Assessment of association between rapid fluctuations in serum sodium and intraventricular hemorrhage in hypernatremic preterm infants.

AIM: This study aims to determine the association between the rapid fluctuations in serum sodium and intraventricular hemorrhage (IVH) or death in hypernatremic preterm infants. STUDY DESIGN: Single center observational study including 216 infants < 1,000 g birth weight and <29 weeks gestational age, who had serum sodium levels monitored at least every 12 hours. Logistic regression analyses were used to identify which of the commonly cited risk factors for IVH, including the rapid (to the extent of ≥10 and ≥15 mmol/L/d) rise or fall in serum sodium, was associated with the primary outcome of any IVH, or the secondary composite outcome of severe IVH or death during the first 10 days of life in hypernatremic infants. RESULTS: Of 216 infants, 126 (58%) studied developed hypernatremia (serum sodium ≥ 150 mmol/L). IVH was more frequent in hypernatremic infants (p = 0.01). Presence of hypernatremia was an independent risk factor for IVH on logistic regression analysis (p = 0.022, odds ratio 2.0, 95% confidence interval: 1.1-3.8). Rapid (≥ 10 and ≥ 15 mmol/L/d) rise or fall in serum sodium in hypernatremic infants was not associated with the outcomes. CONCLUSION: Hypernatremia per se, but not the rapid fluctuations (not exceeding 10-15 mmol/L/d) in serum sodium was independently associated with IVH.

Relationship between acute kidney injury and brain MRI findings in asphyxiated newborns after therapeutic hypothermia.

BACKGROUND: We hypothesized that acute kidney injury (AKI) in asphyxiated neonates treated with therapeutic hypothermia would be associated with hypoxic-ischemic lesions on brain magnetic resonance imaging (MRI). METHODS: Medical records of 88 cooled neonates who had had brain MRI were reviewed. All neonates had serum creatinine assessed before the start of cooling; at 24, 48, and 72 h through cooling; and then on day 5 or 7 of life. A neonatal modification of the Kidney Disease: Improving Global Outcomes guidelines was used to classify AKI. MRI images were evaluated by a neuroradiologist masked to outcomes. Outcome of interest was abnormal brain MRI at 7-10 d of life. RESULTS: AKI was found in 34 (39%) of 88 neonates, with 15, 7, and 12 fulfilling criteria for stages 1, 2, and 3, respectively. Brain MRI abnormalities related to hypoxia-ischemia were present in 50 (59%) newborns. Abnormal MRI was more frequent in infants from the AKI group (AKI: 25 of 34, 73% vs. no AKI: 25 of 54, 46%; P = 0.012; odds ratio (OR) = 3.2; 95% confidence interval (CI) = 1.3-8.2). Multivariate analysis identified AKI (OR = 2.9; 95% CI = 1.1-7.6) to be independently associated with the primary outcome. CONCLUSION: AKI is independently associated with the presence of hypoxic-ischemic lesions on postcooling brain MRI.

Esophageal and rectal temperatures as estimates of core temperature during therapeutic whole-body hypothermia.

We monitored whole-body cooling concurrently by both esophageal and rectal probes. Esophageal temperature was significantly higher compared with simultaneous rectal temperature during cooling, with a temperature gradient ranging from 0.46 to 1.03°C (median, 0.8°C; IQR, 0.6-0.8°C). During rewarming, this temperature difference disappeared.

Acute kidney injury in asphyxiated newborns treated with therapeutic hypothermia.

OBJECTIVE: To test the hypothesis that acute kidney injury (AKI) would be independently associated with increased morbidity and mortality. STUDY DESIGN: A total of 96 consecutively cooled infants were reviewed retrospectively. Modified Acute Kidney Injury Network criteria were used to classify AKI based on absolute rise in serum creatinine (SCr) level from a previous trough (stage I, rise in SCr of 0.3 mg/dL or SCr 150-<200%; stage II, rise in SCr of 200-<300%; stage III, rise in SCr of ≥300%, SCr 2.5 mg/dL, or dialysis). Outcomes were mortality, duration of neonatal intensive care unit (NICU) stay, and duration of mechanical ventilation. RESULTS: AKI occurred in 36 of 96 infants (38%). Overall mortality was 7% and was higher for those with AKI, with the difference approaching statistical significance (14% vs 3% in those without AKI; P = .099). Patients with AKI stayed longer in the NICU (mean, 15.4 ± 9.3 days vs 11 ± 5.9 days; P = .014) and required prolonged mechanical ventilation (mean, 9.7 ± 5.9 days vs 4.8 ± 3.7 days; P < .001). On multivariate analysis, AKI remained predictive of prolonged duration of mechanical ventilation and prolonged NICU stay. CONCLUSION: We used the Acute Kidney Injury Network definition for AKI in asphyxiated newborns undergoing therapeutic hypothermia to demonstrate that the incidence of AKI remains high, but lower than rates published before the advent of therapeutic hypothermia. We highlight the importance of recognizing AKI in asphyxiated newborns undergoing therapeutic hypothermia, along with the potential benefits of early recognition.

A randomized trial of recombinant human granulocyte-macrophage colony stimulating factor for patients with acute lung injury.

RATIONALE: Despite recent advances in critical care and ventilator management, acute lung injury and acute respiratory distress syndrome continue to cause significant morbidity and mortality. Granulocyte-macrophage colony stimulating factor may be beneficial for patients with acute respiratory distress syndrome. OBJECTIVES: To determine whether intravenous infusion of granulocyte-macrophage colony stimulating factor would improve clinical outcomes for patients with acute lung injury/acute respiratory distress syndrome. DESIGN: A randomized, double-blind, placebo-controlled clinical trial of human recombinant granulocyte-macrophage colony stimulating factor vs. placebo. The primary outcome was days alive and breathing without mechanical ventilatory support within the first 28 days after randomization. Secondary outcomes included mortality and organ failure-free days. SETTING: Medical and surgical intensive care units at three academic medical centers. PATIENTS: One hundred thirty individuals with acute lung injury of at least 3 days duration were enrolled, out of a planned cohort of 200 subjects. INTERVENTIONS: Patients were randomized to receive human recombinant granulocyte-macrophage colony stimulating factor (64 subjects, 250 µg/M) or placebo (66 subjects) by intravenous infusion daily for 14 days. Patients received mechanical ventilation using a lung-protective protocol. MEASUREMENTS AND MAIN RESULTS: There was no difference in ventilator-free days between groups (10.7 ± 10.3 days placebo vs. 10.8 ± 10.5 days granulocyte-macrophage colony stimulating factor, p = .82). Differences in 28-day mortality (23% in placebo vs. 17% in patients receiving granulocyte-macrophage colony stimulating factor (p = .31) and organ failure-free days (12.8 ± 11.3 days placebo vs. 15.7 ± 11.9 days granulocyte-macrophage colony stimulating factor, p = .16) were not statistically significant. There were similar numbers of serious adverse events in each group. CONCLUSIONS: In a randomized phase II trial, granulocyte-macrophage colony stimulating factor treatment did not increase the number of ventilator-free days in patients with acute lung injury/acute respiratory distress syndrome. A larger trial would be required to determine whether treatment with granulocyte-macrophage colony stimulating factor might alter important clinical outcomes, such as mortality or multiorgan failure. (ClinicalTrials.gov number, NCT00201409 [ClinicalTrials.gov]).

The effect of late preterm birth on mortality of infants with hypoplastic left heart syndrome.

OBJECTIVES: We evaluated the effect of late preterm (34 to 36 weeks' gestation) delivery on hospital mortality of infants with hypoplastic left heart syndrome (HLHS). STUDY DESIGN: Retrospective review of records of infants born at or after 34 weeks with no other lethal anomalies, cared for in a single tertiary perinatal center between 2002 and 2009. Factors associated with death prior to discharge from the hospital were ascertained using univariate and multivariate analyses. RESULTS: Of the 243 infants with HLHS, 35 were late preterm and 208 were ≥37 weeks (term). Using logistic regression analysis, late preterm delivery (odds ratio [OR] 2.95; 95% confidence interval [CI] 1.35 to 6.45), the presence of other major cardiac defects (OR 3.76; 95% CI 1.31 to 10.81), and the presence of noncardiac congenital anomalies (OR 6.13; 95% CI 1.43 to 26.22) were independently associated with hospital death. CONCLUSION: Late preterm birth of infants with HLHS was independently associated with an increased risk of hospital death compared with those delivered at term.

Clinical Outcomes of Acute Respiratory Failure Associated With Noninvasive and Invasive Ventilation in a Pediatric ICU.

BACKGROUND: It remains unknown if pediatric patients failing initial noninvasive ventilation (NIV) experience worse clinical outcomes than those successfully treated with NIV or those primarily intubated. METHODS: This was a single-center, retrospective review of patients admitted with acute respiratory failure to the University of Michigan pediatric intensive care or cardiothoracic ICUs and receiving NIV or invasive mechanical ventilation as first-line therapy. RESULTS: One hundred seventy subjects met inclusion criteria and were enrolled: 65 NIV success, 55 NIV failure, and 50 invasive mechanical ventilation alone. Of those failing NIV, median time to intubation was 1.8 (interquartile range [IQR] < 1-7) h. On multivariable regression, ICU-free days were significantly different between groups (NIV success: 22.9 ± 6.9 d; NIV failure: 13.0 ± 6.6 d; invasive ventilation: 12.5 ± 6.9 d; P < .001 across all groups). Multivariable regression revealed no difference in ventilator-free days between NIV failure and invasive ventilation groups (15.4 ± 10.1 d vs 15.9 ± 9.7 d, P = .71). Of 64 subjects (37.6%) meeting Pediatric Acute Lung Injury Consensus Conference pediatric ARDS criteria, only 14% were successfully treated with NIV. Ventilator-free days were similar between the NIV failure and invasive ventilation groups (11.6 vs 13.2 d, P = .47). On multivariable analysis, ICU-free days were significantly different across pediatric ARDS groups (P < .001): NIV success: 20.8 + 31.7 d; NIV failure: 8.3 + 23.8 d; invasive alone: 8.9 + 23.9 d, yet no significant difference in ventilator-free days between those with NIV failure versus invasive alone (11.6 vs 13.2 d, P = .47). CONCLUSIONS: We demonstrated that critically ill pediatric subjects unsuccessfully trialed on NIV did not experience increased ICU length of stay or fewer ventilator-free days when compared to those on invasive mechanical ventilation alone, including in the pediatric ARDS subgroup. Our findings are predicated on a median time to intubation of < 2 h in the NIV failure group and the provision of adequate monitoring while on NIV.

The relationship between clinically identifiable intrapartum sentinel events and short-term outcome after therapeutic hypothermia.

OBJECTIVE: To determine the impact of intrapartum sentinel events on short-term outcome post-hypothermia. STUDY DESIGN: Records of 77 infants of 36 weeks' gestation or more, who received therapeutic hypothermia, were reviewed. Some were delivered after a clinically identifiable intrapartum sentinel event (IISE). All survivors had brain magnetic resonance imaging (MRI) at 7 to 10 days of life. The primary outcome of neonatal death related to hypoxic-ischemic encephalopathy was compared in infants born with (n = 39) or without an IISE (n = 38). MRI abnormalities were also compared. Logistic regression analysis was used to determine the variables predicting the primary outcome. RESULTS: The two groups had similar Apgar scores, initial blood pHs, and early neurologic examinations. Base deficit was more severe in the IISE group. Neonatal death and hypoxic-ischemic injury was shown on brain MRI with basal nuclei, cortical, and subcortical white matter lesions extending beyond the watershed areas in infants surviving beyond the neonatal period were more common in the IISE group (P = .014; OR 11.1; 95% CI 1.3-92.6; and P = .034; OR 4.1; 95% CI 1.1-14.9, respectively). Multivariate analysis identified IISE (P = .023; OR 12.2; 95% CI 1.4-105.8) to be independently associated with neonatal death. CONCLUSIONS: IISEs are associated with neonatal death and severe injury as shown in brain MRI, even after hypothermia.

Brainstem hypoxic-ischemic lesions on MRI in infants treated with therapeutic cooling: effects on the length of stay and mortality.

OBJECTIVE: To test the hypothesis that brainstem hypoxic-ischemic injury on magnetic resonance imaging (MRI) would be independently associated with short-term outcomes in cooled asphyxiated infants. METHODS: A total of 90 consecutively cooled asphyxiated infants who survived to have brain MRI were reviewed. A neuroradiologist who was masked to outcomes evaluated MRI images for brainstem involvement. Outcomes were mortality and length of stay. RESULTS: Brainstem lesions were present on post-cooling brain MRI in 20 of the 90 infants (22%). Overall, four infants died before discharge, and all four had brainstem involvement. The infants with brainstem involvement had longer hospital stay (29 days, IQR 20-47 versus 16 days, IQR 10-26; P = 0.0001), compared to infants without brainstem lesions (n = 70); and upon multivariate analysis, brainstem involvement remained independently associated with prolonged hospital stay (ß = 12.4, P = 0.001). CONCLUSION: This study demonstrates the importance of recognizing brainstem injury for the prediction of short-term outcomes in cooled asphyxiated infants.

Do outcomes vary according to the source of admission to the pediatric intensive care unit?

OBJECTIVE: To examine associations between mortality, length of stay, and the sources of admission to tertiary pediatric intensive care. DESIGN: A retrospective analysis of prospectively collected data. SETTING: A tertiary medical center with a 16-bed medical-surgical intensive care unit and a 15-bed cardiac pediatric intensive care unit (PICU). PATIENTS: All admissions from July 1, 1998, through June 30, 2004. Multivariable regression methods compared length of stay and mortality between the sources of PICU admission, controlling for multiple variables, including severity of illness. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 8,897 eligible admissions, 74% were directly from the study hospital's emergency department or operating rooms, while 26% were from indirect sources, including the study hospital's wards (11%) or interhospital transfer from either non-PICU (12%) or PICU settings (3%). Compared with emergency department admissions, ward admissions had higher odds of mortality (odds ratio 1.65, 95% confidence interval 1.08-2.51), transfer admissions from non-PICU settings did not have elevated odds of mortality (odds ratio 0.80, 95% confidence interval 0.51-1.25), and inter-PICU transfer admissions had higher odds of mortality (odds ratio 1.43, 95% confidence interval 0.80-2.56), although not reaching statistical significance. Compared with emergency department admissions, ward admissions stayed almost 4 days longer in the PICU, while interhospital transfer admissions from non-PICU and PICU settings stayed 2 and 6 days longer, respectively. CONCLUSIONS: Outcomes of tertiary pediatric intensive care vary significantly by source of admission. Strategies aimed at reduction of mortality at the tertiary PICU should target transfer admissions from the hospital's wards and from PICUs of other hospitals.

Predicting the need for home gavage or g-tube feeds in asphyxiated neonates treated with therapeutic hypothermia.

BACKGROUND: Asphyxiated infants treated with therapeutic cooling can have persistent oral feeding difficulty because of involvement of neural pathways in the brainstem, cortex, and basal ganglia. The goal is to predict the composite adverse outcome of death or persistent oral feeding difficulty using precooling/cooling attributes, and the severity and distribution of hypoxic-ischemic lesions, especially brainstem lesions on post-cooling brain magnetic resonance imaging (MRI). METHODS: Retrospective review of 86 asphyxiated infants cooled from January 2006 to August 2014. Persistent feeding difficulty was defined as needing feeding support (gastrostomy tube (g-tube) or home gavage feeds) after discharge. Clinical and laboratory risk factors, and the brain MRI abnormalities including the presence of brainstem lesions were compared between infants with and without adverse outcome using univariate analysis. Significant variables were then analyzed in a stepwise logistic regression (LR) model. RESULTS: Infants with adverse outcome (n = 31, 4 died pre-discharge) had longer hospital stay (26 days, interquartile range (IQR) 19-43 vs. 13 days, IQR 9-20; p < 0.01) and reached goal enteral feeds (oral/gavage) later (11 days vs. 8 days, p < 0.01) compared to 55 infants discharged on full oral feeds. The former infants were more likely to have cord pH ≤ 7.15, severely abnormal neurological examination, bleeding diathesis, continued need for ventilation, and positive MRI findings including brainstem lesions. In LR analysis, brainstem lesions on MRI (p = 0.00, odds ratio 19, 95% confidence interval 4-85) was independently associated with the adverse outcome. CONCLUSIONS: Brainstem involvement on post-cooling brain MRI was predictive of adverse outcome. Early identification of these infants may facilitate discussion of home feeding plans between clinicians and parents earlier, thereby potentially reducing the length of hospital stay.

Determining the Accuracy and Reliability of Indirect Calorimeters Utilizing the Methanol Combustion Technique.

BACKGROUND: Several indirect calorimetry (IC) instruments are commercially available, but comparative validity and reliability data are lacking. Existing data are limited by inconsistencies in protocols, subject characteristics, or single-instrument validation comparisons. The aim of this study was to compare accuracy and reliability of metabolic carts using methanol combustion as the cross-laboratory criterion. METHODS: Eight 20-minute methanol burn trials were completed on 12 metabolic carts. Respiratory exchange ratio (RER) and percent O2 and CO2 recovery were calculated. RESULTS: For accuracy, 1 Omnical, Cosmed Quark CPET (Cosmed), and both Parvos (Parvo Medics trueOne 2400) measured all 3 variables within 2% of the true value; both DeltaTracs and the Vmax Encore System (Vmax) showed similar accuracy in measuring 1 or 2, but not all, variables. For reliability, 8 instruments were shown to be reliable, with the 2 Omnicals ranking best (coefficient of variation [CV] < 1.26%). Both Cosmeds, Parvos, DeltaTracs, 1 Jaeger Oxycon Pro (Oxycon), Max-II Metabolic Systems (Max-II), and Vmax were reliable for at least 1 variable (CV ≤ 3%). For multiple regression, humidity and amount of combusted methanol were significant predictors of RER (R2 = 0.33, P < .001). Temperature and amount of burned methanol were significant predictors of O2 recovery (R2 = 0.18, P < .001); only humidity was a predictor for CO2 recovery (R2 = 0.15, P < .001). CONCLUSIONS: Omnical, Parvo, Cosmed, and DeltaTrac had greater accuracy and reliability. The small number of instruments tested and expected differences in gas calibration variability limits the generalizability of conclusions. Finally, humidity and temperature could be modified in the laboratory to optimize IC conditions.

Going back for more: an evaluation of clinical outcomes and characteristics of readmissions to a pediatric intensive care unit.

OBJECTIVE: To determine mortality, length of stay, and factors associated with readmissions to the pediatric intensive care unit (PICU). DESIGN: A retrospective analysis of prospectively collected data. SETTING: A 16-bed medical-surgical tertiary PICU and a coexisting 15-bed pediatric cardiac intensive care unit. PATIENTS: All admissions from July 1, 1998, through June 30, 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of 8,885 total eligible admissions, 711 (8%) were readmissions to the PICU. The median age of the overall cohort was 35.2 months (interquartile range, 5.5-128.2). Readmitted patients were younger (10.4 vs. 37.7 months, p < .01), had greater severity of illness (p < .01), and were more likely to be admitted emergently (p < .01), in comparison with single admissions. In multivariate analyses, readmitted patients had a trend toward higher odds of mortality (odds ratio, 1.39; 95% confidence interval, 0.98-1.98) and stayed 2.96 days longer in the PICU (95% confidence interval, 1.98-3.94) compared with single admissions to the PICU. Factors independently associated with PICU readmission were infant age (odds ratio, 1.98; 95% confidence interval, 1.57-2.49), emergent admission (odds ratio, 2.21; 95% confidence interval, 1.78-2.77), illness severity (odds ratio, 1.03; 95% confidence interval, 1.01-1.04), and time of the year between July and September (odds ratio, 1.52; 95% confidence interval, 1.20-1.93). A diagnosis of trauma was associated with low likelihood of PICU readmission (odds ratio, 0.30; 95% confidence interval, 0.18-0.50). CONCLUSIONS: Patients readmitted to the PICU during the same hospitalization have significantly adverse outcomes. The study highlights important factors associated with PICU readmissions that can be incorporated into efforts to reduce mortality and resource utilization associated with readmission of critically ill children.

Characteristics and outcomes of interhospital transfers from level II to level I pediatric intensive care units.

OBJECTIVE: To examine the characteristics, resource utilization, and outcomes for transfer admissions from level II to level I pediatric intensive care units (PICUs). DESIGN: Retrospective study. SETTING: A 16-bed level I PICU in a tertiary care children's hospital. PATIENTS: All transfer admissions from level II PICUs from January 1, 1997, through December 31, 2003; admissions for cardiac surgery were excluded. Patient characteristics, resource utilization, and outcomes were described and then compared across predefined strata (low <5%, moderate 5-30%, and high >30%) of predicted probability of death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 168 transfer admissions, 45%, 30%, and 25% were in the low, moderate, and high mortality risk groups, respectively. Length of stay at the referring PICU was shortest for the high-risk admissions. The most frequent diagnoses among all risk groups were respiratory failure (49%) and sepsis (14%). High-risk admissions were more likely to receive advanced therapies such as extracorporeal membrane oxygenation (41.5% high risk vs. 39.2% moderate vs. 6.6% low risk, p < .01) and renal replacement therapy (34.2% vs. 17.7% vs. 2.6%, p < .01). The high-risk admissions had longer PICU length of stay and the highest death rates (34% vs. 10% vs. 4%, p < .01) when compared with the moderate- and low-risk admissions, respectively. CONCLUSIONS: This study highlights significant differences in patient characteristics, resource utilization, and outcomes across mortality risk-stratified groups of critically ill and injured children transferred from level II to level I PICU care. Further studies are warranted to investigate decision making that prompt inter-PICU transfers.

Hospital readmission for bronchiolitis.

The objectives of this study were to determine the rate and risk factors for hospital readmission after inpatient treatment for bronchiolitis. We conducted a retrospective cohort study from 2000 to 2002. The readmission rate within 30 days was 3.7% (95% Confidence Interval: 2.1%-6.0%). Readmission was not associated with age, prematurity, respiratory syncytial virus status, receipt of intensive care, or the observation period off supplemental oxygen. Those who required supplemental oxygen had a lower risk of readmission. Identifying children at risk for readmission is challenging. Children who did not require supplemental oxygen may be at greater risk because they are progressing in their illness.

Validation of the V(max) metabolic cart in a simulated pediatric model.

BACKGROUND: The ability to accurately measure resting energy expenditure (REE) using indirect calorimetry, often referred to as the "gold standard" in nutrition needs assessment, is important given the well-established positive correlation between patient outcome and proportion of the nutrition goal met. While many studies have been done to compare various metabolic carts with one another, the literature lacks a large simulator-based validation of any metabolic cart system. MATERIALS AND METHODS: In the present study, 8 specifically trained staff members independently conducted 10 simulation trials each using the V(max) Encore metabolic analyzer in conjunction with a metabolic calibration system, which simulates patient metabolic activity, to validate the accuracy of the V(max) Encore across a wide range of simulated metabolic conditions. Testing conditions consisted of incremental adjustments in calibrated gas infusion with a consistently set tidal volume and respiratory rate. RESULTS: There was a strong, statistically significant correlation between the predicted and actual VO2 and VCO2 data (VO2, R (2) = 0.998; VCO2, R (2) = 0.997). In addition, we observed no significant difference between individuals performing these trials (VO2, P = 1.000, F = 0.021, df = 79; VCO2, P = 1.000, F = 0.030, df = 79). CONCLUSIONS: This study is the first to report on such a wide spectrum of metabolic activity (50-2000 kcal REE) using a calibrated bench model and validates the accuracy, reproducibility, and use of the V(max) Encore metabolic cart.

Nosocomial catheter-related bloodstream infections in a pediatric intensive care unit: risk and rates associated with various intravascular technologies.

OBJECTIVE: Nosocomial bloodstream infections are associated with increased patient morbidity, mortality, and hospital costs. More than 90% of these infections are related to the use of intravascular catheter devices. This study was done to assess the risk and rates of catheter related-bloodstream infections (CR-BSI) associated with different intravascular technologies in a pediatric intensive care unit population. DESIGN: Retrospective cohort study. SETTING: A 16-bed pediatric intensive care unit in a tertiary children's hospital. STUDY POPULATION: All admissions between July 1997 and December 1999 requiring placement of an intravascular access device for care were examined. Patients with CR-BSI were identified through ongoing surveillance using Centers for Disease Control/National Nosocomial Infections Surveillance System definitions for bloodstream infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 2,728 admissions during the review period, 1,043 (38.3%) required placement of an intravascular access device. Bivariate analysis revealed that patients who required intravascular cannulae for extracorporeal life support had a 10-fold increased risk of developing a CR-BSI, and patients requiring vascular access for renal replacement therapy demonstrated a 4-fold increase in the risk of developing CR-BSI compared with the referent group. There was a significant increase in the CR-BSI rate associated with the use of more intravascular access devices per patient admission. Multivariate logistic regression identified the use of extracorporeal life support therapy and the total duration of use of intravascular access devices as significant independent predictors of CR-BSI when controlling for other predictors. CONCLUSION: The use of extracorporeal life support therapy, the presence of multiple intravascular access devices, and the total duration of intravascular access device use were associated with an increase in the rate and risk of developing CR-BSI in our pediatric intensive care unit population. Larger, prospective studies may help elucidate additional factors responsible for these observations.

Immediate changes in lung compliance following natural surfactant administration in premature infants with respiratory distress syndrome: a controlled trial.

OBJECTIVE: To compare immediate changes in lung compliance following the administration of two commercially available natural surfactants. METHOD: We conducted a prospective, randomized study of 40 preterm infants with respiratory distress syndrome requiring surfactant. Infants received either Infasurf or Survanta. The primary outcome measure was the change in compliance assessed by bedside pulmonary monitoring. RESULTS: There were no significant changes in dynamic lung compliance within or between the two groups 1 hour after surfactant administration. However, infants given Survanta required more doses per patient (4 vs 2, p=0.05) and were more likely to require >2 doses (57 vs 26%, p=0.05). Infants requiring >1 dose of surfactant had a greater change in airway pressure and improved oxygenation just before the second dose when treated with Infasurf. CONCLUSIONS: We found no significant difference in acute changes in lung compliance. However, treatment with Infasurf seems to be more long lasting than Survanta.