Impacto de un programa de reducción de infección asociada a catéter en 9 unidades de cuidado intensivo pediátrico en Argentina / Impact of a program aimed at reducing catheter-related infections implemented in nine pediatric intensive care units in Argentina

Las infecciones asociadas a catéteres (IAC) conllevan elevada morbimortalidad, con el aumento del uso de recursos hospitalarios. Objetivo. Describir los resultados de un programa para disminuir la tasa de IAC en las unidades de cuidados intensivos pediátricos de Argentina. Población y métodos. Estudio colaborativo multicéntrico, clínico-epidemiológico, cuasi experimental, de intervención antes y después. Se incluyen niños con catéter venoso central internados en 9 unidades de cuidados intensivos pediátricos de la Ciudad Autónoma de Buenos Aires, conurbano y otras provincias desde junio de 2011 a abril de 2012. Se implementó un paquete de medidas basado en la educación del personal de salud para inserción de catéteres e higiene de manos y uso de listas de verificación con monitoreo de las medidas implementadas. Se compararon el número y la tasa anual de IAC y la tasa de uso de catéter venoso central previa y posterior a la implementación del programa (Stata 8.0). Resultados. El total de IAC preintervención fue de 117 vs. 74 en el pos. La tasa previa fue 8,6/1000 días de uso y la posintervención, de 5,8/1000 días, RR 0,82 (IC 95%: 0,68-0,98), p= 0,015. La tasa de uso de catéter venoso central se redujo de 54% a 49%, diferencia no significativa. Conclusiones. El programa logró un descenso significativo de las tasas de IAC. A partir de él, se implementó la vigilancia de las IAC en todas las unidades de cuidados intensivos pediátricos participantes. La educación y la vigilancia continua son necesarias para mantener y mejorar los resultados alcanzados.

Catheter-related infections (CRIs) cause a high level of morbidity and mortality with the increasing use of hospital resources. Objective. To describe the outcomes of a program implemented to reduce the rate of CRIs in pediatric intensive care units in Argentina. Population and methods. Collaborative, multi center, clinical-epidemiological, quasiexperimental, before-and-after intervention study. Children who had a central venous catheter during hospitalization in 9 pediatric intensive care units in the Autonomous City of Buenos Aires, Greater Buenos Aires, and other provinces between June 2011 and April 2012 were included. A bundle of measures based on health care staff training on catheter insertion, hand hygiene, and checklists was put into practice and implemented measures were monitored. The number and annual rate of CRIs and the rate of central venous catheter use before and after the program implementation were compared (Stata 8.0). Results. The total number of CRIs was 117 and 74 before and after the intervention, respectively. The rate of CRIs was 8.6/1000 days of central venous catheter use and 5.8/1000 days before and after the intervention, respectively; RR: 0.82 (95% confidence interval: 0.68-0.98), p= 0.015. The rate of central venous catheter use decreased from 54% to 49%, a non-significant difference. Conclusions. The program achieved a significant reduction in CRI rates. Based on the program, CRI surveillance was implemented in all participating pediatric intensive care units. Training and continuous surveillance are necessary to maintain and improve the outcomes accomplished with the program.

Impact of a program aimed at reducing catheter-related infections implemented in nine pediatric intensive care units in Argentina. / Impacto de un programa de reducción de infección asociada a catéter en 9 unidades de cuidado intensivo pediátrico en Argentina.

INTRODUCTION: Catheter-related infections (CRIs) cause a high level of morbidity and mortality with the increasing use of hospital resources. OBJECTIVE: To describe the outcomes of a program implemented to reduce the rate of CRIs in pediatric intensive care units in Argentina. POPULATION AND METHODS: Collaborative, multi center, clinical-epidemiological, quasiexperimental, before-and-after intervention study. Children who had a central venous catheter during hospitalization in 9 pediatric intensive care units in the Autonomous City of Buenos Aires, Greater Buenos Aires, and other provinces between June 2011 and April 2012 were included. A bundle of measures based on health care staff training on catheter insertion, hand hygiene, and checklists was put into practice and implemented measures were monitored. The number and annual rate of CRIs and the rate of central venous catheter use before and after the program implementation were compared (Stata 8.0). RESULTS: The total number of CRIs was 117 and 74 before and after the intervention, respectively. The rate of CRIs was 8.6/1000 days of central venous catheter use and 5.8/1000 days before and after the intervention, respectively; RR: 0.82 (95% confidence interval: 0.68-0.98), p= 0.015. The rate of central venous catheter use decreased from 54% to 49%, a non-significant difference. CONCLUSIONS: The program achieved a significant reduction in CRI rates. Based on the program, CRI surveillance was implemented in all participating pediatric intensive care units. Training and continuous surveillance are necessary to maintain and improve the outcomes accomplished with the program.

INTRODUCCIÓN: Las infecciones asociadas a catéteres (IAC) conllevan elevada morbimortalidad, con el aumento del uso de recursos hospitalarios. OBJETIVO: Describir los resultados de un programa para disminuir la tasa de IAC en las unidades de cuidados intensivos pediátricos de Argentina. POBLACIÓN Y MÉTODOS: Estudio colaborativo multicéntrico, clínico-epidemiológico, cuasi experimental, de intervención antes y después. Se incluyen niños con catéter venoso central internados en 9 unidades de cuidados intensivos pediátricos de la Ciudad Autónoma de Buenos Aires, conurbano y otras provincias desde junio de 2011 a abril de 2012. Se implementó un paquete de medidas basado en la educación del personal de salud para inserción de catéteres e higiene de manos y uso de listas de verificación con monitoreo de las medidas implementadas. Se compararon el número y la tasa anual de IAC y la tasa de uso de catéter venoso central previa y posterior a la implementación del programa (Stata 8.0). RESULTADOS: El total de IAC preintervención fue de 117 vs. 74 en el pos. La tasa previa fue 8,6/1000 días de uso y la posintervención, de 5,8/1000 días, RR 0,82 (IC 95%: 0,68-0,98), p= 0,015. La tasa de uso de catéter venoso central se redujo de 54% a 49%, diferencia no significativa. CONCLUSIONES: El programa logró un descenso significativo de las tasas de IAC. A partir de él, se implementó la vigilancia de las IAC en todas las unidades de cuidados intensivos pediátricos participantes. La educación y la vigilancia continua son necesarias para mantener y mejorar los resultados alcanzados.

[Severe pertussis, progression and exchange transfusion as an alternative treatment. Case reports]. / Coqueluche grave, evolución y exanguinotransfusión como tratamiento alternativo. Serie de casos.

Pertussis is a contagious disease that may develop a serious clinical picture by hypoxemia and pulmonary hypertension refractory to treatment. The syndrome of hyperviscosity and arteriolar thrombosis is responsible for the cardiocirculatory collapse. Our objective is to describe the evolution of a series of patients with severe pertussis, some of whom received exchange transfusion (ET) as an alternative treatment. We analyzed 41 patients' clinical charts with diagnosis of pertussis treated in the Pediatric Intensive Care Units during the 2003-2011 period. The mean age was 2.38 months. In the 90.2% of cases, the cause of admission to PICU was respiratory failure; 75% required mechanical respiratory support and 39% developed pulmonary hypertension. The overall mortality was 41.4%. Nine patients were treated by ET, 5 died. Conclusion. Severe pertussis is associated with high mortality. ET reduced the mass of circulating leukocytes in 53.5%; ET could be an alternative to conventional treatment, although controlled studies are required to assert it.

[Non invasive mechanical ventilation in Pediatric Intensive Care, four years of clinical practice]. / Ventilación no invasiva en cuidado Intensivo Pediátrico, cuatro años de experiencia.

UNLABELLED: In the last years, different studies have shown the effectiveness of noninvasive ventilation (NIV) in reducing rate of intubation in chronic and acute respiratory failure, with the direct consequence of lower morbidity and mortality associated with artificial airway, and reduction of days of hospitalization in ICU. OBJECTIVE: To describe our clinical experience in the use of NIV in the pediatric intensive care unit (PICU) and to analyze the characteristics associated with the success of this technique. DESIGN: Retrospective, descriptive and observational study. POPULATION AND METHODS: We reviewed the medical records of all patients treated with NIV between 2006 and 2010. We divided the patients in three groups, according to the clinical setting of application: elective NIV (group 1), rescue NIV (group 2) and preventive NIV (group 3). For each group we collected age, severity (score PIM 2), day of NIV and evolution. We considered failure of NIV if the patient needed intubation (group 1) or reintubation (groups 2 and 3) in the first 72 hours after the application of NIV. RESULTS: During the period of study, 313 children used NIV, some of them in more than one occasion (332 total events): 154 in group 1, 60 in group 2 and 118 in group 3. NIV was applied successfully in 52%, 63% and 77% of the patients in each group, respectively. In group 1, the success of NIV was related with less severity and in all the cases, patients who failed NIV had more days of admission in ICU and worse evolution. CONCLUSIONS: There is an increase in the use of NIV and this technique avoided invasive mechanical ventilation in a high rate of children. The preventive use of NIV demands more studies to define the clinical applications in this setting.

Ventilación no invasiva en cuidado intensivo pediátrico, cuatro años de experiencia / Non invasive mechanical ventilation in pediatric Intensive care four years of clinical practice

Diferentes estudios demostraron la efectividad de la ventilación no invasiva (VNI) para reducir la tasa de intubación en insuficiencia respiratoria aguda y crónica, disminuyendo la orbimortalidadpor la vía aérea artificial y los días de internación en cuidados intensivos.Objetivo. Describir la experiencia en la aplicación de VNI en una unidad de cuidados intensivos pediátricos y analizar las características asociadas al éxito del procedimiento.Diseño. Descriptivo, observacional y retrospectivo. Población y método. Se revisaron las historias clínicas de pacientes que ingresaron a VNI entre 2006 y 2010. Se establecieron 3 grupos, según el contexto clínico de aplicación: VNI electiva (1); VNI de rescate (2); VNI preventiva (3). Para cada grupo se recolectaron edad, gravedad (puntaje PIM 2), días de VNI y evolución. Se consideró fracaso de VNI a la necesidad de intubación (grupo 1) o de reintubación (grupo 2 y 3) en las 72 h posteriores a la aplicación de VNI. Resultados . Ingresaron a VNI 313 niños en quienes se utilizó VNI en 332 ocasiones: 154 correspondieron al grupo electivo, 60 al de rescate y 118al preventivo; la tasa de éxitos fue del 52 por ciento, 63 por ciento y 77 por ciento respectivamente; en el grupo 1 el éxito se asoció a menor gravedad de los niños y en todos los casos los pacientes que fracasaron tuvieron mayor tiempo de internación y peor evolución.Conclusión. La VNI evitó el ingreso a ventilación mecánica invasiva en un alto porcentaje de niños. Su uso preventivo requiere aún estudios para definir las indicaciones de su aplicación.

In the last years, different studies have shown the effectiveness of noninvasive ventilation (NIV) in reducing rate of intubation in chronic and acute respiratory failure, with the direct consequence of lower morbidity and mortality associated with artificial airway, and reduction of days of hospitalization in ICU. Objective. To describe our clinical experience in the use of NIV in the pediatric intensive care unit (PICU) and to analyze the characteristics associated with the success of this technique. Design. Retrospective, descriptive and observational study. Population and methods. We reviewed the medical records of all patients treated with NIV between 2006 and 2010. We divided the patients in three groups, according to the clinical setting of application: elective NIV (group 1), rescue NIV (group 2) and preventive NIV (group 3). For each group we collected age, severity (score PIM 2), day of NIV and evolution. We considered failure of NIV if the patient needed intubation (group1) or reintubation (groups 2 and 3) in the first 72 hours after the application of NIV. Results. During the period of study, 313 children used NIV, some of them in more than one occasion (332 total events): 154 in group 1, 60 in group 2 and 118 in group 3. NIV was applied successfully in 52%, 63% and 77% of the patients in each group, respectively. In group 1, the success of NIV was related with less severity and in all the cases, patients who failed NIV had more days of admission in ICU and worse evolution. Conclusions. There is an increase in the use of NIV and this technique avoided invasive mechanical ventilation in a high rate of children. The preventive use of NIV demands more studies to define the clinical applications in this setting.

Ventilación no invasiva en cuidado intensivo pediátrico, cuatro años de experiencia / Non invasive mechanical ventilation in pediatric Intensive care four years of clinical practice

Diferentes estudios demostraron la efectividad de la ventilación no invasiva (VNI) para reducir la tasa de intubación en insuficiencia respiratoria aguda y crónica, disminuyendo la orbimortalidadpor la vía aérea artificial y los días de internación en cuidados intensivos.Objetivo. Describir la experiencia en la aplicación de VNI en una unidad de cuidados intensivos pediátricos y analizar las características asociadas al éxito del procedimiento.Diseño. Descriptivo, observacional y retrospectivo. Población y método. Se revisaron las historias clínicas de pacientes que ingresaron a VNI entre 2006 y 2010. Se establecieron 3 grupos, según el contexto clínico de aplicación: VNI electiva (1); VNI de rescate (2); VNI preventiva (3). Para cada grupo se recolectaron edad, gravedad (puntaje PIM 2), días de VNI y evolución. Se consideró fracaso de VNI a la necesidad de intubación (grupo 1) o de reintubación (grupo 2 y 3) en las 72 h posteriores a la aplicación de VNI. Resultados . Ingresaron a VNI 313 niños en quienes se utilizó VNI en 332 ocasiones: 154 correspondieron al grupo electivo, 60 al de rescate y 118al preventivo; la tasa de éxitos fue del 52 por ciento, 63 por ciento y 77 por ciento respectivamente; en el grupo 1 el éxito se asoció a menor gravedad de los niños y en todos los casos los pacientes que fracasaron tuvieron mayor tiempo de internación y peor evolución.Conclusión. La VNI evitó el ingreso a ventilación mecánica invasiva en un alto porcentaje de niños. Su uso preventivo requiere aún estudios para definir las indicaciones de su aplicación.(AU)

In the last years, different studies have shown the effectiveness of noninvasive ventilation (NIV) in reducing rate of intubation in chronic and acute respiratory failure, with the direct consequence of lower morbidity and mortality associated with artificial airway, and reduction of days of hospitalization in ICU. Objective. To describe our clinical experience in the use of NIV in the pediatric intensive care unit (PICU) and to analyze the characteristics associated with the success of this technique. Design. Retrospective, descriptive and observational study. Population and methods. We reviewed the medical records of all patients treated with NIV between 2006 and 2010. We divided the patients in three groups, according to the clinical setting of application: elective NIV (group 1), rescue NIV (group 2) and preventive NIV (group 3). For each group we collected age, severity (score PIM 2), day of NIV and evolution. We considered failure of NIV if the patient needed intubation (group1) or reintubation (groups 2 and 3) in the first 72 hours after the application of NIV. Results. During the period of study, 313 children used NIV, some of them in more than one occasion (332 total events): 154 in group 1, 60 in group 2 and 118 in group 3. NIV was applied successfully in 52%, 63% and 77% of the patients in each group, respectively. In group 1, the success of NIV was related with less severity and in all the cases, patients who failed NIV had more days of admission in ICU and worse evolution. Conclusions. There is an increase in the use of NIV and this technique avoided invasive mechanical ventilation in a high rate of children. The preventive use of NIV demands more studies to define the clinical applications in this setting.(AU)