摘要:

ObjectiveTo assess the 2-yr costs of extremely low birthweight infants’ (ELBWIs; birthweight, <1000 g) care in relation to birthweight, outcome, and the costs of normal birthweight infants.DesignCost data were obtained from care-giving hospitals and by a parental questionnaire. Outcome data from the perinatal and neonatal periods and from the first 2 yrs for both ELBWIs and control infants had been prospectively collected to a national ELBWI register.PatientsWe studied 71 ELBWIs and 60 normal birthweight controls born in Helsinki University Hospital in 1996–1997.MeasurementsCollected data comprised costs resulting from care of ELBWIs and normal birthweight control infants and included hospital, outpatient care, medication, rehabilitation, auxiliary means, and travel costs; ancillary costs from daily care; parent’s accommodation during hospitalization periods; and loss of earnings during the infant’s first 2 yrs.Main ResultsThe average total 2-yr healthcare cost was 104,635 Euros for surviving ELBWIs and 3,135 Euros for control infants. In ELBWIs, initial hospital costs alone accounted for 64% of total costs; the costs during the first and second postdischarge years accounted for 20% and 13%, respectively. The mean hospital cost of nonsurviving ELBWIs was 19,950 Euros. A normally developed ELBWI had costs 25-fold, a mildly disabled ELBWI had costs 33-fold, and a severely disabled ELBWI had costs 68-fold those of control infants. Birthweight correlated negatively with intensive care costs but did not correlate with costs after initial discharge.ConclusionTotal costs of ELBWIs decreased over time up to the age of 2 yrs, but even in normally developed ELBWIs, costs remained higher than those of normal birthweight infants. Low birthweight seemed to be related to increased initial hospital costs but not to annual costs after the first discharge.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveDescribe modes of death and factors involved in decision-making together with life support limitation (LSL) procedures.DesignProspective, descriptive, longitudinal, and noninterventional study.SettingSixteen pediatric intensive care units in Argentina.PatientsEvery patient who died during a 1-yr period was included.Measurements and Main ResultsAge, sex, length of stay (LOS), primary and admission diagnosis, underlying chronic disease (CD), postoperative condition (PO). Deaths were classified in four groups: a) failed cardiopulmonary resuscitation (CPR); b) do-not-resuscitate (DNR) status; c) withholding or withdrawing life-sustaining treatment (WH/WD); and d) brain death (BD). Justifications were classified as a) imminent death; b) poor long-term prognosis; c) poor quality of life; and d) family request. Data were collected from medical records and interviews with the attending physicians. Descriptive statistics were performed. Differences among groups were analyzed through contingency tables and analysis of variance when required. Relative risks and confidence intervals of variables potentially related to LSL were analyzed, and logistic regression was performed. There were 6358 admissions and 457 deaths. CPR was performed in 52%, DNR in 16%, WH/WD in 20%, and BD in 11% of dead patients. BD patients were older, LOS and CD prevalence were higher in the WH/WD group. Inotropic drugs were the most frequently limited treatment in 110 patients (55%), CPR in 72 (35.6%), and mechanical ventilation in 63 (31%). Imminent death was the most frequently reported justification for LSL. CD and more staff were associated with a higher probability of LSL.ConclusionsMost of the patients in Argentina underwent CPR before their death. We have a high proportion of patients with CD (65%) and low BD diagnosis. PO condition decreased LSL probability in chronically ill patients. Do-not-resuscitate orders and withholding new treatments were the most common LSL. Active withdrawal was exceptional. The Ethics Committee was consulted in 5% of the LSL population.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveEvaluation of elevated cerebrospinal fluid levels of glutamate in children with bacterial meningitis as a predictor of seizures or other adverse outcomes.DesignProspective cohort study with controls.SettingA 36-bed pediatric intensive care unit and primary pediatric referral center.PatientsFrom 1999 to 2001, a total of 55 patients, between the ages of 0 and 18 yrs, with lumbar punctures performed for suspected meningitis.Measurements and Main ResultsA total of 23 patients had bacterial meningitis confirmed by cerebrospinal fluid/blood culture and elevated cerebrospinal fluid white blood cell counts, and 32 patients, who tested negative, were included as controls. The median age for the patients with meningitis was 1.0 yr (range, 0.0–15.2 yrs), and in the culture-negative group (control group), the median age was 0.3 yrs (range, 0.0–17.0 yrs). The average cerebrospinal fluid white blood cell count was 2707 ± 3897 in the group with bacterial infection, whereas in the control group, the average was 148 ± 259 (p< .01). Patients with bacterial meningitis had a mean cerebrospinal fluid glutamate level of 60.5 ± 88.4 mol/L, whereas the mean cerebrospinal fluid glutamate level in the control group was 4.9 ± 11.0 mol/L (p< .01). However, only 10 of 23 children with bacterial meningitis had a second lumbar puncture performed during the study. There was no correlation between the cerebrospinal fluid white blood cell count and cerebrospinal fluid glutamate levels in either the study or control patients. None of the control patients developed seizures or neurologic deficits, despite some patients having elevated glutamate levels. However, four patients with bacterial meningitis developed seizures after admission to the hospital, and ten were discharged with at least some neurologic sequelae attributable to their infection. Two out of the three who developed seizures and had a repeat lumbar puncture demonstrated persistent elevation of cerebrospinal fluid glutamate levels. In addition, 70% of patients (7 of 10) withStreptococcus pneumoniaemeningitis developed neurologic complications (p= .04).ConclusionsBacterial meningitis in children causes an increase in cerebrospinal fluid glutamate that in many cases persists over time. However, in this limited study, neither higher nor persistent elevation of cerebrospinal fluid glutamate levels is predictive of which patients might develop seizures or other apparent immediate adverse outcomes after invasive infection. The responsible organism seems to have far more significance in predicting the development of adverse sequelae.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether critically ill children are hypermetabolic and to calculate whether predictive equations are appropriate for critically ill children.DesignProspective, clinical study.SettingPediatric intensive care unit.PatientsA total of 57 children (39 boys) aged 9 months to 15.8 yrs.InterventionsNone.Measurements and Main ResultsThe median resting energy expenditure measurement measured by indirect calorimetry was 37.2 (range, 11.9–66.6) kcal·kg−1·day−1. This was significantly lower than would be predicted using either the Schofield (42.7 [26.9–65.4] kcal·kg−1·day−1) or Fleisch equations (42.8 [20.9–66.2] kcal·kg−1·day−1,p< .001) but significantly higher than the White equation developed specifically for pediatric intensive care units (26.2 [8.5–70.1] kcal·kg−1·day−1,p< .0001). Methods comparison analysis showed the limits of agreement were −484 to 300, −461 to 319, and −3.2 to 854 kcal/day, respectively. Multivariate analysis indicated the following factors contribute to hypometabolism and hypermetabolism: age (p= .006), sex (p= .034), time spent in the pediatric intensive care unit (p= .001), diagnosis (p= .015), weight (p= .009), temperature (p= .04), continuous infusion for sedation (p= .04), and neuromuscular blockade (p= .03).ConclusionsChildren do not become hypermetabolic during critical illness. These data suggest that agreement between resting energy expenditure and the predictive equations are so broad that they are inappropriate for use in critically ill children.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveDelineation of multiple organ dysfunction syndrome (MODS) is important because of its frequent occurrence in the pediatric intensive care unit and its association with high mortality. However, studies in children are scarce, all have been done in developed countries, and, unlike adult studies, some showed that sepsis is not related to mortality. The aim of this study was to learn about the epidemiology of MODS in our pediatric intensive care unit and to observe if sepsis is associated with mortality.DesignProspective, observational study.SettingA 16-bed pediatric intensive care unit.PatientsA total of 269 patients admitted to the pediatric intensive care unit during the study period from August 1996 to January 1997.InterventionsNone.Measurements and Main ResultsThere were 276 admissions (269 patients) during the study period. A total of 156 of them (56.5%) had MODS at some time during their pediatric intensive care unit stay, and 132 (84.6%) of the children had it at the time of admission. There were 71 deaths during the study period, and 65 of them (91.5%) had MODS. The organs less frequently involved were gastrointestinal and hepatic. In children with MODS, 87 had sepsis, and mortality in this group (51.7%) was greater than in those who did not present with sepsis (28.9%,p< .001). A Pediatric Risk of Mortality score of ≥15 and the presence of sepsis were associated with an increase in mortality risk (odds ratio, 2.8; 95% confidence interval, 1.36–5.75; and odds ratio, 2.33; 95% confidence interval, 1.18–4.59; respectively).ConclusionsMODS in children usually occurs early, and sepsis increases mortality. Hepatic and gastrointestinal failures are infrequent, and as has been suggested, they could be excluded from the majority of MODS diagnoses.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that prone positioning of patients with acute respiratory distress syndrome results in significant cephalad movement of their endotracheal tubes (ETT).DesignA retrospective review of chest radiographs and patient information.SettingPediatric intensive care unit of a children’s hospital.Measurements and Main ResultsPatients with acute respiratory distress syndrome had digital chest radiographs performed before and immediately after prone positioning as per our routine practice. Based on measurements of the length of the thoracic trachea and the length of the thoracic segment of the ETT, the movement of the ETT subsequent to prone positioning was calculated. Fifteen pairs of radiographs of 14 consecutive patients were evaluated. There were seven girls and seven boys, with ages ranging from 2 months to 18 yrs. All patients had a cephalad movement of their ETT ranging from 10% to 57% of their thoracic tracheal length (p< .001) associated with prone positioning. The mean amplitude of this movement was 34% ± 16%, indicating that if the tip of the ETT is not deeper than one third of the thoracic tracheal length before prone positioning, it might slide into the cervical trachea as a result of this procedure.ConclusionsProne positioning results in cephalad movement of ETT within the trachea. The tip of the ETT should be deeper than one third of the total length of the thoracic trachea before prone positioning to prevent it from moving into the cervical trachea. When prone positioning is done with an ETT originally not deeper than one third of the thoracic trachea, obtaining a chest radiograph immediately after prone positioning is important to determine whether the ETT remained safely situated in the trachea.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesTo investigate the specific characteristics of serum procalcitonin in children with severe infection, to identify relevant factors influencing procalcitonin increase, to assess its prognostic value, and to compare it with C-reactive protein and neutrophil countDesignA prospective observational study and 48 hrs of follow-up of a cohort of cases.SettingA pediatric intensive care unit within a children’s university hospital in collaboration with a laboratory mainly involved in research in pediatric clinical immunologyPatientsA total of 80 children (median age, 3.1 yrs; range, 1 month to 16 yrs) admitted to a pediatric intensive care unit by suspicion of sepsis.InterventionsAll patients were treated according to a protocol using antibiotics, fluid resuscitation, inotropic drugs, and mechanical ventilation when they presented with shock or respiratory failure.Measurements and Main ResultsSerum procalcitonin and C-reactive protein were measured at admission in all patients and, when possible, repeated 6, 12, 24, and 48 hrs later. In most cases, serum procalcitonin was already very high at onset (range, 1.0–722 ng/mL), and it did not increase significantly afterward. Contrary to C-reactive protein, serum procalcitonin did not vary according to the age of patients. The increase of procalcitonin was higher in patients with shock or multiple organ dysfunction syndrome, having a high severity score (Pediatric Risk of Mortality) or in patients who later died.ConclusionsSerum procalcitonin levels show a rapid increase in children with sepsis, even in infants <12 month old, and they have a better prognostic value than C-reactive protein or neutrophil count.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo introduce to the pediatric critical care medicine community a new program in pediatric critical care medicine at the National Institutes of Health.Data SourceSummary of literature review and conference proceedings.Data SynthesisAt the National Institute of Child Health and Human Development (NICHD), a new program in pediatric critical care and rehabilitation research has been established in the National Center for Medical Rehabilitation Research. The program is directed by a pediatric intensivist and is focused on developing research directed toward improving long-term outcomes in pediatric critical care and on incorporating pediatric rehabilitation medicine as a partner in this goal. To provide strategic direction for the new program, the NICHD sponsored a planning conference May 3–4, 2002, at the NICHD in Bethesda, MD. The conference invitees represented a broad range of pediatric critical care medicine clinical and research interests, expertise, and career stages. It also included individuals with expertise in rehabilitation research.ConclusionThe composition of the new program, including its link to physical medicine and rehabilitation, is discussed. In addition, recommendations by the conference participants and program director are provided to foster the development of more randomized, controlled clinical trials and to develop successful clinician scientists in pediatric critical care medicine.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo describe the development of bradycardia during sedation with dexmedetomidine in a patient concurrently receiving digoxin.DesignCase report.SettingThe pediatric intensive care unit of a tertiary care children’s hospital.PatientsA 5-wk-old infant with an atrioventricular septal defect requiring sedation during mechanical ventilation for acute respiratory syncytial virus infection.Measurements and Main ResultsAs part of an ongoing evaluation of dexmedetomidine for sedation in the pediatric intensive care unit, the patient received a loading dose (0.5 &mgr;g/kg) followed by an infusion (0.44 &mgr;g·kg−1·hr−1) of dexmedetomidine. Sedation assessments and hemodynamic data were collected at least every 2 hrs. During the loading dose, the patient’s heart rate decreased from 133 beats/min per min to 116 beats/min. During the ensuing 13 hrs, the heart rate continued to decrease into the mid 90s, with additional episodes of bradycardia into the 40s and 50s. Within 1 hr of discontinuation of the dexmedetomidine infusion, the baseline heart rate had recovered, and no further episodes of acute bradycardia were noted.ConclusionsThis case adds to the limited data regarding dexmedetomidine in pediatric critical care and suggests that caution should be used when considering sedation with dexmedetomidine in patients also receiving digoxin.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesTo compare survival of pediatric umbilical cord blood and bone marrow transplant recipients requiring admission to a pediatric intensive care unit for mechanical ventilation and to determine the effect of organ dysfunction on outcome.DesignRetrospective chart review.SettingTertiary care referral center for pediatric stem cell transplants.PatientsAll children 0–18 yrs old admitted to the pediatric intensive care unit for mechanical ventilation after receiving a stem cell transplant.InterventionsNone.Measurements and Main ResultsData were collected from medical records of 86 patients who received a stem cell transplant and were subsequently admitted to the pediatric intensive care unit for mechanical ventilation. Demographic data were collected at the time of intubation, and physiologic data were collected at 6 hrs and 96 hrs after intubation. The pediatric intensive care unit, hospital, and 2-yr survival rates for umbilical cord blood transplant recipients were 37%, 25%, and 19%, respectively. The survival rates for bone marrow transplant recipients were 47%, 32%, and 21% for the same time periods. Umbilical cord blood and bone marrow transplant recipients with hepatic dysfunction had a significantly worse outcome, as did patients admitted for respiratory failure or sepsis.ConclusionsPediatric recipients of an umbilical cord blood transplant who subsequently required mechanical ventilation had lower pediatric intensive care unit and hospital survival rates compared with patients receiving bone marrow transplantation. Survival at 2 yrs for umbilical cord blood transplant and bone marrow transplant patients was similar. Predictors of outcome for all stem cell transplant recipients requiring mechanical ventilation included pediatric intensive care unit diagnosis requiring intubation and hepatic function. Predictors of outcome can be identified shortly after intubation in pediatric stem cell transplant recipients and may aid in therapeutic decision making and family counseling.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID