Effectiveness of a Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia at the PICU: A Systematic Review and Meta-Analysis.

OBJECTIVES: Ventilator-associated pneumonia is one of the most frequent hospital-acquired infections in mechanically ventilated children. We reviewed the literature on the effectiveness of ventilator care bundles in critically ill children. DATA SOURCES: Embase, Medline OvidSP, Web-of-Science, Cochrane Library, and PubMed were searched from January 1990 until April 2017. STUDY SELECTION: Studies were included if they met the following criteria: 1) implementation of a ventilator care bundle in PICU setting; 2) quality improvement or multicomponent approach with the (primary) objective to lower the ventilator-associated pneumonia rate (expressed as ventilator-associated pneumonia episodes/1,000 ventilator days); and 3) made a comparison, for example, with or without ventilator care bundle, using an experimental randomized or nonrandomized study design, or an interrupted-times series. Exclusion criteria were (systematic) reviews, guidelines, descriptive studies, editorials, or poster publications. DATA EXTRACTION: The following data were collected from each study: design, setting, patient characteristics (if available), number of ventilator-associated pneumonia per 1,000 ventilator days, ventilator-associated pneumonia definitions used, elements of the ventilator care bundle, and implementation strategy. Ambiguities about data extraction were resolved after discussion and consulting a third reviewer (M.N., E.I.) when necessary. We quantitatively pooled the results of individual studies, where suitable. The primary outcome, reduction in ventilator-associated pneumonia per 1,000 ventilator days, was expressed as an incidence risk ratio with a 95% CI. All data for meta-analysis were pooled by using a DerSimonian and Laird random effect model. DATA SYNTHESIS: Eleven articles were included. The median ventilator-associated pneumonia incidence decreased from 9.8 (interquartile range, 5.8-18.5) per 1,000 ventilator days to 4.6 (interquartile range, 1.2-8.6) per 1,000 ventilator days after implementation of a ventilator care bundle. The meta-analysis showed that the implementation of a ventilator care bundle resulted in significantly reduced ventilator-associated pneumonia incidences (incidence risk ratio = 0.45; 95% CI, 0.33-0.60; p < 0.0001; I = 55%). CONCLUSIONS: Implementation of a ventilator-associated pneumonia bundle has the potential to reduce the prevalence of ventilator-associated pneumonia in mechanically ventilated children.

Acute loss of the small bowel in a school-age boy. Difficult choices: to sustain life or to stop treatment?

UNLABELLED: A 9-year-old boy lost almost all his small bowel after an acute volvulus due to a congenital, but previously unsuspected malrotation. Survival using total parenteral nutrition is possible in these cases, but the medical burden is heavy. Small intestinal transplantation was performed for the first time in the Netherlands in 2001 and this patient was treated 3 years earlier. The results of bowel transplantation are not as good as in kidney or liver transplantation. A method of Ethical Case Deliberation helped to elucidate the importance of each contribution in the discussion and provided space and a broad basis for decision-making. The parents refused to allow parenteral nutrition to be started because of the bad prospects for quality of life in the future and the medical team, after thorough deliberation with specialists throughout the country, and consultation of the literature, agreed. CONCLUSION: Despite the many different opinions, the parents felt accepted in their refusal of treatment for their son and the team accepted the decision.