ABSTRACT
BACKGROUND: In infants with single-ventricle physiology, endotracheal suctioning poses risks because of the instability between pulmonary and systemic blood flow. OBJECTIVE: To examine processes and adverse events associated with endotracheal suctioning in the first 48 hours after 3 surgical procedures: the Norwood or Norwood-Sano procedure, pulmonary artery banding, and the modified Blalock-Taussig shunt. METHODS: Prospective observational study in a pediatric intensive care unit. RESULTS: Bedside nurses collected data from 211 episodes of endotracheal suctioning in 24 infants. Most (62%,130/211) suction episodes were unplanned; 38% (81/211) were planned. The most common reason for unplanned suctioning was arterial desaturation (48%, 62/130 episodes). The infants' oxygen saturation levels before suctioning ranged from 27% to 86%. Serious adverse events occurred in 9% (19/211) of suction episodes. In 8 (42%) of the episodes involving a serious adverse event, the patient received no additional intravenous bolus of analgesic or muscle relaxant before suctioning; in 8 episodes (42%), the patient received both an analgesic and a relaxant; in 3 episodes (16%), the patient received either an analgesic or a relaxant but not both. More adverse events occurred with open suctioning (68%, 13/19) than with closed suctioning (32%, 6/19). Most adverse events (68%, 13/19) occurred during the night shift. CONCLUSIONS: Significant hemodynamic instability and adverse events occur during routine suctioning in infants with single-ventricle physiology after surgical palliation.
Subject(s)
Critical Care Nursing/methods , Heart Ventricles/abnormalities , Intensive Care Units, Pediatric , Intubation, Intratracheal/methods , Postoperative Care/methods , Postoperative Complications/prevention & control , Blalock-Taussig Procedure , Female , Humans , Infant , Infant, Newborn , Male , Norwood Procedures , Prospective Studies , Pulmonary Artery/surgery , SuctionABSTRACT
OBJECTIVES: To determine the hemodynamic effect of tracheal suction method in the first 36 hours after high-risk infant heart surgery on the PICU and to compare open and closed suctioning techniques. DESIGN: Pilot randomized crossover study. SETTING: Single PICU in United Kingdom. PARTICIPANTS: Infants undergoing surgical palliation with Norwood Sano, modified Blalock-Taussig shunt, or pulmonary artery banding in the first 36 hours postoperatively. INTERVENTIONS: Infants were randomized to receive open or closed (in-line) tracheal suctioning either for their first or second study tracheal suction in the first 36 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Twenty-four infants were enrolled over 18 months, 11 after modified Blalock-Taussig shunt, seven after Norwood Sano, and six after pulmonary artery banding. Thirteen patients received the open suction method first followed by the closed suction method second, and 11 patients received the closed suction method first followed by the open suction method second in the first 36 hours after their surgery. There were statistically significant larger changes in heart rate (p = 0.002), systolic blood pressure (p = 0.022), diastolic blood pressure (p = 0.009), mean blood pressure (p = 0.007), and arterial saturation (p = 0.040) using the open suction method, compared with closed suctioning, although none were clinically significant (defined as requiring any intervention). CONCLUSIONS: There were no clinically significant differences between closed and open tracheal suction methods; however, there were statistically significant greater changes in some hemodynamic variables with open tracheal suctioning, suggesting that closed technique may be safer in children with more precarious physiology.
Subject(s)
Cardiac Surgical Procedures , Critical Care/methods , Heart Defects, Congenital/surgery , Intubation, Intratracheal , Postoperative Care/methods , Suction/methods , Cross-Over Studies , Female , Humans , Infant , Infant, Newborn , Intensive Care Units, Pediatric , Male , Pilot Projects , Treatment OutcomeSubject(s)
Bronchiolitis, Viral/therapy , Critical Care , Oxygen Inhalation Therapy , Female , Humans , MaleABSTRACT
Bronchiolitis caused by respiratory syncytial virus (RSV) infection is an important cause of severe lung disease in infants, and increasing evidence suggests that it is immunologically mediated. Experiments in mice suggest that this may be due to differential T-cell activation producing either type 1 or type 2 cytokines. We investigated this hypothesis in man by studying 24 infants ventilated with severe RSV bronchiolitis and by measuring messenger RNA (mRNA) for interleukin-4 (IL-4) and interferon-gamma (IFN-gamma), by polymerase chain reaction, in nasopharyngeal aspirates (NPAs) and bronchoalveolar lavage (BAL) fluids. A semiquantitative assay was used to estimate concentrations of mRNA for these cytokines in comparison to mRNA of the constitutively expressed hypoxanthine guanine phosphoribosyl transferase gene. BAL from 18/24 infants showed polarization of cytokine production: 6 with only IFN-gamma mRNA, and 12 with only IL-4 mRNA. For the 6/24 infants in whom both IL-4 mRNA and IFN-gamma mRNA were detected in BAL fluid, each was present in low amounts, compared with those with mRNA for IL-4 or IFN-gamma alone. IL-4 and IFN-gamma mRNA were not detected in any of the NPAs.These findings provide the first direct evidence in infants that in RSV bronchiolitis there are divergent T-cell responses and suggest that more than one mechanism may be responsible for immune-mediated disease enhancement.
