Characterization of pediatric patients receiving prolonged mechanical ventilation.

OBJECTIVE: To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. DESIGN: Prospective cohort. SETTING: Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. PATIENTS: All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. CONCLUSIONS: Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.

Critically ill infants and children with influenza A (H1N1) in pediatric intensive care units in Argentina.

OBJECTIVE: To determine the epidemiological features, course, and outcomes of critically ill pediatric patients with Influenza A (H1N1) virus. DESIGN: Prospective cohort of children in pediatric intensive care units (PICUs) due to Influenza A (H1N1) virus infection. SETTING: Seventeen medical-surgical PICUs in tertiary care hospital in Argentina. PATIENTS: All consecutive patients admitted to the PICUs with influenza A (H1N1) viral infection from 15 June to 31 July 2009. MEASUREMENTS AND MAIN RESULTS: Of 437 patients with acute lower respiratory infection in PICUs, 147 (34%) were diagnosed with influenza A (H1N1) related to critical illness. The median age of these patients was 10 months (IQR 3-59). Invasive mechanical ventilation was used in 117 (84%) on admission. The rate of acute respiratory distress syndrome (ARDS) was 80% (118 of 147 patients). Initial non-invasive ventilation failed in 19 of 22 attempts (86%). Mortality at 28 days was 39% (n = 57). Chronic complex conditions (CCCs), acute renal dysfunction (ARD) and ratio PaO(2)/FiO(2) at day 3 on MV were independently associated with a higher risk of mortality. The odds ratio (OR) for CCCs was 3.06, (CI 95% 1.36-6.84); OR for ARD, 3.38, (CI 95% 1.45-10.33); OR for PaO(2)/FiO(2), 4 (CI 95% 1.57-9.59). The administration of oseltamivir within 24 h after admission had a protective effect: OR 0.2 (CI 95% 0.07-0.54). CONCLUSIONS: In children with ARDS, H1N1 as an etiologic agent confers high mortality, and the presence of CCCs in such patients increases the risk of death.

Unintentional ingestion of 60% hydrogen peroxide by a six-year-old child.

Ingestion of industrial-strength hydrogen peroxide is rare. Fatal outcomes have been reported with solutions of 35%. We report a six-year-old boy who unintentionally ingested an unknown quantity of hydrogen peroxide with a concentration of 60%. Upon admission to our Pediatric Intensive Care Unit he was intubated and received ventilatory assistance for 48h. Upper gastrointestinal endoscopy was performed soon after admission and laparoscopy was performed 24h later. Recovery was satisfactory, and the patient was discharged on day 18 with no evidence of pathological sequelae.