Characterization of pediatric patients receiving prolonged mechanical ventilation.

OBJECTIVE: To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. DESIGN: Prospective cohort. SETTING: Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. PATIENTS: All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. CONCLUSIONS: Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.

How is mechanical ventilation employed in a pediatric intensive care unit in Brazil?

OBJECTIVE: to investigate the relationship between mechanical ventilation and mortality and the practice of mechanical ventilation applied in children admitted to a high-complexity pediatric intensive care unit in the city of São Paulo, Brazil. DESIGN: Prospective cohort study of all consecutive patients admitted to a Brazilian high-complexity PICU who were placed on mechanical ventilation for 24 hours or more, between October 1st, 2005 and March 31st, 2006. RESULTS: Of the 241 patients admitted, 86 (35.7 percent) received mechanical ventilation for 24 hours or more. Of these, 49 met inclusion criteria and were thus eligible to participate in the study. Of the 49 patients studied, 45 had chronic functional status. The median age of participants was 32 months and the median length of mechanical ventilation use was 6.5 days. The major indication for mechanical ventilation was acute respiratory failure, usually associated with severe sepsis / septic shock. Pressure ventilation modes were the standard ones. An overall 10.37 percent incidence of Acute Respiratory Distress Syndrome was found, in addition to tidal volumes > 8 ml/kg, as well as normo- or hypocapnia. A total of 17 children died. Risk factors for mortality within 28 days of admission were initial inspiratory pressure, pH, PaO2/FiO2 ratio, oxygenation index and also oxygenation index at 48 hours of mechanical ventilation. Initial inspiratory pressure was also a predictor of mechanical ventilation for periods longer than 7 days. CONCLUSION: Of the admitted children, 35.7 percent received mechanical ventilation for 24 h or more. Pressure ventilation modes were standard. Of the children studied, 91 percent had chronic functional status. There was a high incidence of Acute Respiratory Distress Syndrome, but a lung-protective strategy was not fully implemented. Inspiratory pressure at the beginning of mechanical ventilation was a predictor of mortality within 28 days and of a longer...