. These differences have implications on planning for injury prevention and trauma management.
Publisher: Elsevier BV
Date: 06-2022
DOI: 10.51893/2022.2.OA9
Abstract: BACKGROUND: Peritoneal dialysis (PD) is a commonly used therapy after infant cardiac surgery. It is unclear whether early PD commenced soon after admission to an intensive care unit (ICU) after cardiac surgery results in better outcomes. OBJECTIVE: To describe the study protocol and statistical analysis plan for the Early Peritoneal Dialysis in Infants after Cardiac Surgery (EPICS) trial. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: The EPICS trial is an open, randomised, two-group, single-centre clinical study of infants ≤ 180 days of age who had cardiac surgery (in Risk-Adjusted Classification for Congenital Heart Surgery version 1 categories 3–6) with cardiopulmonary bypass. Participants will be randomly assigned 1:1 to early PD (treatment group) or no early PD (control group). Those assigned to the treatment group will begin receiving PD soon after ICU admission and continue receiving it for 24 hours. Those in the control group will not receive PD during the first 24 hours. MAIN OUTCOME MEASURES: The primary outcome is a composite measure consisting of one or more of death, cardiac arrest, emergency chest reopening, and requirement for extracorporeal membrane oxygenation (ECMO) within 90 days. The main secondary outcomes are duration of mechanical ventilation, ICU length of stay, hospital length of stay, vasoactive-inotropic score at 24 hours, and cumulative per cent fluid balance by end of Day 2. At Day 90, events such as mortality, requirement for ECMO, cardiac arrest, chest reopening, volume of packed red blood cell transfusion, post-operative infection, readmission to ICU, renal injury and brain injury will be assessed. CONCLUSIONS: The EPICS trial aims to evaluate the role of early PD after infant cardiac surgery in lowering the rate of a composite major outcome. In addition, it will test the effect of early PD on duration of mechanical ventilation, and on ICU and hospital length of stay. TRIAL REGISTRATION: ACTRN12617001614381.
Publisher: SAGE Publications
Date: 11-1992
DOI: 10.1177/0310057X9202000406
Abstract: Over the last ten years the survival of infants born with congenital diaphragmatic hernia who reach the Intensive Care Unit of the Royal Children's Hospital, Melbourne has been constant at 56±6%. Experimental therapies such as extracorporeal membrane oxygenation, high-frequency oscillation and lung transplantation are now being considered as therapeutic options, and as such the ability to predict survival or death of these infants is increasingly important. The records of all infants with congenital diaphragmatic hernia admitted to the Intensive Care Unit between 1 January 1980 and 30 April 1989 were reviewed blood gas, ventilatory details, and outcome information was obtained. Receiver operating curve analysis was used to determine the best predictor of death. An oxygenation index (MAP X F i o 2 /P a o 2 ) 0.3 or ventilation index (PIP X RR X CO 2 /1000) 70 predicted a 94% mortality with a specificity of 96% and a sensitivity of 82%.
Publisher: Wiley
Date: 1991
Abstract: Deciding when to wean neonates from extracorporal membrane oxygenation (ECMO) can be difficult. The usefulness of simple measurements of pulmonary mechanics e.g., dynamic compliance (Cdyn) has been questioned. We investigated the pulmonary mechanics of eight neonates using the interrupter technique, which allows the partitioning of pulmonary mechanics into compartments representing the conducting airways and more peripheral phenomena (viscoelastic properties and "pendelluft"). Three neonates required ECMO for a congenital diaphragmatic hernia (CDH), two for hyaline membrane disease (HMO), two for meconium aspiration syndrome (MAS), and one for pneumonia. All neonates with MAS, HMD, and pneumonia were successfully weaned from ECMO when their Cdyn was 0.3 mL/cmH2O/kg or greater [mean 0.34 +/- 0.06 (SEM)]. All three neonates with CDH died and their highest Cdyn was 0.21, 0.19, and 0.09 mL/cmH2O/kg respectively (mean, 0.16 +/- 0.037). The airway resistance (Raw) and the slower component of pressure change after interruption (delta Pdiff), a measure of the more peripheral phenomena of the lung, were not significantly different in those neonates who survived and those who did not. The values for delta Pdiff in all patients were higher than those in healthy neonates. However, the Raw was not different. This suggests that the major disturbance in pulmonary mechanics was distal to the conducting airways. Those neonates who were successfully weaned from ECMO had a significantly higher Cdyn 24-48 hours prior to decannulation. Considering the lung as a two-compartment model offers no advantages when compared to the one-compartment model for the prediction of the outcome of a neonate on ECMO.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2020
Publisher: Elsevier BV
Date: 1995
DOI: 10.1016/S0022-3476(95)70498-1
Abstract: The purpose of this study was to evaluate prospectively short-latency somatosensory evoked potentials (SEPs) as a predictor of outcome in acute, severe brain injury, and to compare this with the predictive power of the motor component of the Glasgow Coma Scale score and computed tomographic scan. Outcome was measured with the Glasgow Outcome Scale at a minimum of 6 months after injury. We studied 109 patients (aged 0.1 to 16.8 years) with SEPs within 4 days of the onset of coma. Four patients had absent SEPs and a favorable outcome by the Glasgow Outcome Scale (full recovery or moderate disability) two of these patients had meningitis with bilateral subdural effusions, one had a midbrain hemorrhage, and one had a decompressive craniectomy for uncontrolled intracranial hypertension. Normal SEPs had a positive predictive value for favorable outcome of 93% (95% confidence interval (CI), 77% to 99%), and absent SEPs had a positive predictive value for unfavorable outcome by the Glasgow Outcome Scale (severe disability, survival in a persistent vegetative state, or death) of 92% (95% CI, 80% to 98%). If the above identifiable clinical situations in which a physical barrier existed to impede cutaneous reception of the electrical impulse were excluded, the positive predictive value of absent SEPs for poor outcome reached 100% (95% CI, 92% to 100%). An absent motor response to painful stimulus also had 100% positive predictive value (95% CI, 84% to 100%) for unfavorable outcome however, 23% of patients could not be evaluated because of the effects of muscle relaxants or sedatives. In patients with traumatic brain injury, results of computed tomography did not reliably predict outcome. Of the 59 patients with unfavorable outcome, 76% could be identified with SEPs compared with 36% with examination of motor function. We suggest that SEPs be performed in children with acute severe brain injury because they add an important tool to the physician's prognostic armamentarium. We conclude that in the absence of the above mentioned identifiable clinical situations, absent SEPs predict 100% unfavorable outcome, and this finding may warrant consideration of withdrawal of treatment in children with brain injuries.
Publisher: Springer Science and Business Media LLC
Date: 28-04-2005
DOI: 10.1007/S00134-005-2634-0
Abstract: To directly compare the predictive powers of somatosensory evoked potentials (SEPs) to those of motor and pupillary responses. Prospective clinical study in a paediatric intensive care unit. 102 severely brain-injured children less than 15 years of age. SEPs and motor and pupillary responses were serially recorded during the first 9 days after admission. Initial, last and those tests performed on or after day 2 were analysed. Outcome was assessed 5 years after injury. SEPs had equal or superior predictive statistics and ROC curves compared to the other tests with few exceptions. Pupillary responses had higher sensitivity for favourable outcome prediction while for unfavourable outcome prediction the last motor responses had higher sensitivity, and the last pupillary responses had slightly higher specificity. Combining SEPs and motor responses provided the best combination for predicting unfavourable outcome. SEPs are the best overall predictor of outcome while motor and pupillary responses have advantages in some specific areas. The routine use of SEPs should be considered in the prediction of outcome of severely brain-injured patients.
Publisher: Springer Science and Business Media LLC
Date: 29-08-2019
Publisher: Wiley
Date: 02-1994
DOI: 10.1111/J.1440-1754.1994.TB00566.X
Abstract: Between April 1989 and October 1991, 13 severely ill infants, median age 13 days (range 1-180 days), median weight 3.5 kg (range 2.5-4.8 kg), received continuous venovenous haemofiltration (CVVH) for a median duration of 39 h (range 5-234 h). Filtration was performed through a double lumen catheter inserted into a central vein. The indications for filtration included acute renal failure (8), fluid overload (5), inborn errors of metabolism (3) and sepsis (1). Some infants had more than one indication. The median Paediatric Risk of Mortality (PRISM) score on the day of admission to the intensive care unit was 27 (range 8-42). No change in the level of respiratory support was required following the commencement of CVVH. Serum electrolyte concentrations and plasma osmolality remained normal throughout. Serum creatinine fell from a mean of 0.11 mmol/L (95% CI 0.058-0.168) to 0.07 mmol/L (CI 0.034-0.112). Urea fell from a mean of 9.5 mmol/L (CI 4.4-14.6) to 6.5 mmol/L (CI 2.7-10.3). Platelet counts fell by 40-50% from a mean of 126 x 10(6)/mm3 (CI 72-180) to 69 x 10(6)/mm3 (CI 36-103) 18 h following commencement of filtration but no bleeding was encountered. The main complication was a thrombosis of the superior and inferior vena cava in one infant. Four infants survived to be discharged from intensive care. Continuous venovenous haemofiltration, with its inherent advantages over arteriovenous haemofiltration, is feasible in small infants using standard paediatric equipment.
Publisher: BMJ
Date: 08-1991
DOI: 10.1136/HRT.66.2.175
Abstract: To study the dose response characteristics of prostaglandin E1 and epoprostenol (prostacyclin) and directly to compare their effectiveness as pulmonary vasodilators in infants with pulmonary hypertension. A crossover design with each patient receiving both drugs in random order. Infants were studied in the intensive care unit while they were sedated, paralysed, and ventilated. Twenty infants who had undergone corrective cardiac surgery and who were in sinus rhythm, had stable haemodynamic function, and had a pulmonary artery catheter in place. All infants were receiving dopamine and phenoxybenzamine. Baseline haemodynamic measurements were taken and an infusion of the first drug was started at the lowest dose: after 20 minutes the measurements were repeated and the dose increased. This protocol was repeated for all doses of both drugs: 10, 30, and 100 ng/kg/min of prostaglandin E1 and 5, 10, and 25 ng/kg/min of epoprostenol. Cardiac output was measured by the pulsed Doppler ultrasound method. Pulmonary and systemic vascular resistances were calculated from the cardiac output and compared by the Wilcoxon signed ranks test. Both prostaglandin E1 and epoprostenol were effective vasodilators: 5 ng/kg/min of epoprostenol was equivalent to 30 ng/kg/min of prostaglandin E1. Neither drug showed pulmonary specificity.
Publisher: Springer Science and Business Media LLC
Date: 12-2019
DOI: 10.1186/S13054-019-2685-1
Abstract: The surviving sepsis c aign recommends consideration for extracorporeal membrane oxygenation (ECMO) in refractory septic shock. We aimed to define the benefit threshold of ECMO in pediatric septic shock. Retrospective binational multicenter cohort study of all ICUs contributing to the Australian and New Zealand Paediatric Intensive Care Registry. We included patients 16 years admitted to ICU with sepsis and septic shock between 2002 and 2016. Sepsis-specific risk-adjusted models to establish ECMO benefit thresholds with mortality as the primary outcome were performed. Models were based on clinical variables available early after admission to ICU. Multivariate analyses were performed to identify predictors of survival in children treated with ECMO. Five thousand sixty-two children with sepsis and septic shock met eligibility criteria, of which 80 (1.6%) were treated with veno-arterial ECMO. A model based on 12 clinical variables predicted mortality with an AUROC of 0.879 (95% CI 0.864–0.895). The benefit threshold was calculated as 47.1% predicted risk of mortality. The observed mortality for children treated with ECMO below the threshold was 41.8% (23 deaths), compared to a predicted mortality of 30.0% as per the baseline model (16.5 deaths standardized mortality rate 1.40, 95% CI 0.89–2.09). Among patients above the benefit threshold, the observed mortality was 52.0% (13 deaths) compared to 68.2% as per the baseline model (16.5 deaths standardized mortality rate 0.61, 95% CI 0.39–0.92). Multivariable analyses identified lower lactate, the absence of cardiac arrest prior to ECMO, and the central cannulation (OR 0.31, 95% CI 0.10–0.98, p = 0.046) as significant predictors of survival for those treated with VA-ECMO. This binational study demonstrates that a rapidly available sepsis mortality prediction model can define thresholds for survival benefit in children with septic shock considered for ECMO. Survival on ECMO was associated with central cannulation. Our findings suggest that a fully powered RCT on ECMO in sepsis is unlikely to be feasible.
Publisher: Wiley
Date: 05-1984
DOI: 10.1111/J.1440-1754.1984.TB00059.X
Abstract: We report an infant with prolonged persistent pulmonary hypertension (PPH) who failed to respond to various mechanical and pharmacological therapies but who showed spontaneous improvement at 13 days of age. We therefore stress that assisted ventilation should be continued in PPH without major structural cardiac or pulmonary abnormality or ongoing iatrogenic complications, as recovery may occur at any time.
Publisher: American Medical Association (AMA)
Date: 05-07-2022
Publisher: Elsevier BV
Date: 12-2007
DOI: 10.1016/J.HEALUN.2007.09.003
Abstract: We report the case of a 9-year-old girl who developed acute anthracycline-induced cardiotoxicity with severe, refractory congestive heart failure. Rescue treatment with cardiac re-synchronization therapy was initiated, resulting in rapid improvement in left ventricular function and clinical status.
Publisher: Wiley
Date: 12-2015
DOI: 10.1111/PAN.12800
Abstract: Near-infrared spectroscopy (NIRS) provides an assessment of cerebral oxygenation and tissue hemoglobin concentration. The aim of this study was to investigate whether the cerebral oxygenation and hemoglobin concentration measured with NIRS could predict outcomes after pediatric cardiac surgery. We conducted a retrospective observational study in 399 patients who underwent pediatric cardiac surgery. Associations were determined between postoperative outcome and preoperative and postoperative cerebral tissue oxygenation index (TOI), postoperative normalized tissue hemoglobin index (nTHI), concentration changes in oxygenated hemoglobin (Δ[HbO2 ]) and deoxygenated hemoglobin (Δ[HHb]). Thirty-nine children had major postoperative morbidity and 12 died. Using Spearman's correlation analysis, postoperative lower TOI and higher Δ[HHb] were associated with longer stays in the Intensive Care Unit (ICU) (r = -0.48, P < 0.001, r = 0.31, P < 0.001, respectively) and longer duration of intubation (r = -0.48, P < 0.001, r = 0.31, P < 0.001, respectively) and higher probability of death determined by the Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1) (r = -0.39, P < 0.001, r = 0.23, P < 0.001, respectively). In multivariate regression analysis, postoperative TOI was independently associated with major morbidity and mortality and Δ[HHb] was independently associated with major morbidity. In receiver operating characteristic analysis, postoperative TOI and Δ[HHb] predicted major morbidity (Area under the curve [AUC] = 0.72, 0.68, respectively) and mortality (AUC = 0.81, 0.69, respectively). Lower TOI or higher [HHb] at the end of surgery and higher RACHS-1 category predicted worse outcomes.
Publisher: American Thoracic Society
Date: 11-2006
Publisher: AMPCo
Date: 10-1998
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2016
Publisher: SAGE Publications
Date: 08-08-2019
Publisher: Wiley
Date: 02-1985
DOI: 10.1111/J.1440-1754.1985.TB00121.X
Abstract: In a population of 225 very low birthweight infants born over a 21 month period the cerebroventricular system was scanned by ultrasound. One third of the infants developed a periventricular haemorrhage in 41% of infants the haemorrhage was detected before an hour of age and 66% of all haemorrhages occurred within the first 24 hours. Statistically significant associations with periventricular haemorrhage included vaginal delivery, endotracheal intubation and intravenous sodium bicarbonate when this was administered in the first 24 hours. In a stepwise regression analysis, however, these and other potentially significant variables added little to the total accountable variance. A similar analysis of perinatal factors and mortality revealed that decreasing gestation was the major association with death.
Publisher: Elsevier BV
Date: 05-2022
DOI: 10.1016/J.JPEDS.2022.01.031
Abstract: To determine whether the combination of systemic corticosteroids and nebulized epinephrine, compared with standard care, reduces the duration of positive pressure support in children with bronchiolitis admitted to intensive care. We performed a pragmatic, multicenter, open-label, randomized trial between July 2013 and November 2019 in children younger than 18 months old with a clinical diagnosis of bronchiolitis. The intervention group received the equivalent of 13 mg/kg prednisolone over 3 days, then 1 mg/kg daily for 3 days, plus 0.05 mL/kg of nebulized 1% epinephrine made up to 6 ml with 0.9% saline via jet nebulizer and mask using oxygen at 12 l/min every 30 minutes for 5 doses, then 1-4 hourly for 3 days, then as required for 3 days. The primary outcome was clinician-managed duration of positive pressure support in intensive care defined as high-flow nasal-prong oxygen, nasopharyngeal continuous positive airway pressure, or mechanical ventilation. In total, 210 children received positive pressure support. In the corticosteroid-epinephrine group, 107 children received positive pressure support for a geometric mean of 26 (95% CI, 22-32) hours compared with 40 (95% CI 34-47) hours in 103 controls, adjusted ratio 0.66 (95% CI 0.51-0.84), P = .001. In the intervention group, 41 (38%) children experienced at least 1 adverse event, compared with 39 (38%) in the control group. In children with severe bronchiolitis, the duration of clinician-managed pressure support was reduced by regular treatment with systemic corticosteroids and inhaled epinephrine compared with standard care. Australian Clinical Trials Research Network: ACTRN12613000316707.
Publisher: Elsevier BV
Date: 05-2020
DOI: 10.1016/J.ATHORACSUR.2019.09.026
Abstract: Serum creatinine is the most commonly used marker to diagnose acute kidney injury. Studies exploring creatinine patterns in the single-ventricle population are scarce. We studied serum creatinine up to 5 postoperative days after the stage 1 operation and assessed its relationship with outcomes. Neonates who underwent a first-stage single-ventricle operation (Norwood or a Damus-Kaye-Stansel) between 2005 and 2017 were retrospectively analyzed. Peak percentage creatinine change (PPCC) was defined as the difference between the baseline (preoperative) and the peak postoperative level (within 5 postoperative days), expressed as a percentage of the baseline level. Among 187 neonates included, the median PPCC was 38.7% (interquartile range, 14.1%-73.1%), and in-hospital mortality was 17% (31 of 187). A controlled analysis showed that for every 10-minute increase in cardiopulmonary bypass duration (CPB), the PPCC increased by 1.8% (95% confidence interval [CI], 0.7%-2.9% P = .002). Risk of in-hospital death increased log-linearly with PPCC. The adjusted odds ratios for death in the hospital associated with a 50%, 100%, and 200%, increase in peak percentage creatinine change were 1.85 (95% CI, 1.23-2.78), 3.41 (95% CI, 1.15-7.72), and 11.66 (95% CI, 2.28-59.63), respectively. In-hospital death was also associated with CPB duration (adjusted odds ratio, 1.13 per 10-minute increase 95% CI, 1.05-1.22 P = .001). Increase in CPB duration has a strong linear association with increase in PPCC after stage 1 single-ventricle reconstruction. Increase in PPCC and CPB duration has a strong linear association with hospital mortality. It is important to identify therapies that minimize complications associated with prolonged CPB duration in high-risk populations.
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.AUCC.2014.01.003
Abstract: Endotracheal suctioning (ETS) is one of the most common procedures performed in the paediatric intensive care. The two methods of endotracheal suctioning used are known as open and closed suction, but neither method has been shown to be the superior suction method in the Paediatric Intensive Care Unit (PICU). The primary purpose was to compare open and closed suction methods from a physiological, safety and staff resource perspective. All paediatric intensive care patients with an endotracheal tube were included. Between June and September 2011 alternative months were nominated as open or closed suction months. Data were prospectively collected including suction events, staff involved, time taken, use of saline, and change from pre-suction baseline in heart rate (HR), mean arterial pressure (MAP) and oxygen saturation (SpO2). Blocked or dislodged ETTs were recorded as adverse events. Closed suction was performed more often per day (7.2 vs 6.0, p<0.01), used significantly less nursing time (23 vs 38 min, p<0.01) and had equivalent rates of adverse events compared to open suction (5 vs 3, p<0.23). Saline lavage usage was significantly higher in the open suction group (18% vs 40%). Open suction demonstrated a greater reduction in SpO2 and nearly three times the incidence of increases in HR and MAP compared to closed suction. Reductions in MAP or HR were comparable across the two methods. In conclusion, CS could be performed with less staffing time and number of nurses, less physiological disturbances to our patients and no significant increases in adverse events.
Publisher: Elsevier BV
Date: 02-2010
Publisher: Wiley
Date: 06-1988
DOI: 10.1111/J.1440-1754.1988.TB00325.X
Abstract: A 6 year old boy presented with cardiogenic shock following a mild gastroenteritis-like illness. He was subsequently found to have adrenal failure secondary to adrenoleucodystrophy. Despite adequate corticosteroid replacement and intensive cardiorespiratory support, progressive cardiac failure occurred and the patient died. High levels of endogenous catecholamines may be toxic to the myocardium in the absence of sufficient corticosteroid.
Publisher: SAGE Publications
Date: 08-1992
DOI: 10.1177/0310057X9202000305
Abstract: Extracorporeal membrane oxygenation (ECMO) has been used at the Royal Children's Hospital, Melbourne, in the treatment of children with life-threatening respiratory or cardiac failure since May 1988. The main indications for its use are, first, the disease is thought to be reversible, second, the child will survive with an acceptable quality of life and, third, the child has an 80% chance of dying without ECMO. Seven of eighteen children receiving ECMO have survived to leave hospital, and all are functionally normal: these results are similar to international results. It would appear that ECMO is a useful therapy for some children with otherwise fatal cardiorespiratory failure.
Publisher: Springer Science and Business Media LLC
Date: 19-08-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1986
DOI: 10.1212/WNL.36.1.108
Abstract: We studied 14 newborn infants with seizures after birth asphyxia or other causes. Paraldehyde was given as a 200 mg/kg IV bolus followed by an infusion of 16 mg/kg/h (10 cases), or as a 400 mg/kg bolus (4 cases). Serum concentrations of paraldehyde were higher in periods of adequate seizure control than in periods of little or no response. Paraldehyde serum concentrations above 10 mg/dl were associated with anticonvulsant effects and were achieved in most neonates with a 2-hour infusion of 200 mg/kg/h. If there is no effect, serum concentrations are probably below 10 mg/dl and an additional 200 mg/kg can be given safely over 1 hour.
Publisher: Springer Science and Business Media LLC
Date: 19-06-2015
Publisher: BMJ
Date: 07-1993
DOI: 10.1136/ADC.69.1.151
Abstract: Brainstem reflexes were examined in 23 children treated with thiopentone infusion and correlated with serum thiopentone concentrations. The results suggest that if all brainstem reflexes are lost with a serum thiopentone concentration less than 40 mg/l, it is unlikely to be due to the thiopentone alone. Other causes including brain death need to be considered.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 14-08-2020
DOI: 10.1097/PCC.0000000000002470
Abstract: To describe the prevalence and consequences of major adverse events secondary to extubation failure after neonatal cardiac surgery. A single-center cohort study. A medical-surgical, 30-bed PICU in Victoria, Australia. One thousand one hundred eighty-eight neonates less than or equal to 28 days old who underwent cardiac surgery from January 2007 to December 2018. None. Extubation failure was defined as unplanned reintubation within 72 hours after a planned extubation. Major adverse event was defined as one or more of cardiac arrest, emergency chest reopening, extracorporeal membrane oxygenation, or death within 72 hours after extubation. One hundred fifteen of 1,188 (9.7%) neonates had extubation failure. Hospital mortality was 17.4% and 2.0% in neonates with and without extubation failure. Major adverse event occurred in 12 of 115 reintubated neonates (10.4%). major adverse event included cardiac arrest ( n = 10), chest reopening ( n = 8), extracorporeal membrane oxygenation ( n = 5), and death ( n = 0). Cardiovascular compromise accounted for major adverse event in eight: ventricular dysfunction ( n = 3), pulmonary overcirculation ( n = 2), coronary ischemia ( n = 2), cardiac t onade ( n = 1). In a multivariable logistic regression, factors associated with major adverse event were high complexity in cardiac surgery (odds ratio 5.9 95% CI: 1.1–32.2) and airway anomaly (odds ratio 6.0 95% CI: 1.1–32.6). Hospital morality was 25% and 17% in reintubated neonates with and without major adverse event. Around 10% of reintubated neonates suffered major adverse event within 72 hours of extubation. Neonates suffering major adverse event had high mortality. Major adverse event should be monitored and reported in future studies of extubation failure. Along with tracking of extubation failure rates, major adverse event secondary to extubation failure may also serve as a key performance indicator for ICUs and registries.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2015
Publisher: SAGE Publications
Date: 07-07-2022
DOI: 10.1177/02676591211027776
Abstract: Hemolysis is a common complication of extracorporeal membrane oxygenation (ECMO). There are few data on whether carboxyhemoglobin (COHb), a potential marker of hemolysis, are elevated during ECMO support. We conducted a single-center, retrospective study comparing peak COHb levels of children pre-, during, and post-ECMO from January 2017 to August 2020. There were 154 ECMO runs in 147 children (154 PICU admissions) included in the study. The median age was 3.5 (IQR 0.2, 39.2) months. Veno-arterial ECMO was the predominant mode: 146/154 (94.8%). Eighty-seven children (56.5%) underwent cardiac surgery. Peak COHb levels during ECMO were statistically significantly higher compared to pre ECMO (COHb 1.8% (IQR 1.4, 2.6) vs COHb 1.2% (IQR 0.7, 1.7), p 0.001) and post ECMO (COHb 1.6% (IQR 1.3, 2.2), p = 0.009). Children with COHb ⩾2% were younger and had longer duration of ECMO support. Plasma hemoglobin weakly correlated with COHb level ( r = 0.14 p = 0.04). Carboxyhemoglobin levels increased during ECMO support compared to the pre and post ECMO period. Younger age and longer ECMO duration were associated with COHb levels ⩾2%. Plasma hemoglobin weakly correlated with COHb level.
Publisher: Springer Science and Business Media LLC
Date: 02-1996
DOI: 10.1007/BF00863446
Publisher: Springer Science and Business Media LLC
Date: 09-1985
DOI: 10.1007/BF02388350
Abstract: Salvage liver transplantation (SLT) has recently been proposed for recurrent hepatocellular carcinoma after liver resection however, criteria for candidate assessment in SLT have not been thoroughly evaluated. We retrospectively analyzed outcomes and factors affecting survival of 53 recipients who received SLT in the Liver Transplantation Center, The First Affiliated Hospital of Zhejiang University between 2004 and 2012. Thirty recipients fulfilled the Hangzhou criteria, of which 16 also fulfilled the Milan criteria, while the remaining 23 exceeded both criteria. The 1-year, 3-year and 5-year overall survival rates and tumor-free survival rates were both superior in patients fulfilling Milan or Hangzhou criteria compared with those exceeding the criteria. For recipients outside Milan criteria but within Hangzhou criteria, the 1-year, 3-year overall survival rates were 70.1%, 70.1%, similar to recipients within Milan criteria, with the 1-year, 3-year and 5-year overall survival of 93.8%%, 62.1% and 62.1% (P = 0.586). The tumor-free survival rates were also similar between these two subgroups, with 51.9% and 51.9% vs. 85.6%, 85.6% and 64.2% during the same time interval, respectively (P = 0.054). Cox regression analysis identified Hangzhou criteria (within vs. outside, hazard ratio (HR) 0.376) and diameter of the largest tumor (HR 3.523) to be independent predictors for overall survival. The only predictor for tumor-free survival was diameter of the largest tumor (HR 22.289). Hangzhou criteria safely expanded the candidate pool and are feasible in assessment of candidates for SLT. This is helpful in donor liver allocation in transplant practice.
Publisher: SAGE Publications
Date: 03-2016
DOI: 10.1177/0310057X1604400211
Abstract: Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary paediatric intensive care units: Royal Children's Hospital Melbourne, Australia, and Alberta Children's Hospital, Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre-intubation in two-thirds of patients and all post-intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-1988
DOI: 10.1097/00003246-198808000-00005
Abstract: Sixty-four (48%) of 133 children with hematologic malignancy who were admitted to three pediatric ICUs died. Children who required management because of airway obstruction or after general anesthesia had the best outlook (mortality rate of 7% or less) those children who required major circulatory support or mechanical ventilation for hypoxemia did poorly (mortality rate of 84% or greater). Certain conditions in children with hematologic malignancy that require intensive care are associated with a mortality rate of approximately 75%. These include the following: suspected sepsis, interstitial pneumonitis, encephalopathy due to sepsis or hemorrhage. In children with these life-threatening conditions, therapy must be improved because at this stage, the patients do not benefit from admission to the ICU.
Publisher: Springer Science and Business Media LLC
Date: 07-07-2023
DOI: 10.1007/S44253-023-00008-Z
Abstract: In the past decade, molecular diagnostic syndromic arrays incorporating a range of bacterial and viral pathogens have been described. It is unclear how paediatric intensive care unit (PICU) staff diagnose lower respiratory tract infection (LRTI) and integrate diagnostic array results into antimicrobial decision-making. An online survey with eleven questions was distributed throughout paediatric intensive care societies in the UK, continental Europe and Australasia with a total of 755 members. Participants were asked to rate the clinical factors and investigations they used when prescribing for LRTI. Semi-structured interviews were undertaken with staff who participated in a single-centre observational study of a 52-pathogen diagnostic array. Seventy-two survey responses were received most responses were from senior doctors. Whilst diagnostic arrays were used less frequently than routine investigations (i.e. microbiological culture), they were of comparable perceived utility when making antimicrobial decisions. Prescribers reported that for arrays to be clinically impactful, they would need to deliver results within 6 h for stable patients and within 1 h for unstable patients to inform their immediate decision to prescribe antimicrobials. From 16 staff interviews, we identified that arrays were helpful for the diagnosis and screening of bacterial LRTI. Staff reported it could be challenging to interpret results in some cases due to the high sensitivity of the test. Therefore, results were considered within the context of the patient and discussed within the multidisciplinary team. Diagnostic arrays were considered of comparable value to microbiological investigations by PICU prescribers. Our findings support the need for further clinical and economic evaluation of diagnostic arrays in a randomised control trial. Clinicaltrials.gov, NCT04233268 . Registered on 18 January 2020.
Publisher: Elsevier BV
Date: 12-2021
DOI: 10.51893/2021.4.TN
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-1999
DOI: 10.1097/00003246-199910000-00003
Abstract: To assess the effect of plasmafiltration (PF) on biochemical markers of inflammation, cytokines, organ dysfunction, and 14-day mortality in human sepsis. Multicenter, prospective, randomized, controlled clinical trial. Seven university-affiliated intensive care units. Thirty patients (22 adults, eight children) with new (<24 hrs) clinical evidence of infection and sepsis syndrome were enrolled. Fourteen of 30 (nine adults, five children) were randomized to PF. All patients received protocol-driven supportive intensive care, and those randomized to PF received continuous plasma exchange for 34 hrs using a hollow-fiber plasma filter. Illness severity and risk of death were calculated with the Pediatric Risk of Mortality (children) and the Acute Physiology and Chronic Health Evaluation II (adults) scales. Plasma s les (0, 6, 24, and 48 hrs) were assayed for acute-phase proteins (albumin, globulin, C-reactive protein, alpha1-antitrypsin, haptoglobin), inflammatory mediators (complement fragment C3, thromboxane B2), and cytokines (interleukin-6, granulocyte colony-stimulating factor, leukemia inhibitory factor). Sieving coefficients were estimated from filtrate concentrations at 3 hrs. The two groups were matched for incidence of septic shock (13 of 14 vs. 11 of 16), refractory shock (three of 14 vs. six of 16), bacteremia (six of 14 vs. five of 16), severity of illness, and calculated risk of death (0.68 vs. 0.64). There was no difference in mortality. Eight of 14 PF patients (57%) and eight of 16 controls (50%) survived for 14 days (p = .73, Fisher's exact test). Multiple logistic regression revealed age (odds ratio, 16.4:1 95% confidence interval, 2.12-infinity) and shock (10.6:1 1.32-infinity) as significant predictors of death plasmafiltration was associated with a nonsignificant reduction in the risk of death (odds ratio, 1.78:1 95% confidence interval, 0.20-18.1). The mean (SD) number of organs failing in the first 7 days in the PF group was 2.57 (0.94) vs. 2.94 (0.85) in controls (p = .37, Mann-Whitney U test). Both groups had similarly elevated plasma concentrations of all inflammatory mediators except complement fragment C3 at study entry. Leukemia inhibitory factor was detectable in four patients only. PF did not influence mean concentrations of interleukin-6, granulocyte colony-stimulating factor, thromboxane B2, total white cell count, neutrophil count, or platelet count, but it was associated with significant reductions of alpha1-antitrypsin, haptoglobin, C-reactive protein, and complement fragment C3 in the first 6 hrs (p < .05). The sieving coefficients for all inflammatory mediators approached unity. PF caused a significant attenuation of the acute-phase response in sepsis. There was no significant difference in mortality, but there was a trend toward fewer organs failing in the PF group that suggests that this procedure might be beneficial.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2023
Publisher: SAGE Publications
Date: 04-1992
DOI: 10.1177/026765919200700204
Abstract: Over 95% of paediatric Extra Corporeal Membrane Oxygenation (ECMO) centres use a roller pump (RP) rather than a constrained vortex pump (CVP) this is in part because of the concern of excessive haemolysis from the CVP. We have used a CVP in 36 children who received ECMO and 18 children who received cardiac support alone. We have compared our incidence of haemolysis with that recorded in the ECMO registry of the ExtraCorporeal Life Support Organization (ELSO) seven out of our 54 patients and 367 out of 4598 ELSO patients had haemolysis (p = 0.28). We also did a paired laboratory evaluation of both the RP and CVP comparing the haemolysis caused by each pump over five continuous days. The roller pump was more haemolytic than the constrained vortex pump (CVP range day 1, mean 6.8mg/dL to day 5, mean 31.3mg/dL RP range day 1, mean 13.5mg/dL to day 5, mean 232.3mg/dL).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2020
Publisher: Springer Science and Business Media LLC
Date: 09-1998
Publisher: Wiley
Date: 10-2002
DOI: 10.1046/J.1440-1754.2002.00036.X
Abstract: To investigate the effects of inhaled nitric oxide (iNO) and partial liquid ventilation (PLV) on oxygenation and pulmonary haemodynamics in acute lung injury (ALI), and to assess their effects on lung function, systemic haemodynamics and lung injury. Using saline lung lavage, ALI was induced in 18 piglets. A control group was ventilated with conventional mechanical ventilation (CMV) for 2 h. An iNO-first group received iNO for the first hour and then iNO with PLV. A PLV-first group received PLV for the first hour and then PLV with iNO. Variables were measured at baseline, 5 min postlavage, and at 1 h and 2 h postlavage. During the first hour, both treatment groups showed improvement in oxygenation index (OI). At 2 h, the dif-ferences in OI were statistically significant (P = 0.037), with a mean +/- SD of 23.8 +/- 20.7 in the control group, 4.4 +/- 0.9 in the PLV-first group and 6.5 +/- 3.1 in the iNO-first group. The OI was similar in both treatment groups (P = 0.178). At 2 h, the pulmonary artery pressure (PAP) was significantly different (P = 0.04) between groups, with a mean +/- SD PAP of 36.3 +/- 7.2 mmHg in the control group, 27.4 +/- 4.0 mmHg in the PLV-first group and 30.0 +/- 4.1 mmHg in the iNO-first group. The PAP was similar in both treatment groups (P = 0.319). In ALI, oxygenation and pulmonary hypertension are improved with PLV and iNO given together, regardless of the order in which they are commenced.
Publisher: Cambridge University Press (CUP)
Date: 27-02-2014
DOI: 10.1017/S1047951115000116
Abstract: The aim of this study was to evaluate whether the use of therapeutic hypothermia in patients receiving extracorporeal membrane oxygenation after paediatric cardiac surgery is associated with increased complication rates. We undertook a retrospective study to compare the complication rates and clinical course of children after cardiac surgery in two groups – extracorporeal membrane oxygenation without therapeutic hypothermia (group 1) and extracorporeal membrane oxygenation with therapeutic hypothermia (group 2). Therapeutic hypothermia was performed via the extracorporeal membrane oxygenation circuit heater–cooler device. A total of 96 patients were included in this study (59 in group 1 and 37 in group 2). Complications were comparable between group 1 and group 2, except that more patients with therapeutic hypothermia had hypertension while on extracorporeal membrane oxygenation. Therapeutic hypothermia was not independently associated with in-hospital mortality (adjusted odds ratio 1.16, 95% CI: 0.33–4.03 p=0.82). Therapeutic hypothermia can be safely provided to children on extracorporeal membrane oxygenation after cardiac surgery without an increase in complication rates.
Publisher: SAGE Publications
Date: 10-2004
DOI: 10.1177/0310057X0403200519
Abstract: Two cases of critically ill patients who received extracorporeal membrane oxygenation (ECMO) using different forms of circuitry and for different indications are presented. Both patients had life-threatening infections with septic shock and were not able to be supported by conventional means. The first patient had staphylococcal septicaemia and received venoarterial ECMO for circulatory failure. The second patient had psittacosis and received venovenous ECMO for respiratory failure. We discuss the expanding indications for this technology and the role it has to play in adult intensive care.
Publisher: Springer Science and Business Media LLC
Date: 03-1998
Abstract: To evaluate the relationship between intraarterial measured pulsus paradoxus (PP) and photoplethysmographic wave changes. Tertiary pediatric intensive care unit. 62 nonintubated children with or without respiratory disorders. Prospective, clinical study. Simultaneous paper recordings of photoplethysmographic wave, arterial blood pressure, breathing cycle and electrocardiogram. The respiratory dependent changes of the plethysmographic respiratory wave (delta pleth, mm) were defined as the difference between the highest value of the upper peak of the wave (in expiration) and the lowest value of the upper peak (in inspiration). In each patient, ten consecutive breaths were averaged for analysis. Five recordings could not be evaluated (movement artifacts). In 57 children (median age 2.4 years, range 7 days to 17 years), the photoplethysmographic fluctuations (delta pleth, mm) correlated with PP (mm Hg). r = 0.85 95% confidence interval (CI), 0.76 to 0.91. The sensitivity to detect a PP of > 10 mmHg with a plethysmographic fluctuation of > 8 mm was 89% (95% CI, 77 to 100%) and the specificity was 90% (95% CI, 79 to 100%). Pulse oximetry appears to be a rapid and easily performed, noninvasive method for the objective estimation of the degree of PP.
Publisher: Springer Science and Business Media LLC
Date: 06-1995
DOI: 10.1007/BF01706203
Publisher: SAGE Publications
Date: 05-1990
DOI: 10.1177/0310057X9001800212
Abstract: Between January 1983 and July 1988, 2623 patients with croup were admitted to the Royal Children's Hospital, Melbourne. A total of 416 patients (16%) were admitted to the Intensive Care Unit and 176 of these patients required intubation. Of these patients 117 patients were successfully extubated at the first attempt and 59 needed reintubation. Of the patients who were reintubated 35 were given steroids prior to subsequent extubation attempts. Only one patient who had received steroids failed extubation. Of those who did not receive steroids 59% required reintubation. In patients with croup who fail the first extubation the results of this study suggest that steroids significantly increase the success of subsequent extubations.
Publisher: SAGE Publications
Date: 19-03-2017
Abstract: Kawasaki disease is usually a limited illness of early childhood. However, life-threatening cardiac manifestations can occur, either at acute presentation or as a consequence of coronary arterial involvement. We report the successful use of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiac support in two children with Kawasaki disease: one with acute Kawasaki disease shock syndrome, the other with complications of coronary arteritis and subsequent surgery. We also reviewed the reported experience in the ELSO database and available literature.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-1990
DOI: 10.1097/00003246-199009000-00011
Abstract: To determine the long-term outcome of children admitted to a pediatric ICU (PICU), we studied 976 consecutive patients admitted to our PICU in the 12 months ending June 30, 1983, and evaluated their outcome 30 to 36 months after PICU admission. There was no relationship between duration of PICU admission and outcome. Young children were more likely to die than older children, but young children who survived did not have an increased risk of handicap. Of the 974 children available for follow-up, 20% died, 5% had a severe handicap, 2% had a moderate handicap, 12% had a mild handicap, 17% were functionally normal but required medical supervision, and 42% were normal. Thus, 80% of the children survived 30 months or more, and 91% of the survivors will probably lead an independent life.
Publisher: Wiley
Date: 08-1992
DOI: 10.1111/J.1440-1754.1992.TB02674.X
Abstract: Errors in prescription, administration, delivery and interaction of drugs are likely in children in intensive care units because of the large number of often unfamiliar medications these children receive. We evaluated prospectively the frequency and consequence of drug errors in a large multidisciplinary intensive care unit. There was a mistake in drug prescription, administration, delivery or drug interaction in 2% of medication orders, with 12% of these mistakes causing actual harm to the patient. The frequency of drug errors must be appreciated and due care must be taken in checking and delivering drugs to children in an intensive care unit.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2019
DOI: 10.1097/PCC.0000000000001806
Abstract: To identify risk factors associated with mortality in critically ill children requiring continuous renal replacement therapy. Retrospective observational study based on a prospective registry. Tertiary and quaternary referral 30-bed PICU. Critically ill children undergoing continuous renal replacement therapy were included in the study. Continuous renal replacement therapy. Overall mortality was 36% ( n = 58) among the 161 patients treated with continuous renal replacement therapy during the study period and was significantly higher in patients on extracorporeal membrane oxygenation (47.5%, 28 of 59) than in patients not requiring extracorporeal membrane oxygenation (28.4%, 29 of 102 p = 0.022). According to the admission diagnosis, we found the highest mortality in patients with onco-hematologic disease (77.8%) and the lowest in patients with renal disease (5.6%). Based on multivariate logistic regression analysis, the presence of higher severity of illness score at admission (adjusted odds ratio, 1.49 95% CI, 1.18–1.89 p 0.001), onco-hematologic disease (odds ratio, 17.10 95% CI, 4.10–72.17 p 0.001), fluid overload 10%–20% (odds ratio, 3.83 95% CI, 1.33–11.07 p = 0.013), greater than 20% (odds ratio, 15.03 95% CI, 4.03–56.05 p 0.001), and timing of initiation of continuous renal replacement therapy (odds ratio, 1.01 95% CI, 1.00–1.01 p = 0.040) were independently associated with mortality. In our population, the odds of dying increases by 1% for every hour of delay in continuous renal replacement therapy initiation from ICU admission. Mortality in children requiring continuous renal replacement therapy remains high and seems to be related to the underlying disease, the severity of illness, and the degree of fluid overload. In critically ill children at high risk for developing acute kidney injury and fluid overload, earlier initiation of continuous renal replacement therapy might result in decreased mortality.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: Wiley
Date: 2000
Publisher: American Society of Hematology
Date: 21-02-2019
DOI: 10.1182/BLOOD-2018-05-849737
Abstract: Asymptomatic central venous catheter (CVC)–related thrombosis in children varies in incidence from 5% to 69%. The rate of acute and long-term complications, such as postthrombotic syndrome (PTS), from asymptomatic CVC-related thrombosis is unknown. This article reports the outcomes of a prospective study of 189 children in pediatric intensive care that aimed to determine the frequency of asymptomatic CVC-related thrombosis during hospital admission, and the incidence of residual CVC-related thrombosis and clinically significant PTS 2 years later. Risk factors associated with CVC-related thrombosis were also identified. This study is distinct from previous work as children identified to have asymptomatic CVC-related thrombosis were not treated (clinical team kept blinded) and the entire cohort was followed for 2 years to determine the natural history of asymptomatic thrombosis. Ultrasounds of 146 children determined a 21.9% incidence of acute CVC-related thrombosis. Two children were symptomatic. No radiological thrombosis extension or clinical embolization occurred in the 126 children assessed at follow-up. Using 2 recognized PTS scales, clinically significant PTS was reported in 2 children (1 symptomatic, 1 asymptomatic CVC-related thrombosis), however, neither had functional impairment. Cardiac arrest was a risk factor for CVC-related thrombosis during admission and femoral CVC placement was predictive of residual thrombosis 2 years later. This study challenges the notion that critically ill children with asymptomatic CVC-related thrombosis require anticoagulant treatment, as the results demonstrate that the incidence of acute or long-term complications is low. A larger confirmatory study of nontreatment of CVC-related thrombosis in critically ill children is justified.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2017
DOI: 10.1097/PCC.0000000000001249
Abstract: Several population-based studies have shown that gestational age 39–40 weeks at birth is associated with superior outcomes in various pediatric settings. A high proportion of births for neonates with congenital heart disease occur before 39 weeks. We aimed to assess the influence of late-term gestation (39–40 wk) on survival in neonates requiring extracorporeal life support following surgery for congenital heart disease. Retrospective cohort study. The Royal Children’s Hospital, Melbourne, Australia. Neonates requiring extracorporeal life support after cardiac surgery for congenital heart disease. From 2005 to 2014, 110 neonates (10.5% of neonates undergoing cardiac surgery) required extracorporeal life support after cardiac surgery. Indications were failure to separate from cardiopulmonary bypass in 40 (36%), extracorporeal cardiopulmonary resuscitation in 48 (44%), progressive low cardiac output in 15 (14%), and other reasons in seven (6%). Extracorporeal life support duration was 94 hours (interquartile range, 53–135), and 54 (49%) underwent single ventricle repair. Gestation at birth (n [%]) was as follows: less than 37 weeks, 19 (17%) 37–38 weeks, 38 (35%) 39–40 weeks, 50 (45%) 41 weeks or more, 3 (3%). By multivariable analysis (controlling for age, era of extracorporeal life support 2005–2009 vs 2010–2014, single ventricle status and acute renal failure), gestational age of 39–40 weeks was associated with the lowest odds for intensive care mortality: using less than 37 weeks as referent, the adjusted odds ratio (95% CI) for 37–38 weeks was 0.41 (0.12–1.33) for 39–40 weeks, 0.27 (0.08–0.84) and for 41 weeks or more, 1.06 (0.07–14.7). Similar association was also seen in a subcohort of study neonates ( n = 66) who were commenced on extracorporeal life support after admission to intensive care: using less than 37 weeks as referent, the adjusted odds ratio (95% CI) for 37–38 weeks was 0.52 (0.10–2.80) and for 39–40 weeks, 0.15 (0.03–0.81). In this cohort of neonates requiring extracorporeal life support following cardiac surgery, 39–40 weeks of gestation at birth is associated with the best survival. The additional maturity gained by reaching a gestation of at least 39 weeks is likely to confer a survival advantage in this high-risk cohort.
Publisher: Elsevier BV
Date: 03-2021
DOI: 10.51893/2021.1.OA4
Abstract: Abstract Background: The NITric oxide during cardiopulmonary bypass (CPB) to improve Recovery in Infants with Congenital heart defects (NITRIC) trial, a 1320-patient, multicentre, randomised controlled trial, is aiming to improve survival free of ventilation after CPB by using nitric oxide delivered into the oxygenator of the CPB. Objective: To provide a statistical analysis plan before completion of patient recruitment and data monitoring. Final analyses for this study will adhere to this statistical analysis plan, which details all key pre-planned analyses. Stata scripts for analyses have been prepared alongside this statistical analysis plan. Methods: The statistical analysis plan was designed collaboratively by the chief investigators and trial statistician and builds on the previously published study protocol. All authors remain blinded to treatment allocation. Detail is provided on statistical analyses including cohort description, analysis of primary and secondary outcomes and adverse events. Statistical methods to compare outcomes are planned in detail to ensure methods are verifiable and reproducible. Results: The statistical analysis plan developed provides the trial outline, list of mock tables, and analysis scripts. The plan describes statistical analyses on cohort and baseline description, primary and secondary outcome analyses, process of care measures, physiological descriptors, and safety and adverse event reporting. We define the pre-specified subgroup analyses and the respective statistical tests used to compare subgroups. Conclusion: The statistical analysis plan for the NITRIC trial establishes detailed pre-planned analyses alongside Stata scripts to analyse the largest trial in the field of neonatal and paediatric heart surgery. The plan ensures standards for trial analysis validity aiming to minimise bias of analyses. Trial registration: ACTRN12617000821392
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.RESUSCITATION.2018.04.030
Abstract: System-based improvements to the chain of survival have yielded increases in survival from out-of-hospital cardiac arrest (OHCA) in adults. Comparatively little is known about the long-term trends in incidence and survival following paediatric OHCA. Between 2000 and 2016, we included children aged ≤16 years who suffered a non-traumatic OHCA in the state of Victoria, Australia. Trends in incidence and unadjusted outcomes were assessed using linear regression and a non-parametric test for trend. Multivariable logistic regression with multiple imputation was used to identify arrest factors associated with event survival and survival to hospital discharge. Of the 1301 paediatric OHCA events attended by emergency medical services (EMS), 948 (72.9%) received an attempted resuscitation. The overall incidence of EMS-attended and EMS-treated events was 6.7 and 4.9 cases per 100,000 person-years, with no significant changes in trend. Although the proportion of cases with OHCA identified in the call and receiving bystander CPR increased over time, EMS response times also increased. Unadjusted event survival rose from 23.3% in 2000 to 33.3% in 2016 (p trend = .007), and survival to hospital discharge rose from 9.4% to 17.7% over the same period (p trend = .04). Increases in survival to hospital discharge were largely driven by initial shockable arrests, which rose from 33.3% in 2000 to 60.0% in 2016 (p trend = .005). Survival after initial shockable arrests was higher if the first shock was delivered by either first responder or public AED compared with paramedics (83.3% vs. 40.0%, p = .04). After adjustment, the odds of event survival and survival to hospital discharge increased independent of baseline characteristics, by 7% (OR 1.07, 95% CI: 1.03, 1.11 p = .001) and 8% (OR 1.08, 95% CI: 1.01, 1.15 p = .02) per study year, respectively. Survival following paediatric OHCA increased in our region over a 17 year period. This was driven, in part, by improving outcomes for initial shockable arrests.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2013
Publisher: Cambridge University Press (CUP)
Date: 23-07-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1988
Publisher: Springer Science and Business Media LLC
Date: 06-09-2017
DOI: 10.1007/S00381-017-3530-Y
Abstract: Traumatic brain injury (TBI) is a leading killer of children in the developed and developing world. Despite evidence-based guidelines and several recent clinical trials, the progress in developing best practices for children with severe TBI has been slow. This article describes (i) the burden of the disease, (ii) the inadequacies of the evidence-based guidelines, (iii) the failure of the largest clinical trials to prove their primary hypotheses, and (iv) possible advances from an observational cohort study called the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial that has recently completed enrollment.
Publisher: Springer Science and Business Media LLC
Date: 09-12-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
Publisher: BMJ
Date: 08-2019
DOI: 10.1136/BMJOPEN-2018-026664
Abstract: Congenital heart disease (CHD) is a major cause of infant mortality. Many infants with CHD require corrective surgery with most operations requiring cardiopulmonary bypass (CPB). CPB triggers a systemic inflammatory response which is associated with low cardiac output syndrome (LCOS), postoperative morbidity and mortality. Delivery of nitric oxide (NO) into CPB circuits can provide myocardial protection and reduce bypass-induced inflammation, leading to less LCOS and improved recovery. We hypothesised that using NO during CPB increases ventilator-free days (VFD) (the number of days patients spend alive and free from invasive mechanical ventilation up until day 28) compared with standard care. Here, we describe the NITRIC trial protocol. The NITRIC trial is a randomised, double-blind, controlled, parallel-group, two-sided superiority trial to be conducted in six paediatric cardiac surgical centres. One thousand three-hundred and twenty infants years of age undergoing cardiac surgery with CPB will be randomly assigned to NO at 20 ppm administered into the CPB oxygenator for the duration of CPB or standard care (no NO) in a 1:1 ratio with stratification by age ( and ≥6 weeks), single ventricle physiology (Y/N) and study centre. The primary outcome will be VFD to day 28. Secondary outcomes include a composite of LCOS, need for extracorporeal membrane oxygenation or death within 28 days of surgery length of stay in intensive care and in hospital and, healthcare costs. Analyses will be conducted on an intention-to-treat basis. Preplanned secondary analyses will investigate the impact of NO on host inflammatory profiles postsurgery. The study has ethical approval (HREC/17/QRCH/43, dated 26 April 2017), is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12617000821392) and commenced recruitment in July 2017. The primary manuscript will be submitted for publication in a peer-reviewed journal. ACTRN12617000821392
Publisher: Springer Science and Business Media LLC
Date: 23-02-2018
DOI: 10.1007/S12028-017-0480-X
Abstract: Although small series have suggested that younger age is associated with less favorable outcome after severe traumatic brain injury (TBI), confounders and biases have limited our understanding of this relationship. We hypothesized that there would be an association between age and mortality in children within an ongoing observational, cohort study. The first 200 subjects from the Approaches and Decisions for Acute Pediatric TBI trial were eligible for this analysis (inclusion criteria: severe TBI (Glasgow Coma Scale [GCS] score ≤ 8], age 18 years, and intracranial pressure (ICP) monitor placed exclusion: pregnancy). Children with suspected abusive head trauma (AHT) were excluded to avoid bias related to the association between AHT and mortality. Demographics, and prehospital and resuscitation events were collected/analyzed, and children were stratified based on age at time of injury (< 5, 5-< 11, 11-18 years) and presented as mean ± standard error of the mean (SEM). Analyses of variance were used to test the equality of the means across the group for continuous variable, and Chi-square tests were used to compare percentages for discrete variables (post hoc comparisons were made using t test and Bonferroni corrections, as needed). Kaplan-Meier curves were generated for each age subgroup describing the time of death, and log-rank was used to compare the curves. Cox proportional hazards regression models were used to assess the effect of age on time to death while controlling for covariates. In the final cohort (n = 155, 45 excluded for AHT), overall age was 9.2 years ± 0.4 and GCS was 5.3 ± 0.1. Mortality was similar between strata (14.0, 20.0, 20.9%, respectively, p = 0.58). Motor vehicle accidents were the most common mechanism across all strata, while falls tended to be more common in the youngest stratum (p = 0.08). The youngest stratum demonstrated increased incidence of spontaneous hypothermia at presentation and decreased hemoglobin concentrations and coagulopathies, while the oldest demonstrated lower platelet counts. In contrast to previous reports, we failed to detect mortality differences across age strata in children with severe TBI. We have discerned novel associations between age and various markers of injury-unrelated to AHT-that may lead to testable hypotheses in the future.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2011
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.INJURY.2011.06.005
Abstract: Patients with mental illness or depression may sustain self-inflicted injuries that require admission to an Intensive Care Unit (ICU). It is unknown whether the intent of injury leads to a greater likelihood of dying over and above the severity of the initial injury. Given the economic and societal burden of injury of self-harm, we designed this study to compare hospital outcomes of intentionally injured patients presenting to a tertiary ICU compared to unintentional injuries. The regional trauma database was interrogated to produce two datasets that included all adult trauma patients admitted to the Alfred Intensive Care Unit between 01/07/2002 and 30/06/2007. The first included patients that sustained intentional injuries, the second comprised un-intentional injuries and acted as a control group. Logistic regression was used to model factors associated with mortality. Intentionally injured patients made up 4.17% of the total burns, blunt and penetrating trauma admissions to the Alfred ICU over the five-year study period. There was a trend towards higher mortality overall and in all subgroups of patients with intentional injuries when compared to those with un-intentional mechanisms of injury. After adjusting for injury severity and age, a mechanism of injury involving intentional injury was independently associated with a doubling of the odds of death. Our study is the first paper in the literature to describe an increased the risk of death within a group of patients admitted to a trauma and burns ICU following deliberate self-harm.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2010
Publisher: SAGE Publications
Date: 08-1990
DOI: 10.1177/0310057X9001800316
Abstract: There are many unproven methods of ventilation and oxygenation that have been used in children dying from respiratory failure, including extracorporeal devices and high frequency ventilation. However, no objective predictors of death have been developed that enable clinicians to decide when it is reasonable to use these therapies in children over one month of age with acute respiratory failure. To determine predictors of death, we evaluated the charts of all 42 children aged one month to eighteen years admitted to the intensive care unit who were ventilated for more than twelve hours, received greater than 90% oxygen, received a peak inspiratory pressure greater than 25 cmH 2 O and had no pre-existing neurodevelopmental handicap. A combination of a variable reflecting ventilation and a variable reflecting oxygenation reliably predicted death: a combination of ventilation index 40 and oxygenation index 0.4 was associated with a 77% chance of mortality (sensitivity 65% and specificity 74%) a combination of peak inspiratory pressure 40 cmH 2 O and A-aDO 2 580 was associated with an 81% chance of mortality (sensitivity 74% and specificity 79%). These criteria may be useful in predicting death from respiratory failure in children.
Publisher: Elsevier BV
Date: 04-2023
Publisher: SAGE Publications
Date: 02-1991
DOI: 10.1177/0310057X9101900115
Abstract: We prospectively measured toe temperature, rectal temperature, systemic arterial pressure and cardiac output on two occasions one hour apart in 136 children who had had phenoxybenzamine after cardiac surgery while on cardiopulmonary bypass. Repeated measures analysis showed that there was no significant correlation between the change in temperature gradient over one hour in each patient and the change in cardiac index (r = 0.03, P 0.1) or systemic vascular resistance (r = 0.007, P 0.1). Although the peripheral temperature (toe temperature), and the core-peripheral temperature difference are simple, safe and inexpensive to measure in the population studied, they did not provide any guide to either cardiac output or systemic vascular resistance.
Publisher: Wiley
Date: 10-1995
DOI: 10.1111/J.1440-1754.1995.TB00846.X
Abstract: To determine whether pressure in the inferior vena cava (IVC) is similar to central venous pressure. Prospective measurement of both central venous pressure (CVP) and inferior vena cava pressure (IVCP) in the same child each child had to have both catheters in situ. Two measurements of each pressure in reverse order (IVCP then CVP, and CVP then IVCP) were done and the mean of each was recorded. Comparison of the pressures was performed using the method of Bland and Altman. Thirty-nine children had pressures recorded. The CVP ranged from 3 to 17 mmHg. In 22 of 39 measurements IVCP was equal to CVP in 33 of 39 measurements IVCP was different from CVP by 1 mm or less and in 37 of 39 measurements IVCP was different from CVP by 2 mm or less. The mean difference between IVCP and CVP was +0.33 mmHg, the 95% confidence interval was 2.26 to +2.93 mmHg. Measurement of IVCP is a good approximation to CVP and can be routinely used in clinical care of children who do not have raised intra-abdominal pressure.
Publisher: Elsevier BV
Date: 04-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2018
DOI: 10.1097/PCC.0000000000001475
Abstract: To describe in idual perspective over ~30 years in a mixed Cardiac and General ICU, which includes the State Trauma Center, National Cardiac Transplant and Complex Cardiac Center, Extracorporeal Membrane Oxygenation Center, Home Ventilation Program, and the major PICU for 6 million people. Personal experience and reflection, complemented by published local data. Illustrative publications of local other data. Narrative, experiential reflection. I have agreed to palliative care in many patients of erse religious, social, and cultural beliefs while providing long-term ICU care to other patients with similar illnesses and prognosis. This can occur when family meetings allow honest and direct conversation with respect for differences as a clinician, I listen to a family and understand their perspectives and together develop a clear and agreed plan.
No related grants have been discovered for Professor Warwick Butt.