Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study.

BACKGROUND AND OBJECTIVES: Antimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This study aims to assess a paediatric ASP long-term outcomes. METHODS: A quality improvement study assessed by a interrupted time series analysis was conducted in a paediatric tertiary hospital. QOP expressed as proportion of adequate prescriptions, AMC measured by defined daily dose incidence per 1000 occupied bed days, incidence density of bloodstream infections (BSIs) and its related all-cause crude death rate (CDR) were compared between pre (from January 2013 to December 2015) and post (from January 2016 to December 2019) ASP activities intensification, which included a dedicated paediatric infectious diseases physician to actively perform educational interviews with prescribers. RESULTS: Inappropriate prescribing showed a significant downward shift associated to the intervention with a -51.4% (-61.2% to -41.8%) reduction with respect to the expected values. Overall AMC showed no trend change after the intervention. For neonatology a28.8% (-36.8% to -20.9%) reduction was observed. Overall anti-pseudomonal cephalosporin use showed a -51.2% (-57.0% to -45.4%) reduction. Decreasing trends were observed for carbapenem use, with a quarterly per cent change (QPC) of -2.4% (-4.3% to -0.4%) and BSI-related CDR (QPC=-3.6%; -5.4% to -1.7%) through the study period. Healthcare-associated multi-drug-resistant BSI remained stable (QPC=2.1; -0.6 to 4.9). CONCLUSIONS: Intensification of counselling educational activities within an ASP suggests to improve QOP and to partially reduce AMC in paediatric patients. The decreasing trends in mortality remained unchanged.

Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation.

OBJECTIVES: To compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. METHODOLOGY: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 h. We compared two independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. RESULTS: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean ±â€¯standard deviation of patients were 49 ±â€¯65 months, weight 17 ±â€¯16 kg. Mechanical ventilation medium time was 22 h (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8 ±â€¯10,6 min group A and 137,3 ±â€¯45 min group B (P < 0.001), extubation time after removing sedoanalgesia was of 24 ±â€¯21 min group A and 230 ±â€¯102 min group B (P < 0.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation) P = 0,572. CONCLUSIONS: Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.

Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración / Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation

Objetivos: Comparar, entre 2 regímenes de sedoanalgesia, el tiempo trascurrido desde la retirada de la medicación hasta el despertar y hasta la extubación del paciente. Metodología: Estudio observacional, en pacientes pediátricos que, tras cirugía electiva, precisaron sedoanalgesia y ventilación mecánica durante un periodo máximo de 72 h. Comparamos 2 grupos independientes de pacientes: grupo A, pacientes que recibieron sedoanalgesia con propofol-remifentanilo recogidos de forma prospectiva, y grupo B, pacientes que recibieron midazolam-fentanilo recogidos retrospectivamente mediante la revisión de las historias clínicas y base de datos de la unidad. Las variables estudiadas fueron: edad, peso, sexo, tipo de intervención, escalas de valoración de la sedoanalgesia, dosis totales empleadas, tiempo transcurrido desde la retirada de medicación hasta despertar y extubación, y efectos adversos. Resultados: Se recogió a 82 pacientes, 43 en el grupo A y 39 en el grupo B. La edad (media±desviación estándar) de los pacientes fue de 49±65 meses y 17,3±16kg de peso, con un tiempo de ventilación mecánica promedio de 22 h (3-72). Tras retirar la medicación, el tiempo de despertar fue de 11,8±10,6 min en el grupo A y de 137,3±45 min en el grupo B (p<0,001) y el tiempo de extubación de 24±21 min en el grupo A y 230±102 min en el B (p<0,001). El 10,5% de los pacientes del grupo A presentó algún efecto adverso (7,9% agitación y 2,6% bradicardia) y, del grupo B, un 13% (depresión respiratoria tras extubación), con una p=0,572. (AU)

Objectives: Compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. Methodology: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. Results: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22 hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6 minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572. (AU)

Mechanical ventilation during cardiopulmonary bypass in neonates improves postoperative outcome.

OBJECTIVES: Cardiopulmonary bypass generates a systemic inflammatory response. This inflammatory response is reduced if patients are ventilated during bypass, as evidenced by lower levels of postoperative circulating inflammatory mediators. However, this does not appear to make much clinical difference in adults, at least not consistently, but, to our knowledge, has never been assessed in paediatric cardiac surgery, which is the objective of this study. METHODS: This is a prospective clinical study of 12 consecutive neonates operated for the correction of either transposition of the great arteries ± ventricular septal defect or aortic arch hypoplasia ± ventricular septal defect, who were ventilated during cardiopulmonary bypass. These were compared to 11 neonates with the same malformations, who had undergone the same operations but without being ventilated during bypass (historical control group). RESULTS: One patient from the control group died on the 15th postoperative day due to sepsis and multi-organ failure. Bypass times and cross-clamp times were similar in the 2 groups. Ventilation on bypass was associated with significantly lower postoperative serum concentrations of C-reactive protein, shorter mechanical ventilation and lower vasoactive-inotropic score. Duration of stay on intensive care unit (ICU) showed a tendency to be shorter in patients who were ventilated on bypass, but this did not reach statistical significance. There were no differences between the 2 groups with respect to postoperative mixed venous oxygen saturations and serum concentrations of lactate and troponin I. CONCLUSIONS: Mechanical ventilation during cardiopulmonary bypass in neonates improves postoperative outcome.

[Midazolam/fentanyl vs propofol/remifentanil in immediate postoperative with short-term mechanical ventilation]. / Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración.

OBJECTIVES: Compare between 2sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. METHODOLOGY: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. RESULTS: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572. CONCLUSIONS: Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.