Striving for Optimum Noise-Decreasing Strategies in Critical Care: Initial Measurements and Observations.

To identify baseline sound levels, patterns of sound levels, and potential barriers and facilitators to sound level reduction. The study setting was neonatal and pediatric intensive care units in a tertiary care hospital. Participants were staff in both units and parents of currently hospitalized children or infants. One 24-hour sound measurements and one 4-hour sound measurement linked to observed sound events were conducted in each area of the center's neonatal intensive care unit. Two of each measurement type were conducted in the pediatric intensive care unit. Focus groups were conducted with parents and staff. Transcripts were analyzed with descriptive content analysis and themes were compared against results from quantitative measurements. Sound levels exceeded recommended standards at nearly every time point. The most common code was related to talking. Themes from focus groups included the critical care context and sound levels, effects of sound levels, and reducing sound levels-the way forward. Results are consistent with work conducted in other critical care environments. Staff and families realize that high sound levels can be a problem, but feel that the culture and context are not supportive of a quiet care space. High levels of ambient sound suggest that the largest changes in sound levels are likely to come from design and equipment purchase decisions. L10 and Lmax appear to be the best outcomes for measurement of behavioral interventions.

Coagulation assessment in children with diabetic ketoacidosis.

OBJECTIVES: To assess potential hypercoagulability during diabetic ketoacidosis in children. DESIGN: A prospective, controlled pilot study. SETTING: University-affiliated pediatric critical care unit and emergency department in a tertiary care children's hospital. PATIENTS: Children (1-18 years) admitted with an episode of diabetic ketoacidosis and healthy children as controls. All patients with diabetic ketoacidosis managed according to a preestablished protocol. INTERVENTIONS: Thromboelastography was performed using citrated whole-blood samples drawn at the time of admission and upon biochemical and clinical resolution of diabetic ketoacidosis. Citrated whole-blood samples drawn from healthy nondiabetic children acted as control samples. MEASUREMENTS AND MAIN RESULTS: Fifteen patients (11.7 ± 4.1 years) in the diabetic ketoacidosis group and 20 patients (8.9 ± 4.5 years; p = 0.06) in the control group completed the study. Values for standard thromboelastography parameters (R and K time, α angle, maximum amplitude, coagulation index, and Ly30) in the diabetic ketoacidosis group, both on admission and resolution, were within the control range; thromboelastography profiles of diabetic ketoacidosis patients on admission were not significantly different from profiles obtained upon diabetic ketoacidosis resolution. The mean α-angle was significantly higher in known diabetic patients compared with newly diagnosed diabetics on admission; however, it still remained within the control normal range. CONCLUSIONS: Thromboelastographic assay results do not reflect a hypercoagulable state in this group of children with diabetic ketoacidosis. Further investigation is required to examine the potential role of injured endothelium in the suspected hypercoagulability during diabetic ketoacidosis.

Central diabetes insipidus in pediatric severe traumatic brain injury.

OBJECTIVES: To determine the occurrence rate of central diabetes insipidus in pediatric patients with severe traumatic brain injury and to describe the clinical, injury, biochemical, imaging, and intervention variables associated with mortality. DESIGN: Retrospective chart and imaging review. SETTING: Children's Hospital, level 1 trauma center. PATIENTS: Severely injured (Injury Severity Score ≥ 12) pediatric trauma patients (>1 month and <18 yr) with severe traumatic brain injury (presedation Glasgow Coma Scale ≤ 8 and head Maximum Abbreviated Injury Scale ≥ 4) that developed acute central diabetes insipidus between January 2000 and December 2011. MEASUREMENTS AND MAIN RESULTS: Of 818 severely injured trauma patients, 180 had severe traumatic brain injury with an overall mortality rate of 27.2%. Thirty-two of the severe traumatic brain injury patients developed acute central diabetes insipidus that responded to desamino-8-D-arginine vasopressin and/or vasopressin infusion, providing an occurrence rate of 18%. At the time of central diabetes insipidus diagnosis, median urine output and serum sodium were 6.8 ml/kg/hr (interquartile range = 5-11) and 154 mmol/L (interquartile range = 149-159), respectively. The mortality rate of central diabetes insipidus patients was 87.5%, with 71.4% declared brain dead after central diabetes insipidus diagnosis. Early central diabetes insipidus onset, within the first 2 days of severe traumatic brain injury, was strongly associated with mortality (p < 0.001), as were a lower presedation Glasgow Coma Scale (p = 0.03), a lower motor Glasgow Coma Scale (p = 0.01), an occurrence of fixed pupils (p = 0.04), and a prolonged partial thromboplastin time (p = 0.04). Cerebral edema on the initial computed tomography, obtained in the first 24 hrs after injury, was the only imaging finding associated with death (p = 0.002). Survivors of central diabetes insipidus were more likely to have intracranial pressure monitoring (p = 0.03), have thiopental administered to induce coma (p = 0.04) and have received a decompressive craniectomy for elevated intracranial pressure (p = 0.04). CONCLUSIONS: The incidence of central diabetes insipidus in pediatric patients with severe traumatic brain injury is 18%. Mortality was associated with early central diabetes insipidus onset and cerebral edema on head computed tomography. Central diabetes insipidus nonsurvivors were less likely to have received intracranial pressure monitoring, thiopental coma and decompressive craniectomy.

Hypernatremia is associated with increased risk of mortality in pediatric severe traumatic brain injury.

Acquired hypernatremia in hospitalized patients is often associated with poorer outcomes. Our aim was to evaluate the relationship between acquired hypernatremia and outcome in children with severe traumatic brain injury (sTBI). We performed a retrospective cohort study of all severely injured trauma patients (Injury Severity Score ≥12) with sTBI (Glasgow Coma Scale [GCS] ≤8 and Maximum Abbreviated Injury Scale [MAIS] ≥4) admitted to a Pediatric Critical Care Unit ([PCCU]; 2000-2009). In a cohort of 165 patients, 76% had normonatremia (135-150 mmol/L), 18% had hypernatremia (151-160 mmol/L), and 6% had severe hypernatremia (>160 mmol/L). The groups were similar except for lower GCS (p=0.002) and increased incidence of fixed pupil(s) on admission in both hypernatremia groups (p<0.001). Mortality rate was four-fold and six-fold greater with hypernatremia and severe hypernatremia, respectively (p<0.001), and mortality rates were unchanged when patients with fixed pupils or those with central diabetes insipidus were excluded (p<0.001). Hypernatremic patients had fewer ventilator-free days (p<0.001). Survivors with hypernatremia had greater PCCU (p=0.001) and hospital (p=0.031) lengths of stays and were less frequently discharged home (p=0.008). Logistic regression analyses of patient characteristics and sTBI interventions demonstrated that hypernatremia was independently associated with the presence of fixed pupil(s) on admission (odds ratio [OR] 5.38; p=0.003); administration of thiopental (OR 8.64; p=0.014), and development of central diabetes insipidus (OR 5.66; p=0.005). Additional logistic regression analyses demonstrated a significant association between hypernatremia and mortality (OR 6.660; p=0.034). In summary, acquired hypernatremia appears to signal higher risk of mortality in pediatric sTBI and is associated with a higher discharge level of care in sTBI survivors.

Dehydration in children with diabetic ketoacidosis: a prospective study.

OBJECTIVES: To investigate the association between the degree of patient dehydration on presentation with diabetic ketoacidosis (DKA) and clinical and laboratory parameters obtained on admission. DESIGN: Prospective descriptive study. SETTING: A tertiary care children's hospital. PATIENTS: Thirty-nine paediatric patients (1 month-16 years) presenting with 42 episodes of DKA. INTERVENTION: Clinical and biochemical variables were collected on admission. Dehydration was calculated by measuring acute changes in body weight during the period of illness. All patients were treated according to a previously established protocol. MAIN OUTCOME MEASURES: Magnitude of dehydration, defined as % loss of body weight (LBW), was determined by the difference in body weight obtained at presentation and at discharge. The relationship between the magnitude of dehydration and the clinical assessment and biochemical parameters was examined. RESULTS: The median (25th-75th centiles) magnitude of dehydration at presentation was 5.7% (3.8-8.3%) (mean ± SD 6.8 ± 5%). Neither the initial clinical assessment nor the comprehensive biochemical profile at admission correlated with the magnitude of dehydration. Despite considerable variation in the degree of dehydration and biochemical disequilibrium, all patients recovered from DKA within 24 h with a standardised therapeutic approach. Furthermore, the rapidity of patient recovery did not correlate with the magnitude of dehydration on presentation or the amount of fluid administered (median (25th-75th centiles) 48.8 ml/kg (38.5-60.3)) in the first 12 h. CONCLUSION: The magnitude of dehydration in DKA is not reflected by either clinical or biochemical parameters. These findings need confirmation in larger studies.

Complications of mechanical ventilation in the pediatric population.

BACKGROUND: Mechanical ventilation (MV) strategies are continuously evolving in an effort to minimize adverse events. The objective of this study was to determine the complications associated with MV in children. STUDY DESIGN: Prospective observational study. Over a period of 10 consecutive months, 150 patients (median age 0.8 years, IQR 4.4, 59% male) were enrolled in this study. RESULTS: The median duration of MV was 3.1 days (IQR 3.9). A total of 85 complications were observed in 60 (40%) patients (114 complications per 1,000 ventilation days). 16.7% of patients developed atelectasis, 13.3% post-extubation stridor, 9.3% failed extubation, 2.0% pneumothorax, 3.3% accidental extubation, 2.7% nasal or perioral tissue damage and 1.9% ventilator associated pneumonia. Atelectasis occurred most often in the left lower lobe (36%) or in the right upper lobe (26%). The incidence of atelectasis in children <1 year of age was 12% (31 episodes per 1,000 days of ventilation) compared to 18% (57 episodes per 1,000 days of ventilation) in children ≥ 1 year of age (P < 0.05). Patients that failed extubation were ventilated for a median of 8.5 (IQR 8.8) days compared to 2.9 days (IQR, 3.8) in patients that were successfully extubated (P < 0.01). The absence of an air leak prior to extubation did not correlate with failed extubation. Accidental extubation was limited to orally intubated patients. CONCLUSION: MV complications occurred in 40% of patients and most often consisted of atelectasis and post-extubation stridor. Further studies are needed to examine associated risk factors and strategies to reduce their occurrence.

Lung contusion in children--early computed tomography versus radiography.

OBJECTIVE: To investigate, in children, the correlation between the extent of lung contusion as detected on early radiologic examination (chest radiograph [CXR] and/or thoracic computed tomography [TCT]) and subsequent clinical outcome measures. DESIGN: Retrospective chart review study with blinded assessment of thoracic imaging. SETTING: A university-affiliated, level 1 designated pediatric trauma center. INTERVENTIONS: None. PATIENTS: Patients (1-18 yrs) who, between April 2000 and October 2005, were diagnosed with lung contusion were eligible for study entry. The medical records of those patients who underwent early (within the first 24 hrs of admission) thoracic imaging (CXR and/or TCT) were reviewed. A pulmonary contusion score (PCS) was assigned to each thoracic image according to the extent of contusion injury by two investigators blinded to each others score and the clinical details of the patient. RESULTS: Seventy-four patients were included in the study. Twenty patients had undergone CXR only, whereas 54 had undergone both CXR and TCT. The mean PCS on CXR was 3.9 +/- 3.6 compared with 6.5 +/- 3.49 on TCT (p < .001). In eight patients (15%) who underwent TCT and CXR, the CXR failed to demonstrate a lung contusion. The PCS derived from CXR examination correlated positively with lower Pao2/Fio2 (r = -.36, p = .019), higher ventilation index (r = .35, p = .014), and longer length of ventilation (r = .28, p = .019). No such correlation was seen with TCT-derived PCS. CONCLUSIONS: The severity of lung contusion determined by CXR, but not TCT, correlates with impairment of oxygenation, CO2 exchange, and duration of ventilatory support.

Elective tracheostomy in mechanically ventilated children in Canada.

OBJECTIVE: To determine the current practice and opinions of paediatric intensivists in Canada regarding tracheostomy in children with potentially reversible conditions which are anticipated to require prolonged mechanical ventilation. DESIGN AND SETTING: Self-administered survey among paediatric intensivists within paediatrics critical care units (PCCU) across Canada. MEASUREMENTS AND RESULTS: All 16 PCCUs participated in the survey with a response rate of 81% (63 physicians). In 14 of 16 centres one to five tracheostomies were performed during 2006. Two centres did not perform any tracheostomies. The overall rate of tracheostomy is less than 1.5%. Percutaneous technique is used in 3/16 (19%) of centres. Readiness to undertake tracheostomy during the first 21[Symbol: see text]days of illness is influenced by patient diagnosis; severe traumatic brain injury 66% vs. 42% in a 2-year-old with Guillain-Barré syndrome, 48% in a 9-year-old with Guillain-Barré syndrome, and 12% in a child with isolated ARDS. In a child with ARDS 25% of respondents would never consider tracheostomy. Age does not affect timing nor keenness for tracheostomy. The majority, 81%, believe that the risks associated with the procedure do not outweigh the potential benefits. Finally, 51% believe that tracheostomy is underutilized in children. CONCLUSIONS: Elective tracheostomy is rarely performed among ventilated children in Canada. However, 51% of physicians believe it is underutilized. The role of elective tracheostomy and the percutaneous technique in children requires further investigation.