Measuring Acuity and Pediatric Critical Care Nursing Workload by Using ICU CAMEO III.

BACKGROUND: The Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes (ICU CAMEO III) acuity tool measures patient acuity in terms of the complexity of nursing cognitive workload. OBJECTIVE: To validate the ICU CAMEO III acuity tool in US children's hospitals. METHODS: Using a convenience sample, 9 sites enrolled children admitted to pediatric intensive care units (ICUs). Descriptive statistics were used to summarize patient, nursing, and unit characteristics. Concurrent validity was evaluated by correlating the ICU CAMEO III with the Therapeutic Intervention Scoring System-Children (TISS-C) and the Pediatric Risk of Mortality III (PRISM III). RESULTS: Patients (N = 840) were enrolled from 15 units (7 cardiac and 8 mixed pediatric ICUs). The mean number of ICU beds was 23 (range, 12-34). Among the patients, 512 (61%) were diagnosed with cardiac and 328 (39%) with noncardiac conditions; 463 patients (55.1%) were admitted for medical reasons, and 377 patients (44.9%) were surgical. The ICU CAMEO III median score was 99 (range, 59-163). The ICU CAMEO complexity classification was determined for all 840 patients: 60 (7.1%) with level I complexity; 183 (21.8%) with level II; 201 (23.9%), level III; 267 (31.8%), level IV; and 129 (15.4%), level V. Strong correlation was found between ICU CAMEO III and both TISS-C (ρ = .822, P < .001) and PRISM III (ρ = .607, P < .001) scores, and between the CAMEO complexity classifications and the PRISM III categories (ρ = .575, P = .001). CONCLUSION: The ICU CAMEO III acuity tool and CAMEO complexity classifications are valid measures of patient acuity and nursing cognitive workload compared with PRISM III and TISS-C in academic children's hospitals.

Prevalence of ICU Delirium in Postoperative Pediatric Cardiac Surgery Patients.

OBJECTIVES: The objective of this study was to determine the prevalence of ICU delirium in children less than 18 years old that underwent cardiac surgery within the last 30 days. The secondary aim of the study was to identify risk factors associated with ICU delirium in postoperative pediatric cardiac surgical patients. DESIGN: A 1-day, multicenter point-prevalence study of delirium in pediatric postoperative cardiac surgery patients. SETTING: Twenty-seven pediatric cardiac and general critical care units caring for postoperative pediatric cardiac surgery patients in North America. PATIENTS: All children less than 18 years old hospitalized in the cardiac critical care units at 06:00 on a randomly selected, study day. INTERVENTIONS: Eligible children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the study team in collaboration with the bedside nurse. MEASUREMENT AND MAIN RESULTS: Overall, 181 patients were enrolled and 40% (n = 73) screened positive for delirium. There were no statistically significant differences in patient demographic information, severity of defect or surgical procedure, past medical history, or postoperative day between patients screening positive or negative for delirium. Our bivariate analysis found those patients screening positive had a longer duration of mechanical ventilation (12.8 vs 5.1 d; p = 0.02); required more vasoactive support (55% vs 26%; p = 0.0009); and had a higher number of invasive catheters (4 vs 3 catheters; p = 0.001). Delirium-positive patients received more total opioid exposure (1.80 vs 0.36 mg/kg/d of morphine equivalents; p < 0.001), did not have an ambulation or physical therapy schedule (p = 0.02), had not been out of bed in the previous 24 hours (p < 0.0002), and parents were not at the bedside at time of data collection (p = 0.008). In the mixed-effects logistic regression analysis of modifiable risk factors, the following variables were associated with a positive delirium screen: 1) pain score, per point increase (odds ratio, 1.3; 1.06-1.60); 2) total opioid exposure, per mg/kg/d increase (odds ratio, 1.35; 1.06-1.73); 3) SBS less than 0 (odds ratio, 4.01; 1.21-13.27); 4) pain medication or sedative administered in the previous 4 hours (odds ratio, 3.49; 1.32-9.28); 5) no progressive physical therapy or ambulation schedule in their medical record (odds ratio, 4.40; 1.41-13.68); and 6) parents not at bedside at time of data collection (odds ratio, 2.31; 1.01-5.31). CONCLUSIONS: We found delirium to be a common problem after cardiac surgery with several important modifiable risk factors.

Radiofrequency ablation of pediatric AV nodal reentrant tachycardia during the ice age: a single center experience in the cryoablation era.

BACKGROUND: Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) has proven to be an effective therapy in the pediatric population. However, concerns of inadvertent permanent AV nodal block have resulted in many pediatric programs adopting cryoablation as their primary ablation approach for AVNRT. METHODS: A retrospective analysis of the results of pediatric radiofrequency catheter ablation at a single institution over the most recent 5 years (January 2004 through December 2008) was performed. Acute, intermediate, and long-term success, along with the incidence of AV block, were determined. RESULTS: There were 65 patients with a mean age of 12.1 + or - 5.2 years and weight of 46.5 + or - 17.3 kg who underwent radiofrequency catheter ablation for AVNRT. There was 100% acute success with no recurrences at a mean follow up of 32.5 months. Although two patients had a brief second-degree AV block, there was no permanent AV block of any degree. CONCLUSIONS: The safety and efficacy of radiofrequency catheter ablation for pediatric AVNRT demonstrated in this study support its continued application and should not be abandoned as a method of treatment.

Stent implantation is effective treatment of vascular stenosis in young infants with congenital heart disease: acute implantation and long-term follow-up results.

BACKGROUND: Stents implantation in infants has been shown to be feasible, however, there are no published reports examining long-term outcomes. Concerns exist regarding creation of fixed obstructions secondary to the stent if expansion to larger diameters over time is not possible. METHODS: A retrospective analysis of the earliest consecutive series of infants who underwent stent placement at our institution between October 1995 and December 1999. RESULTS: Implantation of 33 stents were attempted in 27 infants, median age = 10 (25-24) months, wt = 8.1 (3.4-14.5) kg. Stents used were as follows: 16 large, 13 medium, and 4 coronary. Acute implant success was 94%. There were three nonprocedure-related deaths within 30 days of implantation, 1 patient was lost to follow-up and 1 had acute stent thrombosis. The remaining 22 patients (26 stents) form the long-term follow-up study group. Nineteen stents underwent 33 redilations. Following latest redilation, 67.0 (37-113) months postimplantation, minimal luminal diameter increased from 7.0 +/- 1.8 mm immediately following implantation to 8.7 +/- 2.3 mm (P < 0.001). Seven stents were electively removed/ligated during a planned surgery. All 18 remaining in situ stents are patent without significant obstruction 102 (84-116) months following implantation. There was one late death 51 months after stent implantation. The remaining 21 patients are alive and well. CONCLUSIONS: Stent implantation in infants is safe and effective. Serial redilation is possible to keep pace with somatic growth; however, efforts should be made to implant stents with adult diameter potential in children who will not require further cardiac surgery. Implantation of small- and medium-sized stents can provide effective palliation and should be considered in carefully selected infants who will ultimately require future surgery.