Examination of Early Endotracheal Aspirate Cultures in Children with Acute Respiratory Failure Due to Presumed Acute Respiratory Tract Infection.

OBJECTIVE: To determine the yield of early endotracheal aspirate cultures in mechanically ventilated pediatric patients with acute respiratory failure due to acute respiratory tract infection and endeavor to guide antibiotic choice in acute respiratory failure with concern for infectious etiology. RESULTS: One-hundred ten admissions were included. Of those samples, 61 percent (67 out of 110) had bacterial growth in tracheal aspirate samples. Ninety percent (99 out of 110) patients have received antibiotics and in 47 percent (53 out of 110) antibiotics were optimized or discontinued according to the culture results. There were no difference in duration of mechanical ventilation or PICU stay in patients with positive versus negative cultures (p: 0.613, P: 0.337). CONCLUSIONS: Our study shows a high yield of positive tracheal aspirate cultures in infants, children and adolescents with acute respiratory failure. The cultures identify common organisms, helps to guide initial antibiotics choice, as well as later optimization or antibiotic discontinuation.

Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis.

OBJECTIVE: Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program. METHODS: This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses. RESULTS: Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents. CONCLUSIONS: There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

High-dose rosuvastatin treatment for multifocal stroke in trauma-induced cerebral fat embolism syndrome: a case report.

BACKGROUND: Fat embolism syndrome is a life-threatening condition with treatment centering on the provision of excellent supportive care and early fracture fixation. No pharmacologic intervention has yet shown any clear benefit. We used high-dose rosuvastatin specifically for its anti-inflammatory effects to treat a patient with severe fat embolism syndrome. We also suggest that magnetic resonance imaging and transcranial Doppler studies are helpful in establishing the diagnosis and for monitoring the patient's course. PATIENT: A 17-year-old boy developed severe cerebral fat embolism syndrome with multifocal strokes after sustaining bilateral femur fractures. RESULTS: In spite of profound and prolonged neurological impairment, our patient experienced dramatic recovery by the time he was discharged from inpatient rehabilitation several weeks after his initial injury. Magnetic resonance imaging revealed the classic "starfield" pattern of infarcts on diffusion-weighted sequences early in the illness. Additionally, serial transcranial Doppler studies demonstrated dramatically elevated microembolic events that resolved completely during the course of treatment. CONCLUSION: We feel that the acute administration of high-dose rosuvastatin early in the development of our patient's illness may have contributed to his ultimate recovery. Therapeutic guidelines cannot be extrapolated from a single patient, but our experience suggests that statin therapy could be potentially beneficial for individuals with severe fat embolism syndrome, and this approach deserves further clinical evaluation. Additionally, the diagnosis and monitoring of cerebral involvement in fat embolism syndrome is facilitated by both magnetic resonance imaging and transcranial Doppler studies.

Long-term dexmedetomidine use and safety profile among critically ill children and neonates.

OBJECTIVE: To determine whether long-term dexmedetomidine dosing is associated with lower opioid and benzodiazepine use without risk of significant hemodynamic changes and/or withdrawal. DESIGN: Retrospective, observational study. SETTING: PICU, cardiovascular ICU, and neonatal ICU in a single, tertiary care, academic children's hospital. SUBJECTS: We included all patients less than or equal to 21 years old, who received dexmedetomidine for greater than or equal to 72 hours from December 2008 to December 2010 resulting in a 98-subject cohort. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: The median duration of dexmedetomidine use was 141 hours. A decrease in systolic blood pressure and heart rate was seen after initiation of dexmedetomidine. After dexmedetomidine was discontinued, systolic blood pressure was statistically significantly higher than baseline. Similarly, heart rate showed a significant increase from baseline following discontinuation of dexmedetomidine. Starting dexmedetomidine was not associated with a significant difference in the dosing of opiates or benzodiazepines. Comfort scores were significantly lower at 2 and 72 hours of dexmedetomidine infusion. After stopping dexmedetomidine, the comfort score for patients at 1 hour was statistically higher than for patients at cessation of the infusion. Thirty percent of patients who were taken off dexmedetomidine, whether weaned or abruptly stopped, had withdrawal symptoms and scores recorded with agitation, tremor, and decreased sleep being most prominent. CONCLUSIONS: Hemodynamic effects of dexmedetomidine did not limit long-term use in this diverse population. After the addition of dexmedetomidine, opioid and benzodiazepine doses did not significantly escalate, and patients were more comfortable as evidenced by decreasing comfort scores. Withdrawal from dexmedetomidine may be an issue and manifests as agitation, tremors, and decreased sleep.