Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014 / Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014

Resumen Objetivo: Describir las frecuencias y características del proceso de Limitación de Tratamiento de So porte Vital (LTSV) en pacientes de la Unidad de Cuidados Intensivos Pediátricos (UCI) entre 2004 2014. Pacientes y Método: Estudio retrospectivo, observacional descriptivo a partir de dos registros de la UCI del Hospital Roberto del Río: 1) ficha clínica individual de seguimiento y 2) ficha de registro de indicadores de calidad incluida LTSV, ambos actualizados diariamente al iniciar la visita clínica. Desde estos registros se analizaron los casos con dilemas bioéticos en los que se propuso LTSV du rante su hospitalización en UCI ("LTSV intra-UCI"). Se menciona la población rechazada de ingresar a UCI ("LTSV pre-UCI") y los fallecidos con LTSV en cama básica. Resultados: De 7.821 ingresos a UCI en el 1,51% (118 pacientes) se establece una LTSV: ONI (Orden de No Innovación) en 78,8% de los casos, retiro de medidas terapéuticas en 14,4% y suspensión de ventilación mecánica en 6,8%. En 23,7% el diagnóstico de base fue neurológico u oncológico, para cada uno. La condición fisiopatológica predominante para una LTSV fue neurológica (39%). El tiempo de estadía en UCI triplica el promedio de estada de los egresos totales de UCI, pero es de amplia variabilidad. Conclusiones: Es factible realizar una LTSV en UCI cuando el equipo incorpora esta perspectiva al trabajo diario junto a la familia. Hay una amplia variabilidad individual en las características del proceso de LTSV, propio del ámbito de la ética clínica.

Abstract Objective: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. Patients and Method: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. Results: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. Conclusion: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

[Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014]. / Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014.

OBJECTIVE: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. PATIENTS AND METHOD: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. RESULTS: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. CONCLUSION: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

Potential effectiveness of copper surfaces in reducing health care-associated infection rates in a pediatric intensive and intermediate care unit: A nonrandomized controlled trial.

BACKGROUND: Studies have consistently shown that copper alloyed surfaces decrease the burden of microorganisms in health care environments. This study assessed whether copper alloy surfaces decreased hospital-associated infections in pediatric intensive and intermediate care units. METHODS: Admitted infants were assigned sequentially to a room furnished with or without a limited number of copper alloyed surfaces. Clinical and exposure to intervention data were collected on a daily basis. To avoid counting infections present prior to admission, patients who stayed in the hospital <72 hours were excluded from analysis. Health care-associated infections (HAIs) were confirmed according to protocol definitions. RESULTS: Clinical outcomes from 515 patients were considered in our analysis: 261 patients from the intervention arm of the study, and 254 from the control arm. Crude analysis showed an HAI rate of 10.6 versus 13.0 per 1,000 patient days for copper- and non-copper-exposed patients, respectively, for a crude relative risk reduction (RRR) of 0.19 (90% confidence interval, 0.46 to -0.22). Conducting clinical trials to assess interventions that may impact HAI rates is very challenging. The results here contribute to our understanding and ability to estimate the effect size that copper alloy surfaces have on HAI acquisition. CONCLUSIONS: Exposure of pediatric patients to copper-surfaced objects in the closed environment of the intensive care unit resulted in decreased HAI rates when compared with noncopper exposure; however, the RRR was not statistically significant. The clinical effect size warrants further consideration of this intervention as a component of a systems-based approach to control HAIs.

Copper surfaces are associated with significantly lower concentrations of bacteria on selected surfaces within a pediatric intensive care unit.

BACKGROUND: Health care-associated infections result in significant patient morbidity and mortality. Although cleaning can remove pathogens present on hospital surfaces, those surfaces may be inadequately cleaned or recontaminated within minutes. Because of copper's inherent and continuous antimicrobial properties, copper surfaces offer a solution to complement cleaning. The objective of this study was to quantitatively assess the bacterial microbial burden coincident with an assessment of the ability of antimicrobial copper to limit the microbial burden associated with 3 surfaces in a pediatric intensive care unit. METHODS: A pragmatic trial was conducted enrolling 1,012 patients from 2 high acuity care units within a 249-bed tertiary care pediatric hospital over 12 months. The microbial burden was determined from 3 frequently encountered surfaces, regardless of room occupancy, twice monthly, from 16 rooms, 8 outfitted normally and 8 outfitted with antimicrobial copper. RESULTS: Copper surfaces were found to be equivalently antimicrobial in pediatric settings to activities reported for adult medical intensive care units. The log10 reduction to the microbial burden from antimicrobial copper surfaced bed rails was 1.996 (99%). Surprisingly, introduction of copper objects to 8 study rooms was found to suppress the microbial burden recovered from objects assessed in control rooms by log10 of 1.863 (73%). CONCLUSION: Copper surfaces warrant serious consideration when contemplating the introduction of no-touch disinfection technologies for reducing burden to limit acquisition of HAIs.

Postmortem studies in the contemporary pediatric intensive care unit.

OBJECTIVES: To describe the implementation of an educational program that achieved high compliance with autopsy requests and consents in a pediatric intensive care unit. To evaluate the concordance between clinical diagnoses and autopsy findings and to identify patient characteristics in which postmortem diagnosis elucidated the primary disease process. DESIGN: Retrospective, observational study. SETTING: A pediatric intensive care unit in a tertiary care teaching hospital. PATIENTS: All pediatric intensive care unit patients with autopsy reports from 2000 to 2005. INTERVENTIONS: An educational program and protocol were initiated in 1995-1996 to raise awareness and formalize the process for autopsy request. From 2000 to 2005, data were collected from medical records and pathology department autopsy reports. Premortem and postmortem diagnoses were compared utilizing the modified Goldman's classification. The associations of Goldman's classification with age of patients and length of stay were explored. MEASUREMENTS AND MAIN RESULTS: After the educational program was instituted, an autopsy rate of >50% was attained compared to 20%-30% in previous years (p < .05). From 2000 to 2005, 139 autopsies were performed. In 111 patients (79.8%), complete concordance of premortem and postmortem diagnoses was found; in 22 cases (16%), there was no concordance and in six cases the postmortem studies failed to explain the mechanism of death. Autopsies provided new and pertinent findings in 47.5% of all studies, with histologic information accounting for 58% of them. A relationship between short length of stay and the presence of autopsy findings elucidating the main disease process was found (p < .05). CONCLUSIONS: It is feasible to produce a sustainable increase in the rate of postmortem studies within an organization. Autopsy results added new information to almost half of the patients, particularly those who died soon after admission. A pediatric intensive care unit strategy to increase and maintain compliance with autopsy requests is an important practice with favorable clinical and educational repercussions.