A noninvasive hemoglobin monitor in the pediatric intensive care unit.

BACKGROUND: Critically ill pediatric patients frequently require hemoglobin monitoring. Accurate noninvasive Hb (SpHb) would allow practitioners to decrease anemia from repeated blood draws, traumatic blood draws, and a decreased number of laboratory Hb (LabHb) medical tests. The Food and Drug Administration has approved the Masimo Pronto SpHb and associated Rainbow probes; however, its use in the pediatric intensive care unit (PICU) is controversial. In this study, we define the degree of agreement between LabHb and SpHb using the Masimo Pronto SpHb Monitor and identify clinical and demographic conditions associated with decreased accuracy. MATERIALS AND METHODS: We performed a prospective, observational study in a large PICU at an academic medical center. Fifty-three pediatric patients (30-d and 18-y-old), weighing >3 kg, admitted to the PICU from January-April 2013 were examined. SpHb levels measured at the time of LabHb blood draw were compared and analyzed. RESULTS: Only 83 SpHb readings were obtained in 118 attempts (70.3%) and 35 readings provided a result of "unable to obtain." The mean LabHb and SpHb were 11.1 g/dL and 11.2 g/dL, respectively. Bland-Altman analysis showed a mean difference of 0.07 g/dL with a standard deviation of ±2.59 g/dL. Pearson correlation is 0.55, with a 95% confidence interval between 0.38 and 0.68. Logistic regression showed that extreme LabHb values, increasing skin pigmentation, and increasing body mass index were predictors of poor agreement between SpHb and LabHb (P < 0.05). Separately, increasing body mass index, hypoxia, and hypothermia were predictors for undetectable readings (P < 0.05). CONCLUSIONS: The Masimo Pronto SpHb Monitor provides adequate agreement for the trending of hemoglobin levels in critically ill pediatric patients. However, the degree of agreement is insufficient to be used as the sole indicator for transfusion decisions and should be used in context of other clinical parameters to determine the need for LabHb in critically ill pediatric patients.

Management and sequelae of a 41-year-old jehovah's witness with severe anhydrous ammonia inhalation injury.

Anhydrous ammonia is a commonly used chemicals that are found in fertilizer, refrigeration, and in other occupational environments. Lung damage because of inhalation of ammonia can be devastating, producing debilitating lung disease and can ultimately lead to death. This is the case of a 41-year-old male, previously healthy, Jehovah's Witness, who was working at a poultry plant facility when an explosion occurred exposing him to toxic levels of anhydrous ammonia. Our patient developed end-stage lung disease after sustaining a severe ammonia inhalation injury. Despite aggressive pulmonary rehabilitation, the patient continued to deteriorate, and his only option for a chance at improved quality of life was a double-lung transplant. To our knowledge, this is the first report of a bloodless lung transplantation for inhalational lung injury in the literature. Further study is needed to better understand the effects of ammonia on lung physiology in order to better manage and treat patients who develop acute and chronic lung complications after exposure.

Chest high-frequency oscillatory treatment for severe atelectasis in a patient with toxic epidermal necrolysis.

Atelectasis is a significant risk factor for the development of pneumonia, especially in pediatric populations more prone to alveolar collapse or those who may have weakened muscular tone. The Metaneb system is a pneumatic, noninvasive physiotherapy technique that delivers chest high-frequency oscillations. Chest high-frequency oscillations have been shown to enhance mucociliary clearance of secretions and help resolve patchy atelectasis. This report describes the case of a 17-year-old female patient who developed significant left-sided atelectasis after extubation and was effectively managed with complete resolution of her atelectasis with the Metaneb system, obviating the need for reintubation.

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

BACKGROUND: An evidence-based teamwork system, Team-STEPPS, was implemented in an academic medical center's pediatric and surgical ICUs. METHODS: A multidisciplinary change team of unit- and department-based leaders was formed to champion the initiative; develop a customized action plan for implementation; train frontline staff; and identify process, team outcome, and clinical outcome objectives for the intervention. The evaluation consisted of interviews with key staff, teamwork observations, staff surveys, and clinical outcome data. RESULTS: All PICU, SICU, and respiratory therapy staff received TeamSTEPPS training. Staff reported improved experience of teamwork posttraining and evaluated the implementation as effective. Observed team performance significantly improved for all core areas of competency at 1 month postimplementation and remained significantly improved for most of the core areas of competency at 6 and 12 months postimplementation. Survey data indicated improvements in staff perceptions of teamwork and communication openness in both units. From pre- to posttraining, the average time for placing patients on extracorporeal membrane oxygenation (ECMO) decreased significantly. The average duration of adult surgery rapid response team events was 33% longer at postimplementation versus pre-implementation. The rate of nosocomial infections at postimplementation was below the upper control limit for seven out of eight months in both the PICU and the SICU. CONCLUSIONS: The implementation of a customized 2.5-hour version of the TeamSTEPPS training program in two areas--the PICU and SICU--that had demonstrated successful ability to innovate suggests that the training was successful.

Comparison of three humidifiers during high-frequency percussive ventilation using the VDR-4® Fail-safe Breathing Circuit Hub.

The VDR-4® high-frequency percussive ventilator (HFPV) has been shown to be beneficial in the management of inhalation injury by improving secretion clearance while maintaining oxygenation and ventilation. Delivery of gas flow during HFPV could lack adequate humidification delivered to the patient because a major portion of the delivered gas flow would bypass the humidifier when using the original VDR-4® ventilator circuit. The authors tested a novel inline vaporizing humidifier and two gas-water interface humidifiers during HFPV using the new VDR-4® Fail-safe Breathing Circuit Hub® to determine whether delivered humidification could be improved. This new humidification system, the Hydrate Omni™, delivers water vapor into the gas flow of the ventilator circuit rather than water droplets as delivered by the gas-water interface humidifiers. Measurements of absolute humidity and gas temperature were made on the three different humidification systems using a test lung model under standard ambient conditions. The authors found that when using the novel inline vaporizer, it provided better humidification when compared with the standard gas-water interface humidifier during HFPV using the new VDR-4® breathing circuit.

Evaluation of a new circuit configuration for the VDR-4 high-frequency percussive ventilator.

High-frequency percussive ventilation (HFPV) by the VDR-4(R) has been a successful mode of ventilation in the management of inhalation injuries for nearly 20 years. A limitation of the standard VDR-4 ventilator circuit is that the sliding venturi manifold is heavy in weight and is normally connected directly to the patient's endotracheal tube (ETT), resulting in potentially hazardous torque on the ETT. In this study, we evaluate the mechanics of a new circuit for the VDR-4 that relocates the sliding venturi manifold portion of the circuit away from the ETT into the ventilator proper. This new VDR-4 circuit configuration may have an important impact on patient safety.

Use of a new novel humidification system with high frequency percussive ventilation in a patient with inhalation injury.

Historically, it has been difficult to provide adequate humidification delivery with the high frequency percussive ventilator (HFPV) used in many burn centers. It is possible burn centers have avoided using HFPV because of the risk of mucus plugging, dried secretions, and cast formation. Experiences with HFPV provided doubt that the HFPV ventilator circuit could supply adequate humidification to patients receiving this mode of ventilation. Independent gas-flow delivery through the ventilator circuit inherent in HFPV provided a challenge in maintaining adequate humidification delivery to the patient. This report describes a dramatic reduction in dried, inspissated secretions by using a novel new humidification device with HFPV. The new device called the Hydrate Omni (Hydrate, Inc., Midlothian, VA) uses a small ceramic disk to provide fine water particles delivered by a pump to the HFPV circuit. This new device may alleviate previous concerns related to the delivery of adequate humidification with the HFPV. This case report was approved by the University of North Carolina School of Medicine Institutional Review Board.

High-frequency percussive ventilation in a pediatric patient with hydrocarbon aspiration.

INTRODUCTION: To describe ventilator management using a high-frequency percussive ventilator (HFPV), after other modes of mechanical ventilation failed. DESIGN: Case series. SETTING: Pediatric intensive care unit. PATIENTS: Previously healthy 11-month-old male with severe aspiration pneumonitis from mineral oil. INTERVENTIONS: The patient was initially placed on a conventional ventilator in a pressure-regulated volume-control mode but needed higher-than-normal pressures to maintain adequate ventilation. A decision was made to switch the patient to a pressure-control/pressure-support mode. At the end of the third day of pressure-control/pressure-support mode, a decision was made to attempt airway pressure-release ventilation. During a trial attempt, saturation levels deteriorated and a decision was made to place the patient on a high-frequency oscillator. The patient remained on this mode of ventilation for 6 days. On the sixth day, the chest radiograph showed a worsening of his pneumonia, and the patient started to deteriorate. A decision was made to try the HFPV in an attempt to mobilize secretions and any residual mineral oil. Immediately after initiating the HFPV and for 4 hrs thereafter, large amounts of secretions -- including a thick, oily substance -- were suctioned from the airways. Within 12-24 hrs, oxygenation improved dramatically and Fio2 was weaned. During the next 12 hrs, the patient was weaned off HFPV onto a conventional ventilator, and he was extubated 48 hrs after initiating HFPV. CONCLUSIONS: In this case, HFPV used as an alternative mode of ventilation successfully mobilized secretions that were otherwise unobtainable and that we believe led to the swift recovery of this child. HFPV should be given consideration as a mode of ventilation when mobilization of secretions is an issue.

Utilization of bronchodilators in ventilated patients without obstructive airways disease.

OBJECTIVE: To examine physician practice in, and the costs of, prescribing inhaled bronchodilators to mechanically ventilated patients who do not have obstructive lung disease. METHODS: This was a prospective cohort study at 2 medical intensive care units at 2 tertiary-care academic medical centers, over a 6-month period. Included were the patients who required > or = 24 hours of mechanical ventilation but did not have obstructive lung disease. Excluded were patients who had obstructive lung disease and/or who had undergone > 24 hours of mechanical ventilation outside the study intensive care units. RESULTS: Of the 206 patients included, 74 (36%) were prescribed inhaled bronchodilators without clear indication. Sixty-five of those 74 patients received both albuterol and ipratropium bromide, usually within the first 3 days of intubation (58 patients). Patients prescribed bronchodilators were more hypoxemic; their mean P(aO(2))/F(IO(2)) ratio was lower (188 mm Hg versus 238 mm Hg, p = 0.004), and they were more likely to have pneumonia (53% vs 33%, p = 0.007). The mean extra cost for bronchodilators was 449.35 dollars per patient. Between the group that did receive bronchodilators and the group that did not, there was no significant difference in the incidence of ventilator-associated pneumonia, tracheostomy, or mortality. The incidence of tachyarrhythmias was similar (15% vs 22%, p = 0.25). CONCLUSION: A substantial proportion of mechanically ventilated patients without obstructive lung disease received inhaled bronchodilators.