RESUMEN
In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.
Asunto(s)
Cuidados Críticos/normas , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/normas , Modelos Organizacionales , Evaluación de Procesos y Resultados en Atención de Salud , Mejoramiento de la Calidad , Humanos , Sociedades Médicas , Estados UnidosRESUMEN
OBJECTIVE: To review and revise the 1987 pediatric brain death guidelines. METHODS: Relevant literature was reviewed. Recommendations were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. CONCLUSIONS AND RECOMMENDATIONS: 1) Determination of brain death in term newborns, infants, and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants <37 wks gestational age are not included in this guideline. 2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. 3) Two examinations, including apnea testing with each examination separated by an observation period, are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hrs for term newborns (37 wks gestational age) to 30 days of age and 12 hrs for infants and children (>30 days to 18 yrs) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for ≥24 hrs if there are concerns or inconsistencies in the examination. 4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco2 20 mm Hg above the baseline and ≥60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. 5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be used to assist the clinician in making the diagnosis of brain death a) when components of the examination or apnea testing cannot be completed safely as a result of the underlying medical condition of the patient; b) if there is uncertainty about the results of the neurologic examination; c) if a medication effect may be present; or d) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed and components that can be completed must remain consistent with brain death. In this instance, the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. 6) Death is declared when these criteria are fulfilled.
Asunto(s)
Muerte Encefálica/diagnóstico , HumanosAsunto(s)
Borrelia burgdorferi/patogenicidad , Bradicardia/etiología , Bloqueo Cardíaco/etiología , Enfermedad de Lyme/complicaciones , Antibacterianos/uso terapéutico , Borrelia burgdorferi/efectos de los fármacos , Niño , Doxiciclina/uso terapéutico , Femenino , Humanos , Enfermedad de Lyme/tratamiento farmacológico , Miocarditis/microbiología , Síncope/etiologíaAsunto(s)
Fiebre del Nilo Occidental/diagnóstico , Niño , Diagnóstico Diferencial , Femenino , HumanosRESUMEN
BACKGROUND: The start of transpyloric feedings is often delayed because of challenges in reliably placing tubes blindly at the bedside. OBJECTIVE: To determine whether tube placement with the guidance of a noninvasive computerized electromagnetic device shortens the time needed to achieve accurate placement of transpyloric feeding tubes in critically ill children. METHODS: In a prospective, randomized trial in a tertiary-care, university-affiliated pediatric intensive care unit, 49 children requiring transpyloric feeding tube placement were randomized to have their tube placed by using conventional blind technique or with the assistance of a noninvasive electromagnetic device. RESULTS: Twenty-seven patients were randomized to blind placement, and 22 were randomized to the electromagnetic device group. The time required to place the tubes successfully was significantly longer (P < .03) in the electromagnetic device group (median, 9.5 minutes; 95% confidence interval, 7-13 minutes) compared with the conventional placement group (median, 5 minutes; 95% confidence interval, 4.0-7.0 minutes). CONCLUSIONS: Placement of transpyloric feeding tubes with the guidance of a noninvasive electromagnetic device significantly increases the time required for accurate placement. Because placement of transpyloric feeding tubes in critically ill children is common practice in many pediatric intensive care units, technology that delays satisfactory placement may be counterproductive in experienced hands.
Asunto(s)
Enfermedad Crítica , Campos Electromagnéticos , Nutrición Enteral , Intubación Gastrointestinal/métodos , Intubación Gastrointestinal/normas , Píloro , Niño , Preescolar , Intervalos de Confianza , Femenino , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico , Masculino , Estudios ProspectivosAsunto(s)
Asma/terapia , Antiasmáticos/uso terapéutico , Antiinflamatorios/uso terapéutico , Asma/epidemiología , Asma/etiología , Niño , Continuidad de la Atención al Paciente , Helio/uso terapéutico , Humanos , Evaluación de Necesidades , Rol de la Enfermera , Oxígeno/uso terapéutico , Planificación de Atención al Paciente , Enfermería Pediátrica/métodos , Factores de Riesgo , Esteroides , Estados Unidos/epidemiologíaRESUMEN
Pediatric obesity has reached epidemic proportions in the United States. Significant obesity-related comorbidities are being noted at earlier ages and often have implications for the acute and critically ill child. This article will review the latest in epidemiologic trends of pediatric obesity and examine how it affects multisystem body organs. The latest data evaluating the specific effects of obesity on acute and critically ill children will be reviewed. Available nonpharmacologic, pharmacologic, and surgical strategies to combat pediatric obesity will be discussed.
Asunto(s)
Cuidados Críticos , Obesidad/complicaciones , Obesidad/prevención & control , Adolescente , Niño , Comorbilidad , Humanos , Obesidad/epidemiología , Obesidad/psicología , Estados Unidos/epidemiologíaRESUMEN
Central venous catheters are often mandatory devices when caring for critically ill children. They are required to deliver medications, nutrition, and blood products, as well as for monitoring hemodynamic status and drawing laboratory samples. Any foreign object that is introduced to the body is at risk for infection. Central venous catheters carry a particularly high risk of infection and these infections can be life threatening. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections. This article discusses risk factors for developing catheter-related bloodstream infections in critically ill children, as well as measures to decrease incidence of catheter-related bloodstream infections, including a review of recommendations from the Centers for Disease Control and Prevention.
Asunto(s)
Cateterismo Venoso Central , Cuidados Críticos/métodos , Infección Hospitalaria/prevención & control , Control de Infecciones/métodos , Sepsis/prevención & control , Antibacterianos/uso terapéutico , Asepsia/métodos , Vendajes , Cateterismo Venoso Central/efectos adversos , Cateterismo Venoso Central/enfermería , Catéteres de Permanencia/efectos adversos , Niño , Infección Hospitalaria/epidemiología , Infección Hospitalaria/etiología , Contaminación de Equipos/prevención & control , Medicina Basada en la Evidencia , Humanos , Mantenimiento , Rol de la Enfermera , Evaluación en Enfermería , Enfermería Pediátrica/métodos , Guías de Práctica Clínica como Asunto , Garantía de la Calidad de Atención de Salud/organización & administración , Medición de Riesgo , Factores de Riesgo , Sepsis/epidemiología , Sepsis/etiología , Cuidados de la Piel/métodos , Cuidados de la Piel/enfermeríaRESUMEN
Temperature measurement is a commonly used assessment parameter when caring for the critically ill child. Interpreting the temperature measurement mode and what constitutes clinically significant thermal instability are poorly defined. Thus, decisions made regarding patient management based on temperature measurement can be challenging for caregivers. Infants and children have unique physioanatomic considerations that impact maintaining thermoregulation. Numerous routes for taking temperature measurements are described including the oral, axillary, tympanic (aural), rectal, skin, urinary bladder, pulmonary artery, esophageal, nasopharyngeal, supralingual (pacifier), and temporal-artery. Numerous studies on temperature measurement have been conducted on children of various ages using a variety of thermometers and routes in both the inpatient and outpatient setting. Although there are limited studies reported on the critically ill child, research data pertinent to the critically ill child from subjects in the neonatal intensive care unit, pediatric intensive care unit, operating room, and inpatient units are summarized.