Assessing Frequency of Respiratory Complications in Children Undergoing Adenotonsillectomy.

OBJECTIVES: To determine the frequency of respiratory complications in children admitted to the ICU after adenotonsillectomy and to identify factors associated with the risk of respiratory complications in this cohort. DESIGN: Retrospective observational study. SETTING: PICU. PATIENT POPULATION: All children admitted to the ICU following adenotonsillectomy from September 30, 2009, to March 30, 2014. MEASUREMENTS AND MAIN RESULTS: Of the 165 children included in the study, 150 (91%) received no respiratory support other than oxygen in the first 2 hours postoperatively. Of the 15 who required support following 2 hours, 14 required nasopharyngeal airways, one required invasive mechanical ventilation, and seven required supplemental oxygen for more than 2 hours. None of the children who received respiratory support for less than 2 hours required subsequent ICU level care. When comparing those who received support for more than 2 hours to those who did not, there were no differences in clinical characteristics except that those who received support were more likely to have chronic neurologic disease including autism, seizures, or cerebral palsy (odds ratio, 3.7; 95% CI, 1.1-11.9; p = 0.04). Intraoperative events were not predictive of need for respiratory support. Most of the children (n = 117/165 or 71%) had sleep studies preoperatively. Abnormal sleep studies (apnea-hypopnea index > 20 [n = 68] or oxygen saturation nadir < 80% [n = 48]) were not associated with need for postoperative respiratory support. CONCLUSIONS: Most children admitted to the ICU following adenotonsillectomy in this population required no support after 2 hours. Preoperative factors such as obesity and abnormal sleep studies were not predictive of need for postoperative respiratory support. Need for respiratory support at 2 hours may be a useful criterion for need for ICU level care in this population.

Increased Use of Noninvasive Ventilation Associated With Decreased Use of Invasive Devices in Children With Bronchiolitis.

To assess how a change in practice to more frequent use of high-flow nasal cannula for the treatment of bronchiolitis would affect the use of invasive devices in children. DESIGN: Retrospective cohort study of children under 2 years old admitted to the ICU with respiratory failure secondary to bronchiolitis. Outcomes and invasive device use were compared between two time periods, before and after the practice change. SETTING: Eighteen bed tertiary care PICU. PATIENTS: A total of 325 children: 146 from 2010 to 2012 and 179 from 2015 to 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were no significant differences between the two time periods regarding gender, race/ethnicity, medical history, and viral profile, although children were younger in the earlier cohort (median age of 1.9 mo [interquartile range, 1.2-3.5] vs 3.3 mo [1.7-8.6]; p < 0.001). There was an increased use of noninvasive ventilation in the second time period (94% from 69%; p < 0.001), as well as a decreased frequency of intubation (13% from 42%; p < 0.001) and reduced central venous catheter placement (7% from 37%; p < 0.001). There was no significant difference in mortality between the two groups. A logistic regression analysis was conducted, which found that time period, intubation, and hospital length of stay were all independently associated with central venous catheter placement. CONCLUSIONS: A practice change toward managing patients with bronchiolitis in respiratory failure with less invasive means was associated with a reduction in the use of other invasive devices. In our cohort, minimizing the use of invasive ventilation and devices was not associated with an increase in mortality and could potentially have additional benefits.

Dexmedetomidine Use in Critically Ill Children With Acute Respiratory Failure.

OBJECTIVE: Care of critically ill children includes sedation but current therapies are suboptimal. To describe dexmedetomidine use in children supported on mechanical ventilation for acute respiratory failure. DESIGN: Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial. SETTING: Thirty-one PICUs. PATIENTS: Data from 2,449 children; 2 weeks to 17 years old. INTERVENTIONS: Sedation practices were unrestrained in the usual care arm. Patients were categorized as receiving dexmedetomidine as a primary sedative, secondary sedative, periextubation agent, or never prescribed. Dexmedetomidine exposure and sedation and clinical profiles are described. MEASUREMENTS AND MAIN RESULTS: Of 1,224 usual care patients, 596 (49%) received dexmedetomidine. Dexmedetomidine as a primary sedative patients (n = 138; 11%) were less critically ill (Pediatric Risk of Mortality III-12 score median, 6 [interquartile range, 3-11]) and when compared with all other cohorts, experienced more episodic agitation. In the intervention group, time in sedation target improved from 28% to 50% within 1 day of initiating dexmedetomidine as a primary sedative. Dexmedetomidine as a secondary sedative usual care patients (n = 280; 23%) included more children with severe pediatric acute respiratory distress syndrome or organ failure. Dexmedetomidine as a secondary sedative patients experienced more inadequate pain (22% vs 11%) and sedation (31% vs 16%) events. Dexmedetomidine as a periextubation agent patients (n = 178; 15%) were those known to not tolerate an awake, intubated state and experienced a shorter ventilator weaning process (2.1 vs 2.3 d). CONCLUSIONS: Our data support the use of dexmedetomidine as a primary agent in low criticality patients offering the benefit of rapid achievement of targeted sedation levels. Dexmedetomidine as a secondary agent does not appear to add benefit. The use of dexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. These data support a broader armamentarium of pediatric critical care sedation.

Cardiovascular Effects of Continuous Dexmedetomidine Infusion Without a Loading Dose in the Pediatric Intensive Care Unit.

BACKGROUND: Use of dexmedetomidine in pediatric critical care is common, despite lack of prospective studies on its hemodynamic effects. OBJECTIVE: To describe cardiovascular effects in critically ill children treated with a constant continuous infusion of dexmedetomidine without a loading dose at highest Food and Drug Administration-approved adult dose. METHODS: Prospective, pilot study of 17 patients with dexmedetomidine infused at a rate of 0.7 µg/kg/h for 6 to 24 hours. Heart rate (HR) and blood pressure (BP) values over time were analyzed by a random effects mixed model. RESULTS: Patients with median age of 1.6 years (1 month to 17 years) and median weight of 11.8 kg (2.8-84 kg) received an infusion for a mean of 16 ± 7.2 hours. There were no cardiac conduction abnormalities. One patient required discontinuation of infusion for predetermined low HR termination criteria at hour 13 of infusion; there was no clinical compromise and it coincided with planned extubation. Decreased HR of 20% from baseline was found in 35% of patients. The mean HR reduction was largest at hour 13 of infusion with a decrease of 13 ± 17 bpm from baseline, but HR changes over time were not statistically significant. Blood pressure effects included a decrease in 12% and an increase in 29%. There was a small but statistically significant increase in systolic BP of 0.4 mm Hg/h of infusion, P < .001. CONCLUSION: A continuous infusion of 0.7 µg/kg/h of dexmedetomidine without a loading dose for up to 24 hours in critically ill children had tolerable effects on HR and BP.

Organ donation after cardiac death in children: acceptance of a protocol by multidisciplinary staff.

BACKGROUND: Organ donation after cardiac death is increasingly implemented, with outcomes similar to those of organ donation after brain death. Many hospitals hesitate to implement a protocol for donation after cardiac death because of the potential negative reactions among health care providers. OBJECTIVES: To determine the acceptance of a protocol for donation after cardiac death among multidisciplinary staff in a pediatric intensive care unit. METHODS: An anonymous, 15-question, Likert-scale questionnaire (scores 1-5) was used to determine the opinions of staff about donation after brain death and after cardiac death in a pediatric intensive care unit of a tertiary-care university hospital. RESULTS: Survey response rate was 67% (n = 60). All physicians, 89% of nurses, and 82% of the remaining staff members stated that they understood the difference between donation after brain death and donation after cardiac death; staff supported both types of donation, at rates of 90% and 85%, respectively. Staff perception was the same for each type of donation (ρ = 0.82; r = 0.92; P < .001). The 20 staff members who provided care directly to patients who were donors after cardiac death considered such donation worthwhile. However, 60% of those providers offered suggestions to improve the established protocol for donation. CONCLUSIONS: The multidisciplinary staff has accepted organ donation after cardiac death and has fully integrated this kind of donation without reported differences from their acceptance of donation after brain death.