Intravenous maintenance fluids revisited.

Intravenous maintenance fluid therapy aims to replace daily urinary and insensible losses for ill children in whom adequate enteric administration of fluids is contraindicated or infeasible. The traditional determination of fluid volumes and composition dates back to Holliday and Segar's seminal article from 1957, which describes the relationship between weight, energy expenditure, and physiologic losses in healthy children. Combined with estimates of daily electrolyte requirements, this information supports the use of the hypotonic maintenance fluids that were widely used in pediatric medicine. However, using hypotonic intravenous fluids in a contemporary hospitalized patient who may have complex physiologic derangements, less caloric expenditure, decreased urinary output, and elevated antidiuretic hormone levels is often not optimal; evidence over the last 2 decades shows that it may lead to an increased incidence of hyponatremia. In this review, we present the evidence for using isotonic rather than hypotonic fluids as intravenous maintenance fluid.

Anticoagulation therapy: indications, monitoring, and complications.

Anticoagulation for thromboembolic disease and bleeding, the main complication of anticoagulation therapy, are uncommon but are potentially life- or limb-threatening conditions that may present in the pediatric emergency department. Thromboembolic disease in children usually occurs as a complication of vascular access, primarily in children with congenital heart disease or cancer. However, complications of anticoagulation therapy used in the treatment of venous thromboembolism, pulmonary embolism, and blocked central venous catheter; arterial thromboembolism, including arterial ischemic stroke, Kawasaki disease, and after cardiac surgery, may warrant a visit to n the pediatric emergency department. Anticoagulation therapy may take the form of unfractionated heparin, low-molecular weight heparin, vitamin K antagonists, acetylsalicylic acid, or thrombolytic therapy. Monitoring anticoagulation therapy in children is very important and follows adult guidelines. Anticoagulant dosing may be adjusted based on activated partial thromboplastin time, anti-factor Xa level, and international normalized ratio.

Does biventricular pacing improve hemodynamics in children undergoing routine congenital heart surgery?

Biventricular (BiV) pacing or cardiac resynchronization therapy (CRT) is an established therapy for heart failure in adults. In children, cardiac dyssynchrony occurs most commonly following repair of congenital heart disease (CHD) where multisite pacing has been shown to improve both hemodynamics and ventricular function. Determining which patient types would specifically benefit has not yet been established. A prospective, repeated measures design was undertaken to evaluate BiV pacing in a cohort of children undergoing biventricular repair for correction of their CHD. Hemodynamics, arterial blood gas, electrocardiographic (ECG), and echocardiographic data were collected. Pacing protocol was undertaken prior to the patient's extubation with 20 min of conventional right ventricular (RV) or BiV pacing, preceded and followed by 10 min of recovery time. Multivariate statistics were used to analyze the data with p values <0.05 considered significant. Twenty-five (14 female) patients underwent surgery at a median (range) age of 5.2 (0.1-37.4) months with no early mortality. The Risk-adjusted classification for Congenital Heart Surgery (RACHS) scores were 2 in 14 patients, 3 in eight patients, and 4 in three patients. None had pre-existing arrhythmias, dyssynchrony, or required pacing pre-operatively. No patient required implantation of a permanent pacemaker post-operatively. The median cardio-pulmonary bypass time was 96 (55-236) min. RV and BiV pacing did not improve cardiac index from baseline (3.23 vs. 3.42 vs. 3.39 L/min/m2; p > 0.05). The QRS duration was not changed with pacing (100 vs. 80 vs. 80 ms; p > 0.05). On echocardiography, the time-to-peak velocity difference between the septal and posterior walls (synchrony) during pacing was similar to baseline and was also not statistically significant. BiV pacing did not improve cardiac output when compared to intrinsic sinus rhythm or RV pacing in this cohort of patients. Our study has shown that BiV pacing is not indicated in children who have undergone routine BiV congenital heart surgery. Further prospective studies are needed to assess the role of multisite pacing in children with ventricular dyssynchrony such as those with single ventricles, those undergoing reoperation or those with high RACHS scores.

Use of methadone for prevention of opioid withdrawal in critically ill children.

BACKGROUND: Opioids are commonly administered to critically ill children for analgesia and sedation, but many patients experience opioid withdrawal upon discontinuation. The authors' institution developed a protocol for using methadone to prevent opioid withdrawal in children who have received morphine by continuous IV infusion for 5 days or longer in the pediatric intensive care unit (PICU). OBJECTIVES: The primary objectives were to determine if opioids were tapered according to the protocol and to determine the conversion ratio for IV morphine to oral methadone that was used. Secondary objectives were to describe the methadone dosage used and the clinical outcomes, to evaluate adjustments to methadone dosing, and to report the incidence of adverse effects. METHODS: A retrospective analysis of charts was conducted for pediatric patients who had received morphine by continuous IV infusion for 5 days or longer followed by methadone in the PICU between May 2008 and August 2009. Validated scoring systems (the Withdrawal Assessment Tool and the State Behavioral Scale) were used to assess symptoms of withdrawal and degree of sedation, respectively. RESULTS: Forty-three patients were included in the study, with median age of 8 months (range 0.25-201 months). For 31 patients (72%), the protocol was not used, and there were no patients for whom the protocol was followed to completion. The median duration of weaning was 10 days (range 0-91 days). The conversion ratio for IV morphine to oral methadone was 1:0.78 for anticipated 5-day weaning and 1:0.98 for anticipated 10-day weaning. During the first 10 days of weaning, 18 patients (42%) experienced withdrawal symptoms. The methadone dose was increased for 11 (26%) of the 43 patients. Patients were sedated for a median of 1 day (range 0-9 days), were comfortable for a median of 6.5 days (range 1-64 days), and were agitated for a median of 2.5 days (range 0-23 days). Naloxone was required for 2 patients. CONCLUSIONS: The institution's methadone protocol was not followed consistently during the study period, and practices for transitioning from morphine by continuous IV infusion to methadone with tapering were also inconsistent. Further studies are needed to determine the optimal conversion ratio for morphine to methadone and the optimal tapering regimen to minimize withdrawal symptoms and adverse events.

Culture, communication and safety: lessons from the airline industry.

BACKGROUND: Communication is a critical component of effective teamwork and both are essential elements in providing high quality of care to patients. Yet, communication is not an innate skill but a process influenced by internal (personal/cultural values) as well as external (professional roles and hierarchies) factors. OBJECTIVE: To provide illustrative cases, themes and tools for improving communication. METHODS: Literature review and consensus opinion based on extensive experience. RESULTS: Professional autonomy should be de-emphasized. Tools such as SBAR and simulation are important in communication and teamwork. CONCLUSION: Tools designed to improve communication and safety in the aviation industry may have applicability to the pediatric intensive care unit.