Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*.

OBJECTIVES: Viral bronchiolitis is an acute infection and inflammatory disease of the respiratory tract, with infants typically presenting with the most severe symptoms. Medical management of bronchiolitis is mostly supportive. Several preliminary studies suggest potential benefit from the use of high-flow nasal cannula systems. Although high-flow nasal cannula is a well-established modality in the newborn intensive care unit, its use in the pediatric intensive care unit for acute respiratory failure is far less established. The objective of this study was to identify any laboratory and clinical variables that may predict high-flow nasal cannula failure in management of bronchiolitis in the pediatric intensive care unit. DESIGN: The study design was a retrospective chart review of all patients admitted to the pediatric intensive care unit from 2006 to 2010 with a diagnosis of viral bronchiolitis. Inclusion criteria included the initiation of high flow nasal cannula therapy at the time of admission and age ≤ 12 months. Exclusion criteria were intubation prior to admission, age >12 months, and the presence of a tracheostomy. PATIENTS: A total of 113 patients with viral bronchiolitis met the inclusion criteria. SETTING: Academic free standing Children's Hospital in the Midwest. INTERVENTIONS: Retrospective chart review. MEASUREMENTS AND MAIN RESULTS: The data were analyzed by comparing those patients who responded to high-flow nasal cannula (n = 92) with those who were nonresponders to high-flow nasal cannula and required intubation (n = 21). No differences were noted between the groups for age, sex, or ethnicity. Mean weight and weight-for-corrected-age percentiles were significantly lower for patients who failed high-flow nasal cannula (p = .016 and .031, respectively), but weight-for-corrected-age percentile was not significant in logistic regression controlling for other variables. Respiratory rate prior to the initiation of high-flow nasal cannula also correlated strongly with respiratory deterioration (p < .001). The PCO2 was significantly higher for both before (p < .001) and after (p < .001) initiation of therapy in the nonresponder group. Pediatric Risk of Mortality III scores for the patients who failed high-flow nasal cannula were significantly higher (p < .001) than those of patients who tolerated this therapy. CONCLUSIONS: History of prematurity and the patient's age did not increase a patient's risk of failure. Nonresponders to high-flow nasal cannula therapy were on the onset, more hypercarbic, were less tachypnic prior to the start of high-flow nasal cannula, and had no change in their respiratory rate after the initiation of high-flow nasal cannula therapy. Nonresponders had higher pediatric risk of mortality scores in the first 24 hrs.

The efficacy of pediatric advanced life support training in emergency medical service providers.

Pediatric advanced life support (PALS) teaches skills unique to pediatric resuscitation. The purpose of this study was to assess the effect of PALS training among emergency medical service (EMS) providers in out-of-hospital trauma and medical resuscitations. A physician panel evaluated all EMS run sheets of pediatric traumas and medical resuscitations brought to a tertiary children's hospital/regional trauma center over a 3-year period. In 183 responses, EMS personnel were the sole providers of medical stabilization. Evaluation included the ability to secure an airway, establish vascular access, shock recognition, and appropriate cardiac rhythm assessment and resuscitation. The panel was blinded to the PALS training status of the responding EMS squad until completion of the review. Pediatric advanced life support-trained EMS personnel responded to 36% of the resuscitations reviewed. A significant difference in successful intubations was noted in PALS-trained squads compared with squads with no PALS training (85% vs 48%; P < 0.001). A significant difference was also noted in the ability to obtain vascular access in shock/arrest cases (100% vs 70%; P < 0.001). Similarly, PALS-trained squads were more successful in intraosseous line placement than non-PALS-trained squads (100% vs 55%; P < 0.01). However, despite better procedural skills, there was no difference in mortality rates between the groups (37% PALS vs 32% non-PALS). We conclude that PALS training improves procedural skills among EMS personnel and should be strongly considered as part of EMS training.

Pediatric intensive care unit nosocomial infections: epidemiology, sources and solutions.

Nosocomial infections in the PICU remain a significant source of morbidity and mortality. The risk of infections in these patients remains high because invasive devices allow organisms to bypass normal host defenses. Additionally, this patient group often has coexisting metabolic or organ system dysfunctions. Antibiotic pressure has led to the development of drug-resistant organisms within the PICU, thereby causing infections that are increasingly difficult to control. The best current approach for preventing PICU infections centers on consistent hand washing between patients, early discontinuation of invasive devices, and appropriate isolation strategies. Insight into the causes and locations of PICU-related infections remains a crucial component in the success of preventive strategies.

Amrinone in pediatric refractory septic shock: An open-label pharmacodynamic study.

OBJECTIVE: To investigate the short-term hemodynamic effects of amrinone in pediatric patients with refractory septic shock. DESIGN: Open-label, clinical trial. SETTING: Pediatric intensive care unit. PATIENTS: Nine patients admitted with a diagnosis of septic shock receiving stable doses of vasopressors and inotropes. INTERVENTIONS: Pediatric patients with septic shock and a pulmonary artery catheter were treated with amrinone in a stepwise fashion at 5, 10, and 15 &mgr;g/kg/min. MEASUREMENTS AND MAIN RESULTS: Heart rate, blood pressure, cardiac index, rate pressure product, systemic vascular resistance index, pulmonary vascular resistance, oxygen delivery, and oxygen consumption were measured at baseline and 90 mins after each amrinone dose. The addition of amrinone increased cardiac index (p <.05) and oxygen delivery (p <.05) without increasing the rate pressure product. Decreases were observed in systemic vascular resistance index (p <.05) and pulmonary vascular resistance (p <.05). No significant changes were seen in heart rate, blood pressure, or oxygen consumption. CONCLUSIONS: In this short-term, dose-response study in children with refractory septic shock, amrinone improved cardiac index and oxygen delivery in pediatric patients with refractory septic shock without increasing myocardial work.