Humidified high-flow nasal cannula oxygen in bronchiolitis reduces need for invasive ventilation but not intensive care admission.

AIM: To describe the changes to paediatric intensive care unit (PICU) admission patterns and ventilation requirements for children with bronchiolitis following the introduction of humidified high-flow nasal cannula oxygen outside the PICU. METHODS: Retrospective study comparing patients <24 months of age with a discharge diagnosis of bronchiolitis admitted to the PICU. A comparison was made between those before humidified high-flow nasal cannula oxygen use (year 2008) to those immediately following the introduction of humidified high-flow nasal cannula oxygen use (year 2011) and those following further consolidation of humidified high-flow nasal cannula oxygen use outside the PICU (year 2013). RESULTS: Humidified high-flow nasal cannula oxygen use up to 1 L/kg/min in the hospital did not reduce PICU admission. Intubation rates were reduced from 22.2% in 2008 to 7.8% in 2013. There was a non-significant trend towards decreased length of stay in the PICU while hospital length of stay showed a significant decrease following the introduction of humidified high-flow nasal cannula oxygen. Age <6 months and respiratory syncytial virus bronchiolitis were associated with an increased chance of failing humidified high-flow nasal cannula oxygen therapy. CONCLUSION: Humidified high-flow nasal cannula oxygen utilised outside of the PICU in our institution for children with bronchiolitis did not reduce admission rates or length of stay to the PICU but was associated with a decreasing need for invasive ventilation and reduced hospital length of stay.

Ventilator-associated pneumonia in a tertiary paediatric intensive care unit: a 1-year prospective observational study.

OBJECTIVES: To determine the incidence, risk factors and impact of ventilator-associated pneumonia (VAP) in a mixed tertiary paediatric intensive care unit. DESIGN: Prospective observational study. METHODS: Patients in the intensive care unit who were mechanically ventilated for more than 48 hours were assessed daily, according to criteria for a diagnosis of VAP. Potential risk factors for VAP, if present, were documented. RESULTS: Of 692 invasively ventilated patients, 269 (38.9%) were ventilated for > 48 hours and met no exclusion criteria. Eighteen (6.7%) patients had episodes of VAP, and the VAP incidence density was 7.02 per 1000 intubation days. The mean admission Paediatric Index of Mortality 2 risk of death was similar in patients with and without VAP (0.084 v 0.056; P =0.8). Patients with VAP (compared with patients without VAP) had a longer median duration of ICU stay, (19.35 v 7.35 days; P < 0.001), duration of ventilation (11.99 v 4.92 days; P=0.024) and duration of hospital stay (35.5 v 20 days; P < 0.001). Univariate analysis showed that reintubation, absence of tube feeding and absence of stress ulcer prophylaxis were risk factors for VAP. While backward selection removed reintubation as a positive predictor during multivariate analysis, tube feeds (hazard ratio (HR), 0.27; 95% CI, 0.09-0.85; P = 0.02) and stress ulcer prophylaxis (HR, 0.29; 95% CI, 0.11-0.76; P = 0.01) were independently associated with reduced VAP incidence. CONCLUSIONS: VAP in children is associated with significant morbidity and increased length of hospital stay. Enteral feeding and stress ulcer prophylaxis while intubated are associated with lower VAP hazards.

Peri-operative management of paediatric patients undergoing cardiac surgery--focus on respiratory aspects of care.

Children requiring cardiac surgery present particular challenges in peri-operative respiratory management. The wide variety of conditions and operations and their varied impact on respiratory function makes dialogue with related medical staff essential. In most circumstances, cardiac performance is the main determinant of respiratory outcomes. Changing cardiologic and surgical approaches have combined to diminish the severity and frequency of pulmonary hypertensive issues and new treatment modalities are simplifying the intensive care approach. Patients with Down's syndrome and 22q11 deletion syndrome present particular issues related to anatomy, physiology and respiratory function. Certain conditions, including tetralogy of Fallot and cavopulmonary connections, present unique circumstances where respiratory management, sometimes including extubation, may assist in optimisation of cardiac performance. These and other conditions highlight the complexities of cardiopulmonary interactions. Cardiac performance remains the principal determinant of outcome after paediatric cardiac surgery and has the biggest impact on respiratory function.

Recombinant activated factor VII in paediatric cardiac surgery.

OBJECTIVE: To review the use of recombinant activated factor VII in paediatric cardiac surgery. DESIGN: Retrospective chart review. SETTING: Paediatric intensive care unit in a stand-alone university-affiliated children's hospital. PATIENTS AND PARTICIPANTS: Cardiac surgical patients who received recombinant activated factor VII (rFVIIa, NovoSeven; NovoNordisk, Copenhagen, Denmark) between June 2002 and June 2003 at The Children's Hospital at Westmead. RESULTS: Six children undergoing cardiac surgery received rFVIIa. Recombinant activated factor VII was administered if bleeding was excessive and persisted despite appropriate investigation and attention to haemostasis by surgical and medical staff. An intravenous dose of 180 microg/kg was given and repeated 2 h later. All of the six patients responded well to rFVIIa with achievement of haemostasis. No adverse events were noted. CONCLUSIONS: Recombinant activated factor VII achieved haemostasis in six paediatric cardiac surgical patients. Good outcomes and no adverse events were noted in these children.

Quality of life of survivors of pediatric intensive care.

OBJECTIVE: Measuring outcome in pediatric intensive care is necessary to equate the high cost of treatment with benefits to the patient. Although mortality rates and morbidity are relatively insensitive measures of the benefits of treatment, quality of life measurement gives insight into the long-term outcomes. The aim of this study was to investigate the long-term quality of life outcome of children admitted to a pediatric intensive care unit. DESIGN: Prospective survey. SETTING: A 13-bed pediatric intensive care unit in a university-affiliated, tertiary referral children's hospital. PATIENTS: Patients were 432 children discharged from the pediatric intensive care unit between May 1992 and April 1994. INTERVENTIONS: Quality of life was measured by using the Royal Alexandra Hospital for Children Measure of Function. The scale has two components, the first part completed by the clinician after parent interview and the second part completed separately by the parent. MEASUREMENTS AND MAIN RESULTS: Parents of 432 children were contacted between 3 and 24 months after discharge. Twenty-seven children (6.3%) had died after discharge from the pediatric intensive care unit; 59.3% (256) had scores indicating a normal quality of life, and 32.4% (140) had a fair quality of life with ongoing health, social, or cognitive problems requiring some intervention. Two percent of survivors (nine children) had scores indicating a poor quality of life as they had continued to experience significant or disabling health problems requiring hospitalization or the equivalent. Predictors of poor quality of life included presence of comorbidities, increased length of stay, and a diagnostic category of malignancy. Diagnostic categories of respiratory, trauma, and cardiac dysfunction were associated with a better outcome. CONCLUSIONS: Our results indicate that the long-term outcome in terms of quality of life after admission to a pediatric intensive care unit is good or normal for the majority of surviving children. Those children with a poor outcome are likely to have significant comorbidities or a diagnosis of malignancy.