ABSTRACT
Both peritoneal dialysis (PD) and continuous hemodiafiltration (CHDF) techniques are used in children who develop acute renal failure as part of multiorgan dysfunction syndrome (MODS). An important goal of renal support in MODS is treatment and prevention of fluid overload. This report describes an experience with PD and CHDF in children with MODS and presents an analysis of fluid balance for each modality. Medical records of patients with MODs treated with PD/CHDF were reviewed. Fluid balance was studied only in patients with documented fluid overload treated with PD/CHDF for more than 24 h. Successful fluid control was defined as more fluid output than input over the course of PD/CHDF. CHDF was used in 37 patients, median age 47 months (range 0.2-284 months), for a mean of 110 h (range 4-733 h). PD was initiated in 25 patients, median age 4 months (range 0.1-156 months), for a mean of 145 h (range 7-992 h). Successful fluid control was achieved in 17 of 26 (65%) CHDF patients and in 5 of 14 (36%) PD patients (P < 0.01, chi-squared). In conclusion, CHDF is more effective than PD in treating and preventing fluid overload in children with MODS.
Subject(s)
Hemofiltration , Multiple Organ Failure/therapy , Peritoneal Dialysis , Child , Fluid Therapy , Hemodynamics/physiology , Hemofiltration/adverse effects , Humans , Intensive Care Units, Pediatric , Kidney Function Tests , Multiple Organ Failure/metabolism , Multiple Organ Failure/physiopathology , Peritoneal Dialysis/adverse effects , Survival Analysis , Treatment OutcomeABSTRACT
OBJECTIVE: To derive a target range of optimal sedation for the COMFORT Scale and to prospectively test that target range against intensivist assessment of adequacy of sedation. DESIGN: Serial prospective agreement cohort studies. SETTING: Twelve-bed pediatric intensive care unit in an urban academic teaching hospital. PATIENTS: Eighty-five mechanically ventilated children (aged 0 to 102 months). INTERVENTIONS: Three serial prospective studies comparing simultaneous, independent ratings conducted by trained observers using an objective scale and intensive care physicians using global assessment. The initial study was designed to derive the target range. The second study was conducted to verify that target range in a second population. The third study was added to evaluate relative variability in methods used in the second study. MEASUREMENTS AND MAIN RESULTS: Adequacy of sedation using visual analog scale and descriptive ratings or the COMFORT Scale (a previously validated behaviorally anchored scale to rate eight behavioral or physiologic dimensions of distress). The first study comprised 100 observations. Groups of patients described by the intensivist as inadequately sedated, optimally sedated, and excessively sedated had different mean COMFORT scores (30.5 +/- 0.7 vs. 22.9 +/- 5.8 vs. 14.3 +/- 0.7, respectively, p < .05). The target range of optimal sedation was defined as COMFORT scores of 17 to 26. The second study verified the target range prospectively in a second group of 96 observations. The COMFORT score was strongly associated with the sedation adequacy rating by the intensivist (p < .001; r2 = .662). COMFORT scores accurately predicted the patient assignment to adequacy of sedation categories by the intensivist in 66.1% of observations. Discrepancy between physicians occurred in 38.5% of 16 paired physician ratings in the second study. In the third study, 120 observations comparing paired COMFORT scores to paired physician ratings of the same subjects demonstrated significantly less variability in COMFORT assessment of adequacy of sedation. COMFORT scores were similarly unbiased (1.1% vs. 0.22%) but more precise (8.0% vs. 16.7%) than intensivist ratings (p < .025). CONCLUSION: Adequacy of sedation is measured more consistently by observers using the COMFORT Scale than by intensivist global assessment.
