Neurally adjusted ventilatory assist in children: an observational study.

OBJECTIVES: To assess patient safety and to evaluate operator acceptance to the technology of neurally adjusted ventilatory assist. DESIGN: A within-patient crossover study. SETTING: A ten-bed tertiary care university hospital pediatric intensive care unit. PATIENTS: A total of 21 mechanically ventilated infants and children aged 2 days to 15 yrs suffering from a variety of disorders. The majority of patients were treated after cardiac surgery. INTERVENTIONS: In patients with pressure-support ventilation, a nasogastric neurally adjusted ventilatory assist catheter was positioned to detect the diaphragm electrical impulse. Initiation and termination of ventilatory support for each breath could then be regulated either through conventional volume or pressure changes or through changes in the detected diaphragm electrical impulse signal. Ventilation was started as pressure-support ventilation for 30 mins, changed to neurally adjusted ventilatory assist for 30 mins, switched back to pressure-support ventilation for 30 mins and then neurally adjusted ventilatory assist until an end-point criterion was reached. MEASUREMENTS AND MAIN RESULTS: There were no serious adverse events during the study and all patients were circulatory and respiratory stable. The neurally adjusted ventilatory assist catheter was easy to place. The treatment time with neurally adjusted ventilatory assist ranged from 1 to 8 hrs (median = 2.5 hrs). During neurally adjusted ventilatory assist, the peak airway pressures decreased as compared with pressure-support mode but the mean airway pressures were not significantly changed.The respiratory rates increased during neurally adjusted ventilatory assist. The neural trigger on was first in 68% (median) whereas the neural trigger off was first in 88% (median) as compared with the pneumatic trigger on and off. Eight of the patients could be extubated in close connection to the termination of the neurally adjusted ventilatory assist treatment. CONCLUSIONS: We feel that neurally adjusted ventilatory assist would be safe and potentially efficacious to ventilate infants and children. It has the potential for improved patient-ventilator synchrony, decreasing airway pressures, and it might lead to earlier extubation.

Survival after PICU admission: The impact of multiple admissions and complex chronic conditions.

OBJECTIVE: Factors predicting survival over time after pediatric intensive care unit (PICU) admissions are not fully understood. The primary aim of the current study was to investigate whether multiple admissions (MADM) compared to single PICU admissions (SADM) were associated with poor survival over time after being admitted to PICU facilities. Our secondary aim was to investigate if the presence of a complex chronic condition (CCC) would further impair prognosis. DESIGN: A closed cohort of all children up to 16 years of age admitted to the three PICUs in Sweden between 2008 and 2010 was prospectively collected and followed until 2012, providing survival data for at least one but up to four years of follow-up. SETTING: Three Swedish tertiary referral centers for pediatric intensive care and extracorporeal membrane oxygenation (ECMO) care were used. PATIENTS: In total, 3,688 Swedish children with 5,019 PICU admissions were included. INTERVENTIONS: No interventions were conducted. MEASUREMENTS: An extensive data set was recorded, including up to four-year survival information following first PICU admission. The patients were assigned to seven admission diagnostic groups, which were then divided into SADM or MADM groups. The difference in survival over time and mortality rates (MR) and mortality rate ratios (MRR) were calculated. SADM and MADM groups with and without an existing CCC were formed. The difference in survival over time between groups was calculated. MAIN RESULTS: A highly significant difference in survival over time was noted between SADM and MADM patients (p<0.0001), which was intensified by the presence of a CCC. MADM patients with a CCC had the worst outcome, while SADM patients without a CCC had the best outcome. MADM patients with no CCC demonstrated decreased survival over time compared to SADM patients with a CCC. Survival over time was statistically worsened for patients with MADM compared to SADM for the following admission diagnostic groups: Cardiovascular, Gastrointestinal/Renal, Respiratory, Neurological, and Miscellaneous. The mortality rate (deaths/patient year of follow-up) during the time of follow-up was 0.023 for SADM and 0.062 for MADM patients. The mortality rate ratio (MRR) between these groups was 2.69. CONCLUSION: Compared to single admissions, multiple admissions to PICU were associated with a significant decrease in survival over time in some but not all diagnostic groups. Regarding our secondary aim, we found that when the presence of a CCC is factored into the survival analysis, survival over time is further impaired.

Airway oximetry improves monitoring of dopamine effects in pediatric cardiac patients.

OBJECTIVE: Simple, preferably noninvasive measurements of cardiac output are useful in pediatric patients receiving inotropic support. Oxygen saturation in pulmonary artery (Svo(2)) gives information about oxygen delivery and demand. Many inotropic drugs influence oxygen consumption. When effects on Svo(2) are studied, after a change in inotropic drug dosage, a change in oxygen consumption needs to be considered to accurately estimate the change in cardiac output. The aim of this investigation was to study whether information on inspired to end-tidal oxygen concentration difference (Fi-eto(2)) in addition to Svo(2) would improve estimation of changes in cardiac output. DESIGN: Prospective observational study of Fi-eto(2), Svo(2), and oxygen saturation from central vein (Scvco(2)) for measurements of circulatory and metabolic effects of changes in dopamine dosage. SETTING: Intensive care unit in a children's hospital. PATIENTS: Twenty patients (age 4 days to 98 months) were studied after cardiac surgery. INTERVENTIONS: Dopamine was administered in doses of 5, 10, 0, and 5 microg x kg(-1) x min(-1), 20 mins on each level. MEASUREMENTS AND MAIN RESULTS: Cardiac output, measured with thermodilution, oxygen saturation from systemic artery (Sao(2)), Svo(2), and Scvco(2) were measured at 15 mins on each dopamine dose. Oxygen consumption was calculated by using the Fick equation. Fi-eto(2) was measured continuously with a paramagnetic oxygen analyzer. Both cardiac output and oxygen consumption were affected by changes in dopamine dosage. Relative changes in cardiac output were poorly correlated to the change in 1/Sa-vo(2) (r(2) =.54). Using Fi-eto(2) improved correlation between changes in cardiac output and changes in Fi-eto(2)/Sa-vo(2) (r(2) =.72). When Svo(2) was replaced by Scvco(2), the correlation between changes in cardiac output and changes in Fi-eto(2)/Sa-cvco(2) was only slightly altered (r(2) =.69). CONCLUSIONS: Dopamine affects oxygen consumption as well as cardiac output. The accuracy of Svo(2)-based estimations of changes in cardiac output after dopamine is enhanced if changes in Fi-eto(2) are also considered. The more easily achievable Scvco(2) gave equivalent information as Svo(2).

[Patient-controlled analgesia in the treatment of postoperative pain in children and adolescents]. / Vaiku ir paaugliu pooperacinio skausmo gydymas skiriant paciento kontroliuojama analgezija.

OBJECTIVE: We aimed to evaluate the efficacy, morphine requirements and side effects in patients managed with patient-controlled analgesia postoperatively. METHODS: Eighty-seven patients, 7 to 22 (median 14) years of age, after orthopedic, abdominal or thoracic surgery, were studied retrospectively. All patients had a preset standard continuous morphine infusion of 10 micrograms/kg/h, 20 micrograms/kg bolus dose, 8 min lock-out time and 100 micrograms/kg/h maximal dose. All patients were additionally treated with non-steroidal anti-inflammatory drugs. Respiratory rate, pain intensity, morphine requirements and nausea/vomiting were evaluated every 3 hours. Pain was assessed using 6-point scale (1-no pain, 6-the worst pain). RESULTS: Median time for pain management was 51 h. Median (range) used dose of morphine was 19.9 (4.9-75.2) micrograms/kg/h. Sixty-one percent of the patients had a mean pain score of 1 or 2, 26%--3, 13%--4 or 5. Nausea/vomiting occurred in 78% of cases. Respiratory rate less than 10 breaths per min was observed in 5.7% of patients. No patient required opioid antagonist to treat respiratory depression. CONCLUSIONS: In the majority of patients patient-controlled analgesia was effective and used doses of morphine were low. Though nausea/vomiting was the most common side effect, decreased respiratory rate was observed in some patients. Regular patient evaluation for vital signs and side effects is recommended.