Prolonged mechanical ventilation as a consequence of acute illness.

OBJECTIVE: To determine why acutely ill children become dependent upon mechanical ventilation and what happens to them. METHODS: A retrospective medical record study of all patients aged between 1 month and 16 years from 1983 to 1996 who required ventilation for more than 28 days. RESULTS: Forty children were ventilated for between 36 and 180 days before discharge or death. Before their presenting illness, 13 (33%) were normal, 15 (37%) had documented predisposing conditions such as bronchopulmonary dysplasia, and the remaining 12 (30%) had diagnoses made after admission. The cause of respiratory failure was central in four patients (10%), spinal cord in eight (20%), neuromuscular in 11 (28%), and pulmonary in 17 (42%). Severe nosocomial infection requiring treatment with intravenous antibiotics occurred in 22. To date, 16 children (40%) have died, and 10 (25%) remain ventilator dependent. Of the 24 survivors, seven (29%) have severe residual neurological deficit. CONCLUSIONS: Increasingly, children are surviving intensive care only to remain ventilator dependent and at risk of significant comorbidity. This study should inform further debate on why such children remain ventilator dependent, and how and where they are managed.

Early response to inhaled nitric oxide and its relationship to outcome in children with severe hypoxemic respiratory failure.

OBJECTIVE: To examine whether the early response to inhaled nitric oxide (iNO) is a measure of reversibility of lung injury and patient outcome in children with acute hypoxemic respiratory failure (AHRF). DESIGN: Retrospective review study. SETTING: Pediatric ICUs. PATIENTS: Thirty infants and children, aged 1 month to 13 years (median, 7 months) with severe AHRF (mean alveolar arterial oxygen gradient of 568+/-9.3 mm Hg, PaO2/fraction of inspired oxygen of 56+/-2.3, oxygenation index [OI] of 41+/-3.8, and acute lung injury score of 2.8+/-0.1). Eighteen patients had ARDS. INTERVENTIONS: The magnitude of the early response to iNO was quantified as the percentage change in OI occurring within 60 min of initiating 20 ppm iNO therapy. This response was compared to patient outcome data. MEASUREMENTS AND RESULTS: There was a significant association between early response to iNO and patient outcome (Kendall tau B r=0.43, p < 0.02). All six patients who showed < 15% improvement in OI died; 4 of the 11 patients (36%) who had a 15 to 30% improvement in OI survived, while 8 of 13 (61%) who had a > 30% improvement in OI survived. Overall, 12 patients (40%) survived, 9 with ongoing conventional treatment including iNO, and 3 with extracorporeal support. CONCLUSIONS: In AHRF in children, greater early response to iNO appears to be associated with improved outcome. This may reflect reversibility of pulmonary pathophysiologic condition and serve as a bedside marker of disease stage.

Prevention of neonatal infections by vaginal chlorhexidine disinfection during labour.

Comparison of two different methods of vaginal disinfection was made with regard to prevention of neonatal infections. In method I, an antepartum vaginal douche with a chlorhexidine solution was used; method II involved the use of chlorhexidine gluconate obstetrical gel during vaginal exploration. We studied 2853 normal deliveries from a total number of 3236 deliveries: 1467 deliveries were allocated randomly to receive a vaginal douche whereas 1386 underwent vaginal exploration using chlorhexidine gel. A total of 203 neonates were transferred to the neonatal unit (120 males and 83 females): 101 belonged to the group where the mothers were subjected to method I, whereas in 102 method II had been used. Within 48 h postpartum 30 neonates from the method I group and 34 neonates from the method II group received systemic antibiotics. There was a tendency towards a higher proportion of full-term neonates with verified septicaemia in the method II group (6 versus 2), whereas the numbers of probable infections were 8 versus 12. The corresponding total numbers in preterm infants were 3 and 2, respectively. These differences were not statistically significant. We conclude that the use of chlorhexidine douche compared with vaginal exploration with chlorhexidine gel provides no additional advantages.