Ventilator-associated events in children: A multicentre prospective cohort study.

BACKGROUND: The Centres for Disease Control and Prevention (CDC) broadened the focus of surveillance from ventilator-associated pneumonia to ventilator-associated event (VAE) for quality purposes. No paediatric definition of VAE (PaedVAE) has been accurately validated. We aimed to analyse the incidence and impact on patient outcomes resulting from the application of the adult and two paediatric VAE (PaedVAE) criteria. SECONDARY OBJECTIVE: to evaluate VAE/PaedVAE as factors associated with increased duration of mechanical ventilation (MV) and Paediatric Intensive Care Unit (PICU) stay. METHODS: Multicentre observational prospective cohort study in 15 PICUs in Spain. VAEs were assessed using the 2013/2015 CDC classification. PaedVAE were assessed using the CDC definition based on mean airway pressure (MAP-PaedVAE) versus a paediatric definition based on positive end-expiratory pressure (PEEP-PaedVAE). Children who underwent MV ≥ 48 h were included. RESULTS: A total of 3626 ventilator-days in 391 patients were analysed. The incidence of VAE, MAP-PaedVAE and PEEP-PaedVAE was 8.55, 5.24 and 20.96 per 1000 ventilator-days, respectively. The median time [IQR] for VAE, MAP-PaedVAE and PEEP-PaedVAE development from the MV onset was 4 [3-12.5], 4 [3-14], and 5 [3-7.75] days, respectively. Among survivors, all three were associated with increased MV duration (> 7 days) and PICU stay (> 10 days) at univariate analysis. Multivariate analysis showed that PEEP-PaedVAE was the only definition independently associated with MV above 7 days [OR = 4.86, 95% CI (2.41-10.11)] and PICU stay [OR = 3.49, 95% CI (1.68-7.80)] above ten days, respectively. CONCLUSIONS: A VAE definition based on slight PEEP increases should be preferred for VAE surveillance in children.

Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation.

OBJECTIVES: To compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. METHODOLOGY: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 h. We compared two independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. RESULTS: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean ±â€¯standard deviation of patients were 49 ±â€¯65 months, weight 17 ±â€¯16 kg. Mechanical ventilation medium time was 22 h (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8 ±â€¯10,6 min group A and 137,3 ±â€¯45 min group B (P < 0.001), extubation time after removing sedoanalgesia was of 24 ±â€¯21 min group A and 230 ±â€¯102 min group B (P < 0.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation) P = 0,572. CONCLUSIONS: Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.

Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración / Midazolam/fentanyl vs. propofol/remifentanil in immediate postoperative with short-term mechanical ventilation

Objetivos: Comparar, entre 2 regímenes de sedoanalgesia, el tiempo trascurrido desde la retirada de la medicación hasta el despertar y hasta la extubación del paciente. Metodología: Estudio observacional, en pacientes pediátricos que, tras cirugía electiva, precisaron sedoanalgesia y ventilación mecánica durante un periodo máximo de 72 h. Comparamos 2 grupos independientes de pacientes: grupo A, pacientes que recibieron sedoanalgesia con propofol-remifentanilo recogidos de forma prospectiva, y grupo B, pacientes que recibieron midazolam-fentanilo recogidos retrospectivamente mediante la revisión de las historias clínicas y base de datos de la unidad. Las variables estudiadas fueron: edad, peso, sexo, tipo de intervención, escalas de valoración de la sedoanalgesia, dosis totales empleadas, tiempo transcurrido desde la retirada de medicación hasta despertar y extubación, y efectos adversos. Resultados: Se recogió a 82 pacientes, 43 en el grupo A y 39 en el grupo B. La edad (media±desviación estándar) de los pacientes fue de 49±65 meses y 17,3±16kg de peso, con un tiempo de ventilación mecánica promedio de 22 h (3-72). Tras retirar la medicación, el tiempo de despertar fue de 11,8±10,6 min en el grupo A y de 137,3±45 min en el grupo B (p<0,001) y el tiempo de extubación de 24±21 min en el grupo A y 230±102 min en el B (p<0,001). El 10,5% de los pacientes del grupo A presentó algún efecto adverso (7,9% agitación y 2,6% bradicardia) y, del grupo B, un 13% (depresión respiratoria tras extubación), con una p=0,572. (AU)

Objectives: Compare between 2 sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. Methodology: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72 hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. Results: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22 hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6 minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572. (AU)

[Midazolam/fentanyl vs propofol/remifentanil in immediate postoperative with short-term mechanical ventilation]. / Sedoanalgesia con midazolam/fentanilo vs. propofol/remifentanilo en postoperatorio inmediato con ventilación mecánica de corta duración.

OBJECTIVES: Compare between 2sedoanalgesia regimes, the time from withdrawal of the medication until the patient wakes up and until extubation. METHODOLOGY: Observational study on pediatric patients after elective surgery that needed mechanical ventilation for a period maximum to 72hours. We compared 2independent groups of patients: group A: patients collected prospectively who received sedoanalgesia with propofof-remifentanil and group B: patients who received midazolam-fentanyl collected retrospectively by reviewing medical records and database of the unit. The main variables studied were: Age, weight, sex, interventions type, sedoanalgesia scales, drugs dosages, time from withdrawal of medication to awakening and extubation, and adverse effects. RESULTS: We collected 82 patients, 43 in group A and 39 in group B. Age (arithmetical mean±standard deviation of patients were 49±65 months, weight 17±16kg. Mechanical ventilation time medium was 22hours (3-72), wake-up time from withdrawal after removing sedoanalgesia was of 11,8±10,6minutes group A and 137,3±45minutes group B (P<.001), extubation time after removing sedoanalgesia was of 24±21minutes group A and 230±102minutes group B (P<.001). Adverse effects were found in 10.5% of patients group A (7.9% agitation, 2.6% bradycardia), and 13% of patients group B (respiratrory depression after extubation), P=.572. CONCLUSIONS: Patients treated with propofol-remifentanil have significantly shorter times to wake up, extubation and withdrawal from mechanical ventilation after stopping the medication. In the midazolam-fentanyl group, respiratory depression was more frequent, although the percentage of adverse effects were similar in both groups. Both the combination of propofol-remifentanil and midazolam-fentanyl appear to be effective as a sedative-analgesic regimen for patients undergoing mechanical ventilation after surgery.

Comparación de niveles de glucemia postoperatoria usando sueros con diferente concentración de glucosa / A comparison of post-surgical plasma glucose levels in patients on fluids with different glucose concentrations

OBJETIVO: Comparar los niveles de glucemia e incidencia de hiperglucemia en el postoperatorio de cirugía general usando sueros con diferente concentración de glucosa. METODOLOGÍA: Ensayo clínico aleatorizado, abierto, no ciego, en pacientes no diabéticos, que ingresan en Cuidados Intensivos Pediátricos tras cirugía electiva, de 6 meses a 14 años, peso superior a 6 kg, glucemia > 60mg/dl y firma de consentimiento informado, manteniéndose a dieta con sueroterapia de mantenimiento intravenosa mediante suero con glucosa al 3,3 o 5%. Se determinan niveles de glucemia preoperatoria, al ingreso, y a las 8, 24 y 48 h, comparando los valores medios y la incidencia de hiperglucemia (glucemia > 150 mg/dl) en ambos grupos. RESULTADOS: Un total de 60 pacientes recibieron suero glucosalino 1/3 (51 mEq/l de sodio y 33 g/l de glucosa) y 70 pacientes suero glucosalino 5/0,9% (154 mEq/l de sodio y 50g/l de glucosa). La glucemia media fue mayor en el grupo al 5%, sin diferencia estadística. No hubo diferencia en la incidencia de hiperglucemia; 8 h: 26% del grupo 3,3% vs. 21,3% del grupo 5% (p = 0,63); 24 h: 20% vs. 22,7% (p = 0,8); 48 h: 19% vs. 23,1% (p = 0,78). CONCLUSIONES: En el postoperatorio de cirugía general, el uso de soluciones glucosadas al 3,3% consigue niveles de glucemia similares a los detectados en pacientes que reciben suero con glucosa 5%, con una incidencia de hiperglucemia similar

OBJECTIVE: To compare plasma glucose levels and incidence of hyperglycaemia in the post-operative period after general surgery using fluids with different glucose. METHODOLOGY: A randomised, open-label, non-blind, clinical trial was conducted on patients admitted to Paediatric Intensive Care Unit after elective surgery. The inclusion criteria were from 6 months to 14 years of age, with a weight greater than 6kg, onset glucose level > 60 mg/dL, and a signed informed consent, with no oral intake and maintenance intravenous fluid therapy using fluids with 3.3% or 5% glucose. Plasma glucose levels were measured before surgery, on admission, and 8, 24, and 48 h, with the mean glucose levels and incidence of hyperglycaemia (glucose level > 150 mg/dL) in both groups being compared. RESULTS: A total of 60 patients received glucose/saline 1/3 (51 mEq/L sodium and 33 g/L glucose), and 70 glucose/saline 5/0.9% (154 mEq/L sodium and 50 g/L glucose). Mean glucose levels were higher in the group receiving glucose 5%, with no statistical difference. There was no significant difference in the incidence of hyperglycaemia; 8h: 26% in the 3.3% group vs. 21.3% in the 5% group (P = .63); 24 h: 20% vs. 22.7% (P = .8); and 48 h: 19% vs. 23.1% (P =. 78). CONCLUSIONS: The use of fluids with 3.3% glucose in the post-operative period of general surgery maintains mean glucose levels in a similar range to that of patients receiving fluids with 5% glucose, with no difference in the incidence of hyperglycaemia

[A comparison of post-surgical plasma glucose levels in patients on fluids with different glucose concentrations]. / Comparación de niveles de glucemia postoperatoria usando sueros con diferente concentración de glucosa.

OBJECTIVE: To compare plasma glucose levels and incidence of hyperglycaemia in the post-operative period after general surgery using fluids with different glucose. METHODOLOGY: A randomised, open-label, non-blind, clinical trial was conducted on patients admitted to Paediatric Intensive Care Unit after elective surgery. The inclusion criteria were from 6 months to 14 years of age, with a weight greater than 6kg, onset glucose level >60mg/dL, and a signed informed consent, with no oral intake and maintenance intravenous fluid therapy using fluids with 3.3% or 5% glucose. Plasma glucose levels were measured before surgery, on admission, and 8, 24, and 48h, with the mean glucose levels and incidence of hyperglycaemia (glucose level >150mg/dL) in both groups being compared. RESULTS: A total of 60 patients received glucose/saline 1/3 (51mEq/L sodium and 33g/L glucose), and 70 glucose/saline 5/0.9% (154mEq/L sodium and 50g/L glucose). Mean glucose levels were higher in the group receiving glucose 5%, with no statistical difference. There was no significant difference in the incidence of hyperglycaemia; 8h: 26% in the 3.3% group vs. 21.3% in the 5% group (P=.63); 24h: 20% vs. 22.7% (P=.8); and 48h: 19% vs. 23.1% (P=.78). CONCLUSIONS: The use of fluids with 3.3% glucose in the post-operative period of general surgery maintains mean glucose levels in a similar range to that of patients receiving fluids with 5% glucose, with no difference in the incidence of hyperglycaemia.

Per-species risk factors and predictors of invasive Candida infections in patients admitted to pediatric intensive care units: development of ERICAP scoring systems.

BACKGROUND: Prediction rules for invasive Candida infection (ICI) are available for adult but not for infants and children managed in pediatric intensive care units (PICU). METHODS: Observational study in 24 PICU with prospective phase (all children admitted during 1 year) and retrospective review of ICI records. Four logistic regression models were performed using ICI by Candida spp., Candida albicans, Candida parapsilosis or Candida tropicalis as dependent variables. Scores were constructed. RESULTS: One hundred and twenty five ICI (47 C. albicans, 37 C. parapsilosis, 19 C. tropicalis and 22 others) and 1022 controls were included. Incidence (cases/100 PICU admissions): 4.22 (all Candida), 2.44 (C. albicans), 1.41 (C. parapsilosis), 0.19 (C. tropicalis). ICI was associated [Area under the receiver operating characteristics curve (AUC) = 0.764, 95% confidence interval (CI) = 0.719-0.809, P < 0.001] with pre-PICU hospitalization ≥ 15 days [odds ratio (OR) = 3.3; score: +3], fever (OR = 2.6; +2), thrombopenia (OR = 2.0; +1) and parenteral nutrition (OR=2.4; +2). Additionally, the following associations were noted: C. albicans ICI (AUC = 0.716, 95% CI = 0.640-0.792, P < 0.001) with chronic metabolic disease (OR = 10.7; score:+4), surgical digestive process (OR = 2.8; +1), fever (OR = 2.8; +1) and parenteral nutrition (OR = 2.3; +1); C. parapsilosis ICI (AUC = 0.808, 95% CI = 0.739-0.877, P < 0.001) with previous colonization (OR = 7.1; score:+3), tracheostomy (OR = 5.1; +2), parenteral nutrition (OR = 4.3; +2), thrombopenia (OR = 3.6; +1) and previous bacterial infection (OR = 3.0; +1) and ICI by C. tropicalis (AUC = 0.941, 95% CI=0.886-0.995, P < 0.001) with thrombopenia (OR = 53.8; score: +10), neutropenia (OR = 7.2; +1), pre-PICU hospitalization ≥ 15 days (OR = 17.2; +3) and hematologic (OR = 22.4; +4) and cardiovascular infectious processes (OR = 5.5; +1). Specificity was >90% for cut offs of 5 (all Candida), 3 (C. albicans), 3 (C. parapsilosis) and 11 (C. tropicalis). CONCLUSIONS: Once validated, these scores may help for identification of ICI by specific species allowing adequate empiric/prophylactic treatment.

C. albicans, C. parapsilosis and C. tropicalis invasive infections in the PICU: clinical features, prognosis and mortality / Infección invasiva por C. albicans, C. parapsilosis y C. tropicalis en la UCI pediátrica: características clínicas, pronóstico y mortalidad

Candida albicans remains the most common agent associated with invasive Candida infection (ICI), but with increasing number of non-albicans species. An epidemiological, observational study exploring host criteria, clinical characteristics and mortality of ICI was performed in 24 pediatric intensive care units (PICU) in Spain. Patients were analyzed in global and distributed by infecting species (for groups with ≥15 patients). A total of 125 ICI were included: 47 by C. albicans, 37 by C. parapsilosis, 19 by C. tropicalis, 4 C. glabrata, and 18 others. Up to 66% of ICI by C. albicans and 75.7% by C. parapsilosis occurred in children ≤24 months, while the percentage of children >60 months was higher in ICI by C. tropicalis. Bloodstream infection was most common among C. tropicalis (78.9%) or C. parapsilosis (83.8%) ICI, but urinary infections were almost as common as bloodstream infections among C. albicans ICI (31.9% and 38.3%, respectively). Fever refractory to antimicrobials was the most frequent host criterion (46.4% patients), but with equal frequency than prolonged neutropenia in C. tropicalis ICI. Thrombopenia was more frequent (p<0.05) in C. parapsilosis (60.7%) or C. tropicalis (66.7%) ICI than in C. albicans ICI (26.5%). Uremia was more frequent (p<0.05) in C. albicans (78.3%) or C. tropicalis (73.3%) than in C. parapsilosis ICI (40.7%). Multiple organ failure and heart insufficiency was higher in C. tropicalis ICI. Short duration (≤7 days) of PICU stay was more frequent in C. albicans ICI. Mortality rates were: 8.5% (C. albicans ICI), 13.5% (C. parapsilosis ICI) and 23.3% (C. tropicalis ICI) (Au)

Candida albicans es el agente más frecuentemente asociado con candidiasis invasiva, pero con un número creciente de casos causados por especies no-albicans. Se realizó un estudio epidemiológico observacional explorando criterios del huésped, características clínicas y mortalidad en 24 unidades de cuidados intensivos pediátricas en España. Se analizó a los pacientes en conjunto y distribuidos por la especie infectante (para aquellos grupos con ≥15 pacientes). Se incluyó un total de 125 candidiasis invasivas: 47 por C. albicans, 37 por C. parapsilosis, 19 por C. tropicalis, 4 por C. glabrata, y 18 casos por otras especies. Hasta un 66% de las candidiasis invasivas por C. albicans y un 75,7% de las causadas por C. parapsilosis ocurrieron en niños ≤24 meses, mientras que el porcentaje de niños con >60 meses fue mayor en el grupo de candidiasis invasiva por C. tropicalis. La candidemia fue la infección más frecuente en el grupo de infecciones por C. tropicalis (78,9%) o C. parapsilosis (83,8%), pero las infecciones del tracto urinario fueron tan frecuentes como la bacteremia entre las infecciones por C. albicans (31,9% y 38,3%, respectivamente). La fiebre refractaria a antimicrobianos fue el criterio de huésped más frecuente (46,4% pacientes), pero con igual frecuencia que la neutropenia prolongada en la candidiasis invasiva por C. tropicalis. La trombopenia fue más frecuente (p<0,05) en las infecciones por C. parapsilosis (60,7%) o C. tropicalis (66,7%) que en las producidas por C. albicans (26,5%). La uremia fue más frecuente (p<0,05) en las infecciones por C. albicans (78,3%) o C .tropicalis (73,3%) que en las producidas por C. parapsilosis (40,7%). El fallo multiorgánico y la insuficiencia cardiaca fueron más frecuentes en el grupo de infecciones por C. tropicalis. La estancia corta (≤7 días) en la unidad fue más frecuente en el caso de infecciones por C.albicans. Las tasas de mortalidad fueron: 8,5% (C. albicans), 13,5% (C. parapsilosis) y 23,3% (C. tropicalis). El análisis de la candidiasis invasiva por las distintas especies de Candida mostró perfiles clínicos diferentes y distintas tasas de mortalidad, haciendo esencial la identificación a nivel especie (AU)