ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether there is sufficient evidence of a benefit of hemofiltration or plasma filtration in sepsis.Data SourcesMedline search, search of references in articles found in Medline search, literature known to local experts.Study SelectionTrials and reports where clinical outcome measures were included.Data ExtractionClinically relevant information was presented.Data SynthesisStudies were grouped according to hemofiltration or plasma filtration and within each of these groups into animal or human studies; then they were graded from case report, through case series, nonrandomized trials, and randomized trials.ConclusionThere is a lack of randomized trials. The available studies show an absence of benefit for hemofiltration. Further studies are needed in plasma filtration.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesThe recognition that alveolar overdistension rather than peak inspiratory airway pressure is the primary determinant of lung injury has shifted our understanding of the pathogenesis of ventilator-induced side effects. In this review, contemporary ventilatory methods, supportive treatments, and future developments relevant to pediatric critical care are reviewed.Data SynthesisA strategy combining recruitment maneuvers, low-tidal volume, and higher positive end-expiratory pressure (PEEP) decreases barotrauma and volutrauma. Given that appropriate tidal volumes are critical in determining adequate alveolar ventilation and avoiding lung injury, volume-control ventilation with high PEEP levels has been proposed as the preferable protective ventilatory mode. Pressure-related volume control ventilation and high-frequency oscillatory ventilation (HFOV) have taken on an important role as protective lung strategies. Further data are required in the treatment of children, confirming the preliminary results in specific lung pathologies. Spontaneous breathing supported artificially during inspiration (pressure support ventilation) is widely used to maintain or reactivate spontaneous breathing and to avoid hemodynamic variation. Volume support ventilation reduces the need for manual adaptation to maintain stable tidal and minute volume and can be useful in weaning. Prone positioning and permissive hypercapnia have taken on an important role in the treatment of patients undergoing artificial ventilation. Surfactant and nitric oxide have been proposed in specific lung pathologies to facilitate ventilation and gas exchange and to reduce inspired oxygen concentration. Investigation of lung ventilation using a liquid instead of gas has opened new vistas on several lung pathologies with high mortality rates.ResultsThe conviction emerges that the best ventilatory treatment may be obtained by applying a combination of types of ventilation and supportive treatments as outlined above. Early treatment is important for the overall positive final result. Lung recruitment maneuvers followed by maintaining an open lung favor rapid resolution of pathology and reduce side effects.ConclusionsThe methods proposed require confirmation through large controlled clinical trials that can assess the efficacy reported in pilot studies and case reports and define the optimal method(s) to treat individual pathologies in the various pediatric age groups.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo examine the relationships between procalcitonin, bacterial infection, sepsis-induced multiple organ failure, and mortality rate in children.DesignCohort study.SettingA multidisciplinary, tertiary-care pediatric intensive care unit.PatientsSeventy-eight children meeting criteria for sepsis or septic shock and 12 critically ill children without sepsis.InterventionsVenous or arterial blood sampling.Measurements and Main ResultsDemographic, epidemiologic, and outcome data were recorded. Plasma from children with sepsis were collected on days 1 and 3, and procalcitonin concentrations were measured by immunoluminometric assay. Organ failure index scores were determined, and multiple organ failure was defined as organ failure index ≥3. Persistent multiple organ failure was defined by presence of multiple organ failure on day 3. Procalcitonin concentrations (median [25th percentile-75th percentile]) were increased among children with sepsis on day 1 (2.4 ng/mL [0.2–24.2],p< .01) but not on day 3 (0.8 ng/mL [0.1–8.1],p= nonsignificant) vs. controls (0.2 ng/mL [0.1–0.5]). This increase in procalcitonin concentration was particularly robust among children with bacterial sepsis on day 1 (7.1 ng/mL [0.9–44.8],p< .001) and on day 3 (2.9 ng/mL [0.1–32.4],p< .05). Procalcitonin concentrations were not increased among children with fungal, viral, or culture-negative sepsis vs. controls. Procalcitonin concentrations were persistently increased over time among patients with bacterial sepsis who had persistent multiple organ failure (p< .05) and who died (p< .01) but not among patients with nonbacterial sepsis.ConclusionsProcalcitonin is persistently increased among children with poor outcome from bacterial sepsis. Further study is needed to better delineate this differential procalcitonin response to bacterial vs. nonbacterial sepsis and to characterize any mechanistic role that procalcitonin might play in the development of bacterial sepsis-induced multiple organ failure and mortality.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine whether the interpretations of digital radiographs by pediatric critical care physicians displayed on the bedside personal computer differ from the interpretations of images displayed on the diagnostic workstation.DesignPaired comparison.SettingA 38-bed pediatric critical care unit in a 372-bed pediatric university hospital.SubjectsFour pediatric critical care fellows and four pediatric critical care staff physicians.InterventionsEight critical care physicians interpreted 114 radiographs in random order on two separate occasions. Each radiograph was assessed for the presence or absence of five chest abnormalities, the correct or incorrect endotracheal tube position, and the position of central venous catheters. These interpretations were scored against a gold standard.Measurements and Main ResultsSensitivity and specificity were calculated for the presence or absence of five chest abnormalities and the identification of correct or incorrect endotracheal tube position. Kappa was calculated to assess agreement in the interpretation of central catheter position. Regarding chest abnormalities, improvement in sensitivity on the diagnostic workstation was statistically significant for one critical care fellow. The specificity on the diagnostic workstation was significantly worse for two critical care fellows and two critical care staff physicians. Regarding endotracheal tube position, improvement in sensitivity on the diagnostic workstation was statistically significant for one critical care staff physician. There were no statistically significant differences between the two viewing modalities for specificity measures. For central venous catheter position, there were no statistically significant differences in the interobserver or intra-observer agreements between the two viewing modalities.ConclusionsWith the exception of diffuse chest abnormalities, pediatric critical care physicians can use the Web-based bedside personal computer for clinical decision-making with the confidence that the decisions will be similar to those made on the diagnostic workstation.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the association between neurologic outcome and the alterations of jugular venous oxygen saturation (Sjvo2) or the increase in arteriovenous difference of lactate content (AVDL) in children with severe traumatic brain injury.DesignObservational prospective cohort study.SettingMultidisciplinary pediatric intensive care unit of a university hospital.PatientsA total of 27 pediatric patients with severe traumatic brain injury, with a Glasgow Coma Scale after resuscitation of <9, who were admitted to the pediatric intensive care unit within 36 hrs after injury.InterventionsIntermittent measurement of Sjvo2and AVDL.Measurements and Main ResultsSjvo2and AVDL were assessed simultaneously every 6 hrs. The primary dependent variable measured was assessed independently 3 months after trauma according to the Pediatric Cerebral Performance Category. Patients were classified into two groups: group 1 (favorable outcome, Pediatric Cerebral Performance Category 1–3) and group 2 (unfavorable outcome, Pediatric Cerebral Performance Category 4–6); 81% were included in group 1 and 19% in group 2. A total of 354 measurements of Sjvo2and AVDL were made, with a mean of 13.1 ± 7.9 per patient. The number of abnormal measurements of Sjvo2and increased AVDL used to predict the neurologic outcome was selected according to the area under the receiver operating characteristic curve. Mortality was 15% (four patients). The strongest association was found between a poor neurologic outcome and two or more pathologic AVDL measurements (higher than −0.37 mmol/L; relative risk, 17.6; 95% confidence interval, 2.5–112.5;p= .001). The presence of two or more measurements of Sjvo2of ≤55% was significantly associated with a poor neurologic outcome (relative risk, 6.6; 95% confidence interval, 1.5–29.7;p= .003). The frequency of measurements of Sjvo2of ≥75% was not different between groups 1 and 2.ConclusionIn children with severe traumatic brain injury, two or more measurements of Sjvo2of ≤55% or two or more pathologic AVDL measurements were associated with a poor neurologic outcome. Further studies are needed to recommend the use of these variables as a guideline to optimize treatment.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

LEARNING OBJECTIVESOn completion of this article, the reader should be able to:1. Explain the mechanism of action of streptokinase.2. Outline an alternative to surgical decortication of empyema.3. Recognize that intrapleural instillation of fibrinolytic agents is not associated with bleeding complications.The authors have disclosed that they have no financial relationships with commercial companies pertaining to this educational activity.Visit thePediatric Critical Care MedicineOnline website (www.pccmjournal.com) for information on obtaining continuing medical education credit.ObjectiveTo describe the use of intrapleural instillation of fibrinolytic agents as adjunctive therapy for children with complicated pleural effusions and empyema.DesignRetrospective chart review.SettingTertiary care children’s hospital in an academic medical center.PatientsNineteen consecutive patients (median age, 36 months; range, 9 months to 13 yrs) with complicated pleural effusion or empyema by clinical, radiographic, and laboratory criteria who failed to have adequate drainage of the fluid collection by tube thoracostomy.InterventionsPatients who remained symptomatic with fever or respiratory distress and who had pleural fluid that could not be drained by tube thoracostomy were treated by intrapleural instillation of either urokinase (13 patients) or streptokinase (six patients) 8–72 hrs after chest tube insertion.Measurements and Main ResultsFibrinolytic therapy increased the volume of chest tube drainage in 15 (79%) of 19 patients. Fourteen of the 19 patients were successfully managed without referral for surgical drainage. No significant adverse events or side effects were noted.ConclusionIntrapleural instillation of fibrinolytic agents appears to be an effective and less invasive alternative to surgical drainage for children who have complicated pleural effusions or empyemas that do not drain adequately with tube thoracostomy alone.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

LEARNING OBJECTIVESOn completion of this article, the reader should be able to:1. Identify the potential etiologies of anemia in critically ill infants with bronchiolitis.2. Conclude that erythropoietin therapy improves reticulocyte count but does not reduce transfusion requirements in infants with bronchiolitis.3. Conclude that the effiacy of erythropoietin therapy in treating anemia varies in the ICU depending on the underlying cause of the anemia and co-morbid condition.The authors have disclosed that they have no financial relationships with commercial companies pertaining to this educational activity.Visit thePediatric Critical Care MedicineOnline website (www.pccmjournal.com) for information on obtaining continuing medical education credit.ObjectiveCritically ill children with bronchiolitis often require red blood cell transfusions. Anemia normally results in increased circulating erythropoietin concentrations; however, critical illness has been associated with a blunted erythropoietin response. Treatment with erythropoietin decreases the need for red blood cell transfusion in several disease states. We hypothesized that critically ill children with bronchiolitis and anemia would have a circulating erythropoietin deficiency and that treatment with exogenous erythropoietin would increase reticulocyte count and hematocrit and reduce red blood cell transfusion requirements.DesignRandomized, blinded, placebo-controlled trial.SettingChildren’s hospital.PatientsCritically ill children with bronchiolitis, anemia, and respiratory failure. Anemia was defined as a hematocrit >2 sd below normal for age.InterventionPatients were randomized to one of two groups. In the erythropoietin group, patients received daily intravenous erythropoietin. In the control group, patients received daily intravenous placebo. Both groups were treated with elemental iron.Measurements and Main ResultsBlood for complete blood count, reticulocyte count, and ferritin and erythropoietin concentration was obtained at admission and discharge. Red blood cell transfusions were administered to patients with a persistent oxygen requirement and a hematocrit of <25%. Outcome variables included number of red blood cell transfusions, change in reticulocyte count, ferritin values, and circulating erythropoietin values between groups. Forty-four patients completed the study (mean 3.1 ± 0.6 months), with a baseline hematocrit of 27.6 ± 0.5%, ventilator days of 8.2 ± 0.6, and pediatric intensive care unit length of stay of 9.8 ± 0.6 days. There were no significant baseline demographic differences between the control and erythropoietin groups. Ten of 22 (45%) children in the erythropoietin group required red blood cell transfusion compared with 11 of 22 (50%) in the control group (p= nonsignificant). The increase in reticulocyte count was greater in the erythropoietin group compared with the control group (2.1 ± 0.3% to 4.7 ± 0.7%,p= .003 vs. 2.1 ± 0.3% to 2.7 ± 0.5%,p= nonsignificant).ConclusionsDespite a favorable reticulocyte and circulating erythropoietin response, red blood cell transfusion requirements were not significantly diminished by erythropoietin treatment in children with bronchiolitis and respiratory failure. Erythropoietin cannot be routinely recommended for this patient population.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe authors present the use of synthetic factor VIIa to treat bleeding after cardiopulmonary bypass and surgical repair of an atrial septal defect in an infant with trisomy 10 and pulmonary hypertension.DesignCase report.SettingUniversity-affiliated pediatric intensive care unit.PatientsA 4-mo-old, 3.7-kg infant.Main ResultsAfter a single dose of synthetic factor VIIa, there was normalization of the prothrombin and partial thromboplastin time and cessation of bleeding.ConclusionThe potential benefits of synthetic factor VIIa when compared with conventional therapy with fresh frozen plasma are discussed. Previous experience with synthetic factor VIIa in pediatric-aged patients and the cardiothoracic surgical population is presented.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

There have been few reports of the use of extracorporeal life support (ECLS) to provide cardiac support in children with low cardiac output as a result of arrhythmias. We present two patients in whom venoarterial ECLS was used to provide support for cardiogenic shock secondary to intractable supraventricular tachycardia. In both cases, the arrhythmia terminated once bypass was established. In one case, the time on ECLS was used to optimize drug treatment, and in the other case, radiofrequency ablation was successfully undertaken during ECLS.

ISSN:1529-7535    

出版商:OVID    

年代:2003

数据来源: OVID