High-frequency percussive ventilation improves oxygenation and ventilation in pediatric patients with acute respiratory failure.

PURPOSE: High-frequency percussive ventilation (HFPV) in pediatrics has been described predominantly in burned patients. We aimed to describe its effectiveness and safety in noninhalational pediatric acute respiratory failure (ARF). METHODS: We conducted an observational study in a tertiary care pediatric intensive care unit on 31 patients with ARF failing conventional ventilation transitioned to HFPV. Demographics, ventilator settings, oxygenation index, oxygen saturation index, oxygen saturation as measured by pulse oximetry/fraction of inspired oxygen (Fio2), and Pao2/Fio2 were recorded before and during HFPV. RESULTS: Initiation of HFPV was associated with improvements in oxygenation index, oxygen saturation index, Pao2/Fio2, and oxygen saturation as measured by pulse oximetry/Fio2 as early as 12 hours (P < .05), which continued through 48 hours after transition. Improved oxygenation occurred without an increase in mean airway pressures. Reductions in Paco2 occurred 6 hours after initiation of HFPV and continued through 48 hours (P < .01). Improved gas exchange was accompanied by reduced peak-inflating pressures at all time intervals after initiation of HPFV (P < .01). Vasopressor scores were similar before and after initiation of HFPV in patients requiring vasoactive support. Twenty-six (83.9%) of 31 patients survived to hospital discharge. CONCLUSIONS: In a heterogeneous population of pediatric ARF failing conventional ventilation, HFPV efficiently improves gas exchange in a lung-protective manner.

Patterns of medication exposures in hospitalized pediatric patients with acute renal failure requiring intermittent or continuous hemodialysis.

OBJECTIVES: Care for the pediatric patient with acute renal failure who requires hemodialysis (including continuous renal replacement therapy) is made more complex, as this intervention may significantly affect drug clearance, potentially altering, to a degree that is largely unknown, the effectiveness and safety of the multiple medications used to manage this complex patient population. This study aims to describe patterns of drug utilization among a large cohort of pediatric patients requiring hemodialysis and to document the easily accessible existing data available for dosing guidance of frequently prescribed medications. STUDY DESIGN: Retrospective cohort using the Pediatric Health Information System database. SETTING: Forty freestanding children's hospitals throughout the United States. PATIENTS: Two thousand seven hundred thirty-eight pediatric patients with acute renal failure treated with hemodialysis from 2007 to 2011. INTERVENTION: A retrospective review of all patients requiring hemodialysis from 2007 to 2011 was conduction using the Pediatric Health Information System Database. MAIN RESULTS: Over 6% of pediatric patients with acute renal failure treated with hemodialysis were exposed to hemodialysis for over 2 weeks. Cumulative exposure to distinct drugs increased substantially with more prolonged courses of hemodialysis. Of the 50 most frequently prescribed medications in the cohort with acute renal failure treated with hemodialysis, 10% have readily available and easily accessible information to guide dosing adjustments with the use of hemodialysis. Furthermore, only 18% of these medications have clear recommendations for dosing in pediatric patients of all age groups with renal failure. CONCLUSIONS: Pediatric patients with acute renal failure managed with hemodialysis are exposed to a broad variety of medications, with a high prevalence of polypharmacy. There is a trend for longer courses of hemodialysis in these patients, which leads to an increase in cumulative drug exposure, complexity of drug interactions, and potential toxicity. For the vast majority of medications that are being used to treat this complex patient population, pediatric dosing guidance is not easily accessible. These findings underscore the need for targeted pharmacologic studies of medications used in the pediatric population managed with hemodialysis.