The effects of early and repeated prone positioning in pediatric patients with acute lung injury.

STUDY OBJECTIVE: To describe the physiologic changes and to evaluate the safety of placing pediatric patients with acute lung injury (ALI) prone for 20 h/d during the acute phase of their illness. DESIGN: Single-center prospective case series. SETTING: Tertiary-level pediatric ICU. PATIENTS: Consecutive patients with bilateral pulmonary parenchymal disease requiring intubation and mechanical ventilation with a PaO(2)/fraction of inspired oxygen (FIO(2)) ratio /= 20 mm Hg in PaO(2)/FIO(2) ratio or a decrease of >/= 10% in oxygenation index when shifted from a supine to a prone position during the study period. During the 107 patient-days and 214 positioning cycles, no critical incidents occurred. Furthermore, no patient experienced a persistent decrease in oxygen saturation as measured by pulse oximetry (SpO(2)) of > 10% from values obtained when in the supine position, failed to keep their SpO(2) at > 85%, or experienced an increased respiratory rate of > 40 breaths/min when prone. Using the COMFORT score, patients were objectively rated to be equally comfortable in both the supine and prone positions. Patients also were able to resume spontaneous ventilation and to progress toward endotracheal extubation while in the prone position. Iatrogenic injury associated with prolonged prone positioning included stage II pressure ulcers in six patients (24%). CONCLUSIONS: The pediatric patients in this series demonstrated improvements in oxygenation without serious iatrogenic injury after prone positioning. This study provides a foundation for a prospective randomized study investigating the effect of early and repeated prone positioning on clinical outcomes in pediatric patients with ALI.

Prone positioning of patients with acute respiratory distress syndrome: a systematic review.

A computerized bibliographic search of published research and a citation review of English-language publications about prone positioning of patients with acute respiratory distress syndrome were done. Information on prone positioning related to technique, patients' responses, complications, and recommendations to prevent complications was extracted. In the 20 pertinent clinical studies found, 297 patients (mean age, 39 years) with acute respiratory failure were positioned prone. Timing from the onset of respiratory failure to when the patient was first positioned prone varied, as did the frequency of prone positioning. Patients spent from 30 minutes to 42 hours prone. In 47% of the studies in which abdominal position was noted, chest and pelvic cushions were used to allow the abdomen to protrude while the patient was prone. Improved oxygenation within 2 hours was reported in 69% of patients, and the improvements were cumulative and persistent. Aside from early intervention, factors predictive of patients' responses were inconsistent, and patients' initial responses were not predictive of subsequent responses. Iatrogenic critical events were rare. Dependent edema of the face was prevalent. Pressure ulcers were reported in studies with longer periods of prone positioning. The most serious complication, corneal abrasion requiring corneal transplantation, was reported in one patient. Clinical knowledge about prone positioning is limited. Phase 1 studies focusing on how to safely turn and care for critically ill patients positioned prone for prolonged periods are needed.

Weaning from mechanical ventilation: patterns in young children recovering from acute hypoxemic respiratory failure.

OBJECTIVE: The purpose of the study was to describe the patterns of weaning from mechanical ventilation in young children recovering from acute hypoxemic respiratory failure. METHODS: Decision-making rules on progressive weaning were developed and applied to existing data on 82 patients 2 weeks to 6 years old in the Pediatric Acute Respiratory Distress Syndrome Data Set. RESULTS: Three patterns of weaning progress were detected: sprint, consistent, and inconsistent. Length of ventilation and weaning progressively increased from the sprint, to the consistent, to the inconsistent subset. Patients in the inconsistent subset were most likely to have a systemic (sepsis or shock) trigger of acute respiratory distress syndrome and to be rated as having at least moderate disability at discharge. Hypothesis-generating univariate and then multivariate logistic regression analyses indicated that patients who experienced more days of mechanical ventilation before the start of weaning and who had a higher oxygenation index during the weaning process were most likely to have an inconsistent pattern of weaning. CONCLUSION: Patterns of weaning are discernible in a population of young children and indicate a subset at risk for inconsistent weaning. Knowing the patterns of weaning may help clinicians anticipate, perhaps plot, and then modulate a patient's weaning trajectory.

Nutrition and shock in pediatric patients.

Critically ill patients, including those in shock, often present with significant metabolic derangement in protein and energy metabolism characterized by: increased protein breakdown which is not suppressed by protein or energy intake; reprioritization of protein synthesis with increased synthesis of acute-phase proteins; decreased synthesis of structural proteins; and high protein turnover. In addition, there is also glucose and lipid intolerance. Adequate nutritional and metabolic support of the critically ill child under these conditions is a challenging endeavor. Traditionally, critically ill children have received nutritional requirements based on those of healthy children despite the fact that the critically ill population is physiologically and metabolically different. Furthermore, nutritional requirements in healthy children are largely based on limited data. With emerging knowledge of non-nutritional functions of nutrients, adequacy of nutritional support and requirements will eventually depend on the goals to be achieved: nutritional, physiologic, and/or pharmacologic.

Patient-nurse synergy: optimizing patients' outcomes.

Given the current demands of the healthcare environment, a clear sense of the unique contributions of nursing to patients' outcomes is critical. This paper articulates a model that describes nursing practice on the basis of the needs and characteristics of patients. The model was developed by the American Association of Critical-Care Nurses Certification Corporation to link certified practice to patients' outcomes. The fundamental premise of this model, known as the Synergy Model, is that patients' characteristics drive nurses' competencies. When patients' characteristics and nurses' competencies match and synergize, outcomes for the patient are optimal. This paper presents the major tenets of the Synergy Model: patients' characteristics of concern to nurses, nurses' competencies important to patients, and patients' outcomes that result when patients' characteristics and nurses' competencies are mutually enhancing. By creating safe passage for patients, nurses make a significant contribution to the quality of patients' care, containment of costs, and patients' outcomes. Although the Synergy Model will be used as a blueprint for the certification of acute and critical care nurses, it is conceptually relevant to the entire profession. Dissemination of this model may help situate nursing within the current healthcare environment and facilitate intradisciplinary dialogue.

Mutuality--an expression of nursing presence.

Nursing exists in the details of relationships. One crucial element of therapeutic nurse-patient/parent relationships is the attribute of mutuality. Mutuality not only embodies the philosophy of family-centered-care, it acknowledges and supports the evolution of parents and nurses toward greater competency in their role. Using concept analysis, this article explores the phenomenon of mutuality. The desired outcome is to provide a theoretical and operational definition of mutuality that will help guide practice and direct future research in the area of therapeutic nurse-parent relationships.

Skin integrity in the pediatric population: preventing and managing pressure ulcers.

PURPOSE: To summarize clinical and empirical knowledge about pressure ulcers in infants and children and to describe an approach developed at Children's Hospital, Boston, to prevent and manage pressure ulcers. POPULATION: Acutely ill children with potential or actual alteration in skin integrity due to pressure ulcers. CONCLUSIONS: The three-pronged approach for pressure ulcer prevention and management developed by the Skin Care Task Force at the Children's Hospital, Boston, decreases unnecessary variation in practice surrounding the prevention and care of pressure ulcers in acutely ill children. PRACTICE IMPLICATIONS: The Skin Care Task Force recommends use of Braden Q for pediatric risk assessment, a skin care algorithm for prevention of pressure ulcers, and a pressure ulcer algorithm for staging and managing pressure ulcers.

Providing comfort to critically ill pediatric patients: isoflurane.

Isoflurane is a fluorinated ether used primarily as an inhalation anesthetic. Rapid titratable effects, limited metabolism, and a reliable mode of administration make isoflurane an appealing alternative to the use of intravenous sedatives and narcotics in critically ill patients requiring prolonged mechanical ventilation. This article, in reviewing this novel approach to management of patient discomfort, focuses on nursing practice issues and provides a critical analysis of isoflurane use in the intensive care unit.

Care of the child supported on high frequency oscillatory ventilation.

High frequency oscillatory ventilation is a new mode of ventilatory support of acute respiratory failure in the pediatric population. Delineating the nursing care required of this fragile group of infants and children is challenging, because there is a paucity of published data and national clinical experience. The author reviews a management plan that was used to guide the care of over 40 patients, ranging in age from 1 months to 24 years, with acute respiratory failure supported on high frequency oscillatory ventilation. In total, seven patient-care problems and associated interventions are delineated.

Effects of the nursing Mutual Participation Model of Care on parental stress in the pediatric intensive care unit--a replication.

The pediatric intensive care unit (PICU) hospitalization of a child is stressful for parents. Helping parents to decrease their stress is warranted so that they can function in a vital role that is therapeutic to them and their critically ill child. Although many interventions have been recommended to help parents decrease their stress, only the Nursing Mutual Participation Model of Care (NMPMC) has been tested in the clinical setting. This article reports a study that expands on Curley's original work by investigating the effects of the NMPMC on parental stress when implemented by PICU staff nurses. Fifty-six parents participated in the study, which used a quasi-experimental design. Sequential sampling placed the first 31 subjects into the control group and the next 25 subjects in the experimental group. The experimental group received care from staff nurses instructed in the NMPMC. The dependent measure was the Parental Stressor Scale:Pediatric Intensive Care Unit (PSS:PICU) administered within 24 to 48 hours of PICU admission, every 48 hours thereafter, and 24 hours after PICU discharge. The results indicated that parents in the experimental group perceived less stress than the control group, specifically the stress related to alterations in parental role in the PICU setting. Implications for nursing care are discussed.

Challenges in nursing: infants with congenital diaphragmatic hernia.

Despite advances in the care of infants born with congenital diaphragmatic hernia, mortality rate continues to be high. Immediate survival is directly related to the degree of pulmonary hypoplasia present. The spectrum is wide, from minimal pulmonary hypoplasia, in which neonates do well, to severe pulmonary hypoplasia, which is incompatible with life. Between these two extremes lie infants with compromised pulmonary function whose long-term survival depends on the clinical strengths of their multidisciplinary team. Over the past year, 23 infants with congenital diaphragmatic hernia were cared for in the Multidisciplinary Intensive Care Unit at Children's Hospital, Boston. A retrospective chart review enabled the authors to describe the trajectory of illness and generate nursing practice guidelines. This article presents the nursing care issues that were identified in this challenging population.

Extracorporeal membrane oxygenation: current use and future directions.

Extracorporeal membrane oxygenation (ECMO) is the process of using prolonged cardiopulmonary bypass to support patients with reversible respiratory and/or cardiac failure who are refractory to maximal conventional therapy. This process has been used extensively for critically ill neonates, with encouraging results. The use of ECMO in the pediatric population has been limited but is increasing. The history, mechanics, and current applications of ECMO are discussed in this article. Critical care nursing management of the pediatric or neonatal ECMO patient focuses on optimizing recovery of the pulmonary and/or cardiac system while preventing complications. A case study of a pediatric ECMO patient is presented which illustrates the complex nursing care issues related to use of this intervention. Future directions for ECMO are addressed.

End-tidal CO2 monitoring in critically ill infants and children.

End-tidal carbon dioxide (ETCO2) monitoring is an effective tool to continuously assess the adequacy of ventilation in critically ill infants and children. Optimal clinical application of this noninvasive monitoring technique requires an understanding of the physiologic principles of ETCO2 monitoring and its unique technologic considerations.

Effects of the nursing mutual participation model of care on parental stress in the pediatric intensive care unit.

The pediatric intensive care unit (PICU) hospitalization of a child is stressful for parents. Helping parents to decrease their stress is warranted so that they can function in the vital role that is therapeutic to them and their critically ill child. Many parent-supportive nursing interventions have been recommended but none has been tested in the clinical setting. A quasi-experimental design was used to study the effects of the nursing mutual participation model of care (NMPMC) on the perceived environmental stress of parents in the PICU. Thirty-three parents, experiencing the PICU for the first time, participated in the study. Sequential sampling divided the participants into two groups, control and experimental. The experimental group participated in the NMPMC, designed to be supportive to and guided by the perceived individual needs of each parent. The dependent measure was the Parental Stressor Scale: Pediatric Intensive Care Unit administered within 24 to 48 hours of PICU admission, every 48 hours thereafter, and 24 hours after PICU discharge. The results indicate that the NMPMC is helpful in alleviating parental stress, specifically the stress related to interruption in the parent-child relationship, in the PICU setting.