Noninvasive Ventilation in a Pediatric Trauma Center: A Cohort Study.

OBJECTIVE: To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury. STUDY DESIGN: A single center observational cohort study. SETTING: Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre). POPULATION: During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV. INCLUSION/EXCLUSION CRITERIA: Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation. MEASUREMENTS AND RESULTS: Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated. CONCLUSIONS: AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.

Validation of the Glycemic Stress Index in Pediatric Neurosurgical Intensive Care.

BACKGROUND: Studies have suggested that both the degree and the duration of hyperglycemia are independent risk factors for adverse outcome both in pediatric anesthesia and in critically ill children. In a recent paper, we combined intraoperative glycemic variations and length of surgery creating a metabolic glucose-related stress index called "Glycemic Stress Index" (GSI). AIM: To validate GSI for predicting PICU stay in a population of children undergoing different major neurosurgical procedures. METHODS: A total of 352 patients with craniotomy were enrolled. Basic clinical data and PICU length of stay were recorded real time. Intraoperative blood loss has been determined considering the estimated red cell volume loss ratio. GSI was calculated and subjected to ROC analysis having as targets PICU length of stay >100 or >200 h. RESULTS: The overall mean PICU stay was 35 h. Correlation analysis confirmed a low but highly significant direct correlation between GSI and PICU length of stay. ROC analysis showed an area under the ROC curve (AUC) of 0.74 (p = 0.03) for GSI to predict PICU stay >200 h and an AUC of 0.67 (p = 0.01) to predict PICU stay >100 h. Best predictive cutoff values were 4.5 and 3.9, for PICU stay >200 and >100 h, respectively. Overall accuracy for the test is higher in predicting PICU stay >200 h. CONCLUSIONS: GSI significantly predicts prolonged PICU stay after major neurosurgery in a mixed population of children affected by different neurosurgical conditions.

Weaning of Children With Burn Injury by Noninvasive Ventilation: A Clinical Experience.

The aim of this study was to report the respiratory management of a cohort of infants admitted to a Pediatric Intensive Care Unit (PICU) over a 7-year period due to severe burn injury and the potential benefits of noninvasive ventilation (NIV). A retrospective review of all pediatric patients admitted to PICU between 2009 and 2016 was conducted. From 2009 to 2016, 118 infants and children with burn injury were admitted to our institution (median age 16 months [IQR = 12.2-20]); 51.7% of them had face burns, 37.3% underwent tracheal intubation, and 30.5% had a PICU stay greater than 7 days. Ventilated patients had a longer PICU stay (13 days [IQR = 8-26] vs 4.5 days [IQR = 2-13]). Both ventilation requirement and TBSA% correlated with PICU stay (r = .955, p < .0001 and r = .335, p = .002, respectively), while ventilation was best related in those >1 week (r = .964, p < .0001 for ventilation, and r = -.079, p = .680, for TBSA%). NIV was introduced in 10 patients, with the aim of shorten the invasive ventilation requirement. As evidenced in our work, mechanical ventilation is frequently needed in burned children admitted to PICU and it is one of the main factors influencing PICU length of stay. No difference was found in terms of PICU length of stay and invasive mechanical ventilation time between children who underwent NIV and children who did not, despite children who underwent NIV had a larger burn surface. NIV can possibly shorten the total invasive ventilation time and related complications.