Antipyretic Efficacy of Acetaminophen and Ibuprofen in Critically Ill Pediatric Patients.

OBJECTIVES: To determine the antipyretic efficacy of acetaminophen (IV, enteral, rectal) and ibuprofen (enteral) in critically ill febrile pediatric patients. DESIGN: Retrospective cohort study. SETTING: Quaternary care pediatric hospital ICUs. PATIENTS: Pediatric patients less than 19 years old who were febrile (≥ 38.0°C), received a dose of IV acetaminophen, enteral acetaminophen, rectal acetaminophen, or enteral ibuprofen and had at least one temperature measurement in the following 6 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 3,341 patients (55.8% male, median age 2.5 yr [interquartile range, 0.63-9.2 yr]) met study criteria. Baseline temperature was median 38.6°C (interquartile range, 38.3-38.9°C) measured via axillary (76.9%) route. Patients became afebrile (87.5%) at median 1.4 hours (interquartile range, 0.77-2.3 hr) after the first dose of medication, a -2.9 ± 1.6% change in temperature. Antipyretic medications included as follows: enteral acetaminophen (n = 1,664), IV acetaminophen (n = 682), rectal acetaminophen (n = 637), and enteral ibuprofen (n = 358). Enteral ibuprofen had a significantly greater odds of defervescence on multivariable logistic regression analysis (p = 0.04) with a decrease of -1.97 ± 0.89°C while IV acetaminophen was significant for a decreased time to defervescence at median 1.5 hours (interquartile range 0.8-2.3 hr) after a dose (p = 0.03). Patient age, presence of obesity, and baseline temperature were significant for decreased antipyretic efficacy (p < 0.05). CONCLUSIONS: Enteral ibuprofen was the most efficacious antipyretic and IV acetaminophen had the shortest time to defervescence.

Sudden unexplained cardiac arrest in apparently healthy children: a single-center experience.

This study aimed to determine the causes of sudden cardiac arrest (SCA) in apparently healthy children at a single center in the era of primary prevention (screening questionnaire [SQ]) and secondary prevention (automated external defibrillator [AED] and the automated implantable cardioverter defibrillator [AICD]). Any child 0 to 18 years of age without prior known disease, except for attention deficit disorder, who underwent out-of-the hospital cardiopulmonary resuscitation was included in the study as a SCA subject. A retrospective chart review was used to evaluate the efficacy of the SQ, electrocardiogram (ECG), chest roentgenogram (CXR), and echocardiogram. The findings showed that for 44 of 6,656 children admitted to intensive care with SCA, an AED was used for 39%, an AICD was placed in 18%,and survival to hospital discharge was 50%. The etiology for SCA was identified in 57% of the cases, mostly in those older than 1 year, and the majority of these had a cardiac etiology (50%), whereas 7% had rupture of an arteriovenous malformation. Stimulant medication use was seen in 11% of the SCA subjects. In the best-case scenario of hypothesized primary prevention, a prior SQ, CXR, ECG, or echocardiogram may have detected respectively 18, 9, 23 and 16% of the at-risk cases, and 32% of the cases may have been detected with ECG and SQ together. Based on a historical control cohort, a positive ECG was significantly higher in the children with SCA (p = 0.014). An ECG together with a screening SQ may be more effective in identifying children potentially at risk for SCA than an SQ alone.

Traumatic portacaval shunt: a case report and literature review.

Computed tomography (CT) evaluation of the acute polytrauma patient has become well established as a mainstay of ER triage in hemodynamically stable patients. The radiologist plays a pivotal role in directing management by identifying and appropriately categorizing the severity of a patient's injuries. High-grade liver injuries have undergone an increasing trend of nonoperative management over the last several decades, with concurrent decrease in mortality. However, we present a case of a patient with a grade V liver laceration, in whom a rare portacaval shunt was also present. In the setting of this rare injury, the radiologist will likely be the first person to recognize and categorize a severe complication, which may indicate the need for a fundamental change in patient management.

Active surveillance culturing impacts methicillin-resistant Staphylococcus aureus acquisition in a pediatric intensive care unit.

OBJECTIVE: To determine whether active surveillance culturing for methicillin-resistant Staphylococcus aureus (MRSA) decreases nosocomial MRSA acquisition in the pediatric intensive care unit. DESIGN: Before and after observational study. SETTING: A tertiary care, 20-bed, pediatric intensive care unit. PATIENTS: All patients admitted to the pediatric intensive care unit. INTERVENTIONS: Anterior nares cultures for MRSA were obtained on admission and weekly in the pediatric intensive care unit from January 2007 to December 2009 as part of a hospital quality improvement project. MEASUREMENTS AND MAIN RESULTS: MRSA admission prevalence and nosocomial incidence density were determined retrospectively for 2006 and prospectively for 2007-2009. Nosocomial MRSA incidence density during the intervention period was determined monthly and analyzed by trend analysis by using a general linear model. The correlation of active surveillance culturing compliance with nosocomial acquisition of MRSA was analyzed. Possible confounding by healthcare worker hand hygiene compliance observed during the intervention period was also analyzed by multivariate linear regression analysis. The yearly MRSA incidence density significantly decreased from 2006 to 2009 (6.88 per 1,000 patient days to 1.45 per 1,000 patient days, p < .001) and from 2007 to 2009 (7.32 per 1,000 patient days to 1.45 per 1,000 patient days, p < .001). Trend analysis demonstrated a significant decline in MRSA acquisition over time following the introduction of active surveillance culturing (p < .001). Surveillance culturing was significantly associated with the decline in MRSA acquisition observed in the pediatric intensive care unit by multivariate regression analysis when controlling for hand hygiene (p = .01). CONCLUSIONS: Active surveillance culturing resulted in significantly decreased nosocomial acquisition of MRSA in a pediatric intensive care unit setting. Admission and weekly active surveillance culturing appears to be an effective tool to decrease the spread of MRSA in the pediatric intensive care unit, independent of improvement in hand hygiene compliance. The impact on hospital-acquired MRSA infections and the cost benefit of active surveillance culturing require further study.