Assessing pulmonary arterial hypertension in infants with severe chronic lung disease of infancy: a role for a pulmonary artery catheter?

The treatment of pulmonary arterial hypertension (PAH) associated with chronic lung disease of infancy (CLDI) is becoming commonplace. However, an optimal approach to the monitoring of this treatment has not been clearly established, and data suggest that such therapy may not be without risk. This study assessed the feasibility and safety of pulmonary artery catheter (PAC) placement and its role in the management of PAH associated with CLDI. The medical records of 12 infants with CLDI requiring chronic mechanical ventilation who underwent PAC monitoring were reviewed. Data analyzed included demographics, hemodynamic data, PAH pharmacological therapy, respiratory support, echocardiographic data, sedation level, complications related to PAC use, and mortality. In this analysis, PAC placement and monitoring was found to be feasible, appeared safe, and was associated with the ability to wean inspired oxygen, decrease sedation, and titrate PAH therapy without untoward effect. However, no definitive conclusions can be drawn from this report given its small sample size and uncontrolled, retrospective design. It is hoped that these data will renew interest in PAC monitoring for CLDI and foster prospective study where its true value can be ascertained.

Cost-effectiveness of exogenous surfactant therapy in pediatric patients with acute hypoxemic respiratory failure.

OBJECTIVE: To determine whether the use of exogenous surfactant (Infasurf) in pediatric acute hypoxemic respiratory failure is cost-effective. DESIGN: Deterministic cost-effectiveness analysis based on a Markov model. The model was calibrated using outcomes and resource utilization observed in a multiple-centered, prospective, randomized, controlled unblinded trial of Infasurf in pediatric acute hypoxemic respiratory failure. Costs were short-run direct costs estimated from the perspective of the hospital as provider. Primary outcomes were expected costs, expected survival rates, and incremental cost per life saved. SETTING: Patients in the trial were treated in one of eight pediatric intensive care units of tertiary medical centers. PATIENTS: Forty-two children with acute hypoxemic respiratory failure who were randomized to receive either standard therapy or exogenous surfactant in addition to standard therapy. MEASUREMENTS AND MAIN RESULTS: Our baseline analysis suggests that for a 10-kg child, the Infasurf strategy is both less costly (62,922 US dollars vs. 74,006 US dollars) and more effective (survival: 90.3% vs. 85.1%) and therefore dominates standard treatment. Cost savings were realized in the model because patients in the surfactant group were more likely to leave the pediatric intensive care unit sooner. The Infasurf strategy continues to dominate for children up to 60 kg. At 70 kg, the cost to save an additional life using the Infasurf strategy is 79,805 US dollars, which is still cost-effective if the provider is willing to make this tradeoff. CONCLUSIONS: For the majority of pediatric patients with acute hypoxemic respiratory failure, exogenous surfactant is cost-effective. If the use of this medication becomes standard care, a greater variety of packaging sizes could lead to decreased acquisition costs and increase the number of patients for whom this treatment is cost-effective.

Decreasing unplanned extubations: utilization of the Penn State Children's Hospital Sedation Algorithm.

OBJECTIVE: To determine whether institution of a standardized algorithm of goal-directed sedation impacted the incidence of unplanned extubations in critically ill pediatric patients. DESIGN: Prospective, observational study with historical controls. SETTING: Pediatric intensive care unit (PICU) in a tertiary care university-based children's hospital. PATIENTS: All mechanically ventilated children admitted to the PICU during a 10-yr period. INTERVENTIONS: After examining the data pertaining to unplanned extubations, the Penn State Children's Hospital Sedation Algorithm (PSCHSA) was instituted as an absolute requirement for all mechanically ventilated children. Physician orders for the goal sedation level and the appropriate medications to achieve that goal were obligatory for every ventilated patient. Data were then collected for 5 yrs after institution of the PSCHSA. MEASUREMENTS AND MAIN RESULTS: Before utilization of the PSCHSA, unplanned extubation rates ranged between 0.44 and 0.63 per 100 intubated patient days. In the 4 yrs after mandatory use of the PSCHSA for management of all ventilated patients, unplanned extubation rates were between 0 and 0.19 per 100 intubated patient days, demonstrating a significant decrease (p<.001). Throughout the entire study period, no changes were made in the model of patient care that would alter the rate of unplanned extubations. Despite a higher percentage of PICU patients that were intubated, length of stay in the PICU did not increase, suggesting that oversedation did not led to increased ventilator days. CONCLUSIONS: Utilization of the PSCHSA resulted in a decreased number of unplanned extubations without increasing the length of PICU stay. Implementation of the PSCHSA is needed in other PICUs to validate these findings.

A prospective assessment of the effect of aminophylline therapy on urine output and inflammation in critically ill children.

BACKGROUND: Aminophylline, an established bronchodilator, is also purported to be an effective diuretic and anti-inflammatory agent. However, the data to support these contentions are scant. We conducted a prospective, open-label, single arm, single center study to assess the hypothesis that aminophylline increases urine output and decreases inflammation in critically ill children. METHODS: Children less than 18 years of age admitted to the pediatric intensive care unit who were prescribed aminophylline over a 24-h period were eligible for study. The use and dosing of aminophylline was independent of the study and was at the discretion of the clinical team. Data analyzed consisted of demographics, diagnoses, medications, and markers of pulmonary function, renal function, and inflammation. Data were collected at baseline and at 24-h after aminophylline initiation with primary outcomes of change in urine output and inflammatory cytokine concentrations. RESULTS: Thirty-five patients were studied. Urine output increased significantly with aminophylline use [median increase 0.5 mL/kg/h (IQR: -0.3, 1.3), p = 0.05] while blood urea nitrogen and creatinine concentrations remained unchanged. Among patients with elevated C-reactive protein concentrations, levels of both interleukin-6 (IL-6) and IL-10 decreased at 24 h of aminophylline therapy. There were no significant differences in pulmonary compliance or resistance among patients invasively ventilated at both time points. Side effects of aminophylline were detected in 7 of 35 patients. CONCLUSION: Although no definitive conclusions can be drawn from this study, aminophylline may be a useful diuretic and effective anti-inflammatory medication in critically ill children. Given the incidence of side effects, the small sample size and the uncontrolled study design, further study is needed to inform the appropriate use of aminophylline in these children.

Safety and efficacy of sedation with propofol for transoesophageal echocardiography in children in an outpatient setting.

BACKGROUND: Transoesophageal echocardiography has become a powerful tool in the diagnosis and management of children with congenital cardiac malformations. Unlike adults, children will not tolerate transoesophageal echocardiography under light sedation. This study was undertaken, therefore, to evaluate the safety and efficacy of deep sedation with propofol for transoesophageal echocardiography in children examined in an outpatient setting. METHODS: This is a retrospective study of patients undergoing transoesophageal echocardiography with propofol given in bolus aliquots to achieve a level of sedation adequate to insert the transoesophageal echocardiographic probe and maintain sedation throughout the procedure. RESULTS: We included a total of 118 patients, 57% being male, with a mean age of 12.9 years. Adequate sedation was achieved using a mean propofol dose of 8.3 milligrams per kilogram, with the dose per kilogram decreasing concomitant with increasing weight of the patient. Patients less than two years of age were intubated for the procedure. There were no clinically significant changes in cardiac function or haemodynamics. Non-intubated patients received supplemental oxygen prior to, or just after, the onset of sedation, with transient hypoxaemia observed in one-fifth. Complications were rare, with minor problems occurring in 7.6%, and major ones in 4%. CONCLUSIONS: Transoesophageal echocardiography can be performed on an outpatient basis in children with a wide spectrum of congenital cardiac malformations, and propofol is an ideal sedative agent in this setting. Although not common, preparations must be made for significant haemodynamic and respiratory complications. In our study, we intubated all the children under 2 years of age.