ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo compare resource utilization and outcomes between cohorts of pediatric and adult intensive care unit (ICU) patients from a single institution.DesignProspective, observational cohort study.SettingA large, urban, tertiary care medical center.PatientsA total of 780 patients consecutively admitted to the pediatric ICU, adult medical ICU, and adult surgical ICU.Measurements and Main ResultsICU, hospital and 6-month survivals and hospital costs from index ICU admission. Predicted mortality by Pediatric Risk of Mortality III and Acute Physiology and Chronic Health Evaluation II. Health status at 6 months from index ICU admission. Pediatric patients had lower ICU (7.8% vs. 13.7%;p= .01), hospital (10.1% vs. 16.9%;p= .009), and 6-month (16.2% vs. 29.2%;p< .001) mortalities compared with adult patients. Adult patients had significantly lower probability of survival for 6 months from initial ICU admission compared with pediatric patients. The difference in survival was primarily accounted for by adult and pediatric medical patients. No differences could be observed between pediatric and adult ICU patients for mean hospital costs ($33,316 ± $48,467 vs. $32,877 ± $46,411;p= .92). Pediatric and adult patients incurred increasing costs with increasing risks of mortality. More than 50% of pediatric patients had a risk of mortality <0.5% compared with 1.2% of adult patients, but there was no difference in the mean use of ICU-specific interventions.ConclusionsPediatric critical care patients have better short-term and longer-term survival compared with adult patients. The difference in survival is accounted for by the lower survival of adult medical patients. Despite the survival differences, pediatric and adult ICU patients incur similar hospital costs, and the proportions of patients who receive active ICU interventions are similar.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveThis study compares patient-ventilator synchrony, work of breathing and patient effort in neonates during different modes of patient-triggered ventilation.DesignClinically stable neonates received intermittent mandatory ventilation (IMV), synchronized intermittent mandatory ventilation (SIMV), pressure assist/control ventilation (A/C), and pressure support ventilation (PSV) in a random order for 20 mins. With each mode patient-ventilator synchrony, work of breathing, and patient effort were evaluated.SettingNeonatal level III intensive care unit of a university hospital.Measurements and ResultsSeven clinically stable neonates (31.4 ± 2 wks gestation, weighing 1.49 ± 0.38 kg) were randomly ventilated with the above four modes using a Bird VIP ventilator. Esophageal pressure, airway pressure, and flow were measured using a CP-100 neonatal monitor (Bicore). Data for five consecutive breaths in each mode were analyzed. Patient effort and work of breathing differed significantly among modes of ventilation. The inspiratory pressure time product was least with A/C (0.54 ± 0.29 cm H2O·sec) and increased with PSV (0.60 ± 0.39 cm H2O·sec), SIMV (1.46 ± 0.55 cm H2O·sec), and IMV (2.74 ± 1.05 cm H2O·sec) (p< .05). A similar trend was observed for work of breathing, with work least during A/C (0.07 ± 0.04 joules per liter [J/L]), followed by PSV (0.17 ± 0.14 J/L), SIMV (0.33 ± 0.13 J/L), and IMV (0.41 ± 0.16 J/L) (p< .05). Marked dyssynchrony between patient-initiated and ventilator-initiated inspiration occurred only during IMV.ConclusionAsynchrony can be avoided by the use of assisted, patient triggered modes of ventilation and, of the available modes, pressure A/C results in the least effort and work of breathing for clinically stable neonates.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate the incidence, onset, and severity of complications in children after chest tube removal.DesignA prospective evaluation of patients.SettingPediatric intensive care unit in a tertiary care university hospital.PatientsOne hundred and one consecutive children requiring intraoperative placement of chest tubes for cardiac or noncardiac thoracic surgery.InterventionsNone.Measurements and Main ResultsOf the 120 chest tubes placed in 101 patients, 16 were associated with positive findings after removal. Of these 16, only six required changes in management, and only two were serious complications. There was no association of complications with duration of chest tube placement. Children who developed complications were younger. All serious complications were immediately apparent after chest tube removal.ConclusionSerious complications of chest tube removal in children are very uncommon and in this series were immediately apparent.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo compare ketamine and propofol sedation in children undergoing diagnostic and therapeutic procedures.DesignRetrospective study.SettingA six-bed pediatric intensive care unit and a pediatric hematology oncology clinic.PatientsFrom 1996 to 1998, 405 procedures were performed on patients between 1 month and 22 yrs of age.InterventionsAll patients but one were sedated intravenously with either propofol or ketamine; those who received ketamine also received midazolam and either atropine or glycopyrrolate. Vital signs were monitored continuously. Procedures included bone marrow biopsies, lumbar punctures, esophagoduodenoscopies, colonoscopies, and other miscellaneous procedures. A pediatric intensivist performed all sedations.Measurements and Main ResultsTwo hundred sixty-one procedures were conducted with propofol and 144 with ketamine. The mean time (±sd) from administration of the first dose of medication until the patient was awake was 36.6 (15.0) mins for the propofol group and 69.2 (43.2) mins for the ketamine group. The mean time to awakening was significantly longer for the ketamine group, even after adjusting for the length of the procedure, American Society of Anesthesiologists score, and setting of procedure (inpatient or outpatient;p= .0001). Only one unplanned endotracheal intubation in the propofol group and two in the ketamine group occurred. Patients were significantly more likely to have airway (p= .01) or hemodynamic (p= .002) effects with propofol than with ketamine, although these effects were essentially minor in nature.ConclusionsBoth propofol and ketamine provided safe and effective sedation for the short, painful procedures performed. Because the patients who received propofol awakened almost twice as quickly as the patients who received ketamine, the sedation service operated more efficiently when propofol was used. The major complication rates for propofol and ketamine were small, and the differences between the two groups were not statistically significant. We conclude that with proper monitoring, intravenous propofol can be used safely and effectively for short procedures in the pediatric setting.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo investigate the short-term hemodynamic effects of amrinone in pediatric patients with refractory septic shock.DesignOpen-label, clinical trial.SettingPediatric intensive care unit.PatientsNine patients admitted with a diagnosis of septic shock receiving stable doses of vasopressors and inotropes.InterventionsPediatric patients with septic shock and a pulmonary artery catheter were treated with amrinone in a stepwise fashion at 5, 10, and 15 &mgr;g/kg/min.Measurements and Main ResultsHeart rate, blood pressure, cardiac index, rate pressure product, systemic vascular resistance index, pulmonary vascular resistance, oxygen delivery, and oxygen consumption were measured at baseline and 90 mins after each amrinone dose. The addition of amrinone increased cardiac index (p< .05) and oxygen delivery (p< .05) without increasing the rate pressure product. Decreases were observed in systemic vascular resistance index (p< .05) and pulmonary vascular resistance (p< .05). No significant changes were seen in heart rate, blood pressure, or oxygen consumption.ConclusionsIn this short-term, dose-response study in children with refractory septic shock, amrinone improved cardiac index and oxygen delivery in pediatric patients with refractory septic shock without increasing myocardial work.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate postoperative serum concentrations of growth hormone (GH), insulin-like growth factor I (IGF-I), C-reactive protein (CRP), and prealbumin as predictors of clinical outcome as defined by the incidence of 30-day postoperative mortality, the postoperative length of pediatric intensive care unit (PICU) stay, and the risk of postoperative infection in infants of high surgical risk undergoing operative correction of congenital cardiac defects.DesignProspective, observational study.SettingPICU of a university hospital.PatientsA high surgical risk group of 36 children admitted for elective cardiac surgery.InterventionMeasures of serum levels of IGF-I, basal GH, prealbumin, and CRP. These parameters were followed from the hospital admission until the discharge from the PICU at specific time points: preoperative and on the second, fifth, and tenth postoperative days.Measurements and Main ResultsSurgical stress response was marked by an increase of GH and CRP levels and a fall in prealbumin levels on the second postoperative day. Prealbumin, CRP, and GH returned to preoperative levels on average 10 days following surgery; the values of IGF-I, which had decreased on the fifth day, remained below those values observed before the surgery. Patients whose PICU stay was ≤ 10 days showed significant decreases in GH and CRP serum levels and an increase in IGF-I and prealbumin levels on postoperative day 5 compared with the patients who stayed > 10 days. The sustained high CRP (≥ 8.4 mg/dL,p< .05) and GH (≥ 66 mIU/L,p< .03) values on the fifth day were associated with increased mortality in contrast with patients in whom the values were returning to preoperative levels.ConclusionsSerial monitoring of serum GH, IGF-I, CRP, and prealbumin levels may be useful as a means to a) stratify the acute metabolic response to surgically induced injury insult and b) predict clinical outcome as defined by the length of stay in the PICU and the likelihood of 30-day survival following open-heart surgery in infants.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveThe objective of the present study was to examine the impact of major heart surgery with cardiopulmonary bypass (CPB) in childhood on serum leptin concentrations in relation to plasma cortisol, epinephrine, norepinephrine, and insulin.DesignControlled, prospective study.SettingIntensive care unit of a university hospital.Patients and InterventionsWe enrolled 20 pediatric patients undergoing open heart surgery and 20 children with major surgery not necessitating CPB (surgical control group). Leptin was measured by radioimmunoassay, cortisol and insulin were measured by chemiluminescence, and epinephrine and norepinephrine were measured by high-pressure liquid chromatography.Measurements and Main ResultsIn the CPB group, leptin dropped from 0.4 ± 0.1 preoperatively (mean ± sem) to 0.2 ± 0.1 ng/mL intraoperatively (p< .05). It increased to 1.6 ± 0.7 ng/mL 12 hrs after surgery (p< .01) and declined thereafter. In the surgical controls, leptin rose from 0.5 ± 0.2 ng/mL before surgery to 1.8 ± 0.8 ng/mL 12 hrs after surgery (p= .001). In both groups, plasma cortisol, insulin, and epinephrine significantly increased after surgery. There was no relationship between the maximum increase of serum leptin and the other hormones.ConclusionsPatients with CPB surgery and non-CPB surgery show a similar increase in serum leptin, indicating that sepsislike inflammatory syndrome does not further increase elevated leptin concentrations following major surgery. In this complex situation, serum leptin does not appear to be merely regulated by its known stimuli and suppressors.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo review the incidence, diagnosis, and management of superior vena cava syndrome (SVCS) after surgery for congenital heart disease.DesignRetrospective clinical review. All patients were computer registered. Our database includes daily follow-up.SettingPediatric cardiac surgery intensive care unit in a university hospital.PatientsA total of 1853 consecutive pediatric cardiac operations performed in 285 neonates and 1568 older children from 1993 to 1999 are reviewed.Measurements and Main ResultsThe diagnosis of SVCS was suspected clinically: Color changes and swelling of the upper part of the body, confirmed by echo-Doppler, showed no or minimal flow in the superior vena cava at the beginning and collateral flow later on. Nine patients developed SVCS (0.5%). All the study patients were neonates. The prevalence of SVCS in our neonatal patients was 3.15% (nine of 285), with no SVCS in older children. Accompanying complications included chylothorax (five), hydrocephalous (four)—three of whom required ventriculoperitoneal shunt during follow-up. Thrombolytic therapy was used in five patients, and thrombectomy was used in one patient. The ventilation period ranged from 4 to 46 days (mean 20.1 days), and the length of hospital stay ranged from 37 to 120 days (mean 61.3 days). No mortality was observed during follow-up.ConclusionsSVCS is an uncommon, severe complication following neonatal cardiac surgery. It may cause chylothorax, hydrocephalus, and severe respiratory complications leading to high morbidity. Early diagnosis and thrombolytic therapy may prevent the progression of this syndrome to its subsequent sequels.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveThe objective of this study was to analyze the incidence and significance of hepatic dysfunction after cardiac surgery in children.DesignProspective, observational study.SettingPediatric intensive care unit of a university hospital.PatientsThe study consisted of 232 children ranging in age from newborn to 17 years with no history of liver disease.Measurements and Main ResultsAspartate aminotransferase (AST), alanine aminotransferase (ALT), gammaglutamyltranspeptidase (GGT), alkaline phosphatase, total and conjugated bilirubin, blood glucose, urea, creatinine, and coagulation studies were determined at admission, at 24 and 48 hrs, and at 7 days. Hepatic dysfunction was taken as an ALT of > 100 IU/L or a moderate or high hepatic score. The statistical study included bivariate analysis and multivariate logistic regression to study the risk factors for hepatic dysfunction. Twenty-one patients (9%) showed an ALT > 100 IU/L, and 29.3% had a moderate or high hepatic score. A relationship was found between hepatic dysfunction and the type of cardiopathy (D-transposition of the great arteries and coarctation of the aorta), shock, the administration of dopamine or epinephrine, renal insufficiency, the presence of pulmonary changes (pulmonary edema, atelectasis, pulmonary hypertension, hypoxemia), hematologic disturbances (prothrombin time, kaolin-cephalin time, fibrinogen, and platelets), and the need for a greater number of transfusions of packed cells, plasma, and platelets. Compared with 7.6% of the rest of the patients (p< .001), 38% of patients with an ALT > 100 IU/L died. The hepatic score of those patients who died was 4.2 (2.3)—higher than that of the survivors at 1.5 (1.8), (p< .001). Shock and renal insufficiency were the factors most significantly related to the development of hepatic dysfunction.ConclusionsHepatic dysfunction is an uncommon complication in children after cardiac surgery. This complication is related mainly to hemodynamic disturbances and renal insufficiency and is an indicator of poor prognosis.

ISSN:1529-7535    

出版商:OVID    

年代:2001

数据来源: OVID