Comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure.

IMPORTANCE: Outcomes associated with use of high-frequency oscillatory ventilation (HFOV) in children with acute respiratory failure have not been established. OBJECTIVE: To compare the outcomes of HFOV with those of conventional mechanical ventilation (CMV) in children with acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective, observational study using deidentified data obtained from all consecutive patients receiving mechanical ventilation aged 1 month to 18 years in the Virtual PICU System database from January 1, 2009, through December 31, 2011. The study population was divided into 2 groups: HFOV and CMV. The HFOV group was further divided into early and late HFOV. Propensity score matching was performed as a 1-to-1 match of HFOV and CMV patients. A similar matching process was performed for early HFOV and CMV patients. EXPOSURE: High-frequency oscillatory ventilation. MAIN OUTCOMES AND MEASURES: Length of mechanical ventilation, intensive care unit (ICU) length of stay, ICU mortality, and standardized mortality ratio (SMR). RESULTS: A total of 9177 patients from 98 hospitals qualified for inclusion. Of these, 902 (9.8%) received HFOV, whereas 8275 (90.2%) received CMV. A total of 1764 patients were matched to compare HFOV and CMV, whereas 942 patients were matched to compare early HFOV and CMV. Length of mechanical ventilation (CMV vs HFOV: 14.6 vs 20.3 days, P < .001; CMV vs early HFOV: 14.6 vs 15.9 days, P < .001), ICU length of stay (19.1 vs 24.9 days, P < .001; 19.3 vs 19.5 days, P = .03), and mortality (8.4% vs 17.3%, P < .001; 8.3% vs 18.1%, P < .001) were significantly higher in HFOV and early HFOV patients compared with CMV patients. The SMR in the HFOV group was 2.00 (95% CI, 1.71-2.35) compared with an SMR in the CMV group of 0.85 (95% CI, 0.68-1.07). The SMR in the early HFOV group was 1.62 (95% CI, 1.31-2.01) compared with an SMR in the CMV group of 0.76 (95% CI, 0.62-1.16). CONCLUSIONS AND RELEVANCE: Application of HFOV and early HFOV compared with CMV in children with acute respiratory failure is associated with worse outcomes. The results of our study are similar to recently published studies in adults comparing these 2 modalities of ventilation for acute respiratory distress syndrome.

Introduction of a rounding sticker improves care and reduces infection rates in the Pediatric Intensive Care Unit (PICU).

As part of our plan to decrease infection rates, we instituted a rounding sticker used during daily rounds. This sticker is a checklist that serves as a reminder of interventions known to improve quality of care in the PICU. It is completed daily and placed in the bedside chart of all patients in the Pediatric Intensive Care Unit (PICU) at Arkansas Children's Hospital. Date was collected on central venous catheter days, foley catheter days, arterial line days, infection rates, GI prophylaxis use, neuromuscular blocker use, and changes in medications before and after institution of the rounding sticker. Following rounding sticker use, there was a 56% reduction in urinary tract infections [4.13/1000 device days vs 1.8/1000 device days; p = 0.027], as well as an increase in GI prophylaxis (1846 vs 2399) and enoxaparin (119 vs 151) use.

Child health-related quality of life following neurocritical care for traumatic brain injury: an analysis of preference-weighted outcomes.

BACKGROUND: Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking. OBJECTIVE: This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge. SETTING/PATIENTS: Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation. MAIN OUTCOME MEASURES: The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity. METHODS: Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission. RESULTS: A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores. CONCLUSIONS: The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status.

CONTEXT: The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well. OBJECTIVE: This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status. DESIGN: An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children's hospitals. PARTICIPANTS: Children aged

Hospitalizations for critically ill children with traumatic brain injuries: a longitudinal analysis.

OBJECTIVE: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988-1999 to describe the benefits of improved treatment. DESIGN: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals. SETTING: Hospital inpatient stays from all types of U.S. community hospitals. PARTICIPANTS: The study sample included all children aged 0-21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately dollar 17 billion, whereas acute care hospitalization costs increased by dollar 1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a dollar 3.76 billion loss in economic benefits. CONCLUSIONS: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.

Physician risk attitudes and hospitalization of infants with bronchiolitis.

OBJECTIVES: To determine whether the risk attitudes of pediatric emergency physicians are related to the likelihood that otherwise healthy infants with bronchiolitis will be admitted for inpatient care. METHODS: Risk aversion and discomfort with diagnostic uncertainty were assessed among 46 pediatric emergency physicians from three hospitals participating in the Child Health Accountability Initiative. Study physicians managed 397 otherwise healthy infants ages 0 to 12 months presenting to their hospital emergency departments with bronchiolitis. Mean risk aversion and discomfort with diagnostic uncertainty scores were compared across physician gender, years of experience, and formal training in emergency medicine. Additional analyses based on infants as the analytic unit determined admission rates of physicians scoring high and low on risk attitude measures. This model was controlled for severity of illness. RESULTS: Scores on measures of risk aversion and discomfort with uncertainty were similar for male and female physicians and for physicians who had completed pediatric emergency medicine fellowship training and those without such training. Risk aversion scores were significantly higher for physicians with 15 or more years of experience. Admission rates for infants with bronchiolitis were no higher among physicians scoring above the median on risk attitude measures. When adjusted for severity of illness, physicians' risk attitudes were not associated with admission rates. CONCLUSIONS: Recent growth in per-capita admissions for bronchiolitis is not accounted for by physician intolerance for diagnostic uncertainty. Physician risk attitudes should be considered in the context of hospital admissions for other pediatric conditions with unclear prognoses.