Influencing the timing of parenteral nutrition initiation in the pediatric intensive care unit.

BACKGROUND: Lack of benefit and potential harm of early parenteral nutrition (PN) initiation in critically ill children was highlighted in the 2016 published results of a large multicenter, randomized controlled trial. OBJECTIVES: The purpose of this project was to implement a process to delay PN initiation for up to five days after admission to our pediatric intensive care unit (PICU). METHODS: Patients greater than thirty days of age, admitted to the PICU beginning July 1, 2016 were included in the analysis of the healthcare improvement initiative to decrease early PN initiation. A meeting was held with PICU fellows, attending physicians, dietitians, and pharmacists to reach a consensus to delay initiation of parenteral nutrition until PICU day five. The dietitian, with pharmacist support, reiterated recommendations on rounds and in formal notes. RESULTS: A total of 2333 patients were identified in the pre-intervention group and a total of 2491 patients in the post-intervention group. The percentage of patients receiving PN prior to day five within the PICU was 5.5% in the pre-intervention group versus 3.1% in the delayed PN group (p<0.001). PICU patients receiving PN less than or equal to three days decreased from 2.6% pre-intervention to 1.5% post-intervention (p=0.01). For the subset of patients who were initiated on PN after admission to the PICU, median PICU length of stay was 7 days versus 6 days in the pre-intervention versus post-intervention group (p=0.26). CONCLUSIONS: Decrease in PN utilization was seen in the pre and post-intervention groups as assessed by percentage of patients initiated on PN prior to day five of PICU admission. Consensus among practitioners with consistent recommendations from the frontline dietitian and pharmacist, with nutrition support team collaboration, contributed to the evidence based quality initiative results. Delaying PN did not adversely affect length of stay pre versus post-intervention.

Retrospective comparison of two enoxaparin dosing and monitoring protocols at a pediatric hospital.

PURPOSE: The study analyzes the effectiveness and safety of a higher than standard enoxaparin dosing protocol implemented for pediatric patients requiring initiation of therapeutic anticoagulation. METHODS: A retrospective review of 2 enoxaparin dosing and monitoring protocols was performed. The standard protocol used 1.5 mg/kg/dose (in patients <3 months of age) and 1 mg/kg/dose (in patients ≥3 months of age) with anti-Xa monitoring following the first dose. The high-dose protocol was implemented at 1.7 mg/kg/dose (in patients <3 months of age), 1.5 mg/kg/dose (in patients 3 through 11 months of age), 1.2 mg/kg/dose (in patients 1 through 4 years of age), and 1.1 mg/kg/dose (in patients 5 through 17 years of age), with anti-Xa monitoring after the second dose. Primary outcomes were number of dosing changes prior to and time to first target anti-Xa level. Secondary outcomes included percentage of patients with anti-Xa levels above target level. RESULTS: The median number of dose changes required to achieve a target anti-Xa level was 1 (interquartile range [IQR], 0-1.5) and 0 (IQR, 0-1) for the standard-dose (n = 87) and high-dose groups (n = 132) (p = 0.17), respectively. The median number of dose adjustments to achieve target anti-Xa levels in the 3 through 11 months of age subgroup declined from 2 (IQR, 1-3.25) to 0 (IQR, 0-1) in the standard- versus high-dose groups, respectively (p < 0.01). No difference was seen in other age subgroups. Patients with above-target levels did not differ statistically between groups. CONCLUSION: Initiating enoxaparin at higher doses in pediatric patients may result in fewer dosing changes than standard dosing. Benefit was demonstrated for the 3-11 months of age high-dose subgroup. Across all groups, the high-dose strategy was safe and did not result in a statistically significant increase in above-target levels.

Influencing the timing of parenteral nutrition initiation in the pediatric intensive care unit

Background: Lack of benefit and potential harm of early parenteral nutrition (PN) initiation in critically ill children was highlighted in the 2016 published results of a large multicenter, randomized controlled trial. Objectives: The purpose of this project was to implement a process to delay PN initiation for up to five days after admission to our pediatric intensive care unit (PICU). Methods: Patients greater than thirty days of age, admitted to the PICU beginning July 1, 2016 were included in the analysis of the healthcare improvement initiative to decrease early PN initiation. A meeting was held with PICU fellows, attending physicians, dietitians, and pharmacists to reach a consensus to delay initiation of parenteral nutrition until PICU day five. The dietitian, with pharmacist support, reiterated recommendations on rounds and in formal notes. Results: A total of 2333 patients were identified in the pre-intervention group and a total of 2491 patients in the post-intervention group. The percentage of patients receiving PN prior to day five within the PICU was 5.5% in the pre-intervention group versus 3.1% in the delayed PN group (p<0.001). PICU patients receiving PN less than or equal to three days decreased from 2.6% pre-intervention to 1.5% post-intervention (p=0.01). For the subset of patients who were initiated on PN after admission to the PICU, median PICU length of stay was 7 days versus 6 days in the pre-intervention versus post-intervention group (p=0.26). Conclusions: Decrease in PN utilization was seen in the pre and post-intervention groups as assessed by percentage of patients initiated on PN prior to day five of PICU admission. Consensus among practitioners with consistent recommendations from the frontline dietitian and pharmacist, with nutrition support team collaboration, contributed to the evidence based quality initiative results. Delaying PN did not adversely affect length of stay pre versus post-intervention

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Pediatric lateral neck infections - Computed tomography vs ultrasound on initial evaluation.

OBJECTIVE: Review the evaluation of children with a deep lateral neck infection and define the impact of initial imaging modality on outcomes and costs. METHOD: Case series, pediatric patients <18 years of age admitted to a tertiary care hospital with lateral neck infection between 01/01/14-05/31/16 as identified by ICD-9 and ICD-10 codes: 289.3 (lymphadenitis, unspecified), 682.1 (cellulitis and abscess of neck), 683 (acute lymphadenitis), I88.9 (nonspecific lymphadenitis, unspecified), L02.11 (cutaneous abscess of neck), L03.221 (cellulitis of neck), and L03.222 (acute lymphangitis of neck). Patients were divided into two groups based on initial imaging modality: primary ultrasound or primary computed tomography. Differences in length of stay, type and total number of imaging studies obtained, number of procedures, hospital readmission, and hospital cost were compared between cohorts. RESULTS: There were 40 (31%) primary ultrasound and 88 (69%) primary computed tomography patients (128 total). Median length of stay was 46 (IQR: 25,90) hours (1.9 days) for primary ultrasound and 63 (IQR: 39,88) hours (2.6 days) for primary computed tomography patients (p = 0.33). Drainage was performed in 48% of both groups. Additional imaging occurred in 17 (43%) primary ultrasound and 18 (20%) primary computed tomography patients (p = 0.02). Readmission occurred in 8 patients (6.3%). Retropharyngeal infection was encountered in 13 patients (10%); this was only discovered in patients who had a computed tomography performed. Median cost per primary ultrasound patients was $5363 (IQR: 3011, 7920) and $5992 (IQR: 3450, 8060) for primary computed tomography patients. CONCLUSIONS: The primary imaging modality (ultrasound or computed tomography) used to work-up children with a lateral neck infection did not impact length of stay or hospital cost. However, a significant subset had a coexisting retropharyngeal infection that was only identified on computed tomography. Future studies are needed to identify appropriate criteria for imaging in the work-up of lateral neck infections.

Association Between Vancomycin Trough Concentrations and Duration of Methicillin-Resistant Staphylococcus aureus Bacteremia in Children.

In a multicenter retrospective study, we sought to determine the optimal vancomycin trough concentration that would impact the duration of methicillin-resistant Staphylococcus aureus bacteremia in children. We found that a median vancomycin trough concentration of <10 µg/mL within the first 72 hours may be associated with a longer duration of bacteremia compared to a median trough concentration of ≥10 µg/mL.

Epidemiology of Methicillin-Resistant Staphylococcus aureus Bacteremia in Children.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with high rates of treatment failure in adults. The epidemiology, clinical outcomes, and risk factors for treatment failure associated with MRSA bacteremia in children are poorly understood. METHODS: Multicenter, retrospective cohort study of children ≤18 years hospitalized with MRSA bacteremia across 3 tertiary care children's hospitals from 2007 to 2014. Treatment failure was defined as persistent bacteremia >3 days, recurrence of bacteremia within 30 days, or attributable 30-day mortality. Potential risk factors for treatment failure, including the site of infection, vancomycin trough concentration, critical illness, and need for source control, were collected via manual chart review and evaluated using multivariable logistic regression. RESULTS: Of 232 episodes of MRSA bacteremia, 72 (31%) experienced treatment failure and 23% developed complications, whereas 5 (2%) died within 30 days. Multivariable analysis of 174 children treated with vancomycin with steady-state vancomycin concentrations obtained found that catheter-related infections (odds ratio [OR], 0.36; 95% confidence interval [CI]: 0.13-0.94) and endovascular infections (OR, 4.35; 95% CI: 1.07-17.7) were associated with lower and higher odds of treatment failure, respectively, whereas a first vancomycin serum trough concentration <10 µg/mL was not associated with treatment failure (OR, 1.34; 95% CI, 0.49-3.66). Each additional day of bacteremia was associated with a 50% (95% CI: 26%-79%) increased odds of bacteremia-related complications. CONCLUSIONS: Hospitalized children with MRSA bacteremia frequently suffered treatment failure and complications, but mortality was low. The odds of bacteremia-related complications increased with each additional day of bacteremia, emphasizing the importance of achieving rapid sterilization.

Infectious Etiologies and Patient Outcomes in Pediatric Septic Shock.

BACKGROUND: Septic shock remains an important cause of death and disability in children. Optimal care requires early recognition and treatment. METHODS: We evaluated a retrospective cohort of children (age <19) treated in our emergency department (ED) for septic shock during 2008-2012 to investigate the association between timing of antibiotic therapy and outcomes. The exposures were (1) receipt of empiric antibiotics in ≤1 hour and (2) receipt of appropriate antibiotics in ≤1 hour. The primary outcome was development of new or progressive multiple system organ dysfunction syndrome (NP-MODS). The secondary outcome was mortality. RESULTS: Among 321 patients admitted to intensive care, 48% (n = 153) received empiric antibiotics in ≤1 hour. These patients were more ill at presentation with significantly greater median pediatric index of mortality 2 (PIM2) scores and were more likely to receive recommended resuscitation in the ED (61% vs 14%); however, rates of NP-MODS (9% vs 12%) and hospital mortality (7% vs 4%) were similar to those treated later. Early, appropriate antibiotics were administered to 33% (n = 67) of patients with identified or suspected bacterial infection. These patients had significantly greater PIM2 scores but similar rates of NP-MODS (15% vs 15%) and hospital mortality (10% vs 6%) to those treated later. CONCLUSIONS: Critically ill children with septic shock treated in a children's hospital ED who received antibiotics in ≤1 hour were significantly more severely ill than those treated later, but they did not have increased risk of NP-MODS or death.

A Retrospective Study of the Impact of Rapid Diagnostic Testing on Time to Pathogen Identification and Antibiotic Use for Children with Positive Blood Cultures.

INTRODUCTION: Rapid identification of bloodstream pathogens provides crucial information that can improve the choice of antimicrobial therapy for children. Previous impact studies have primarily focused on adults. Our objective was to evaluate the impact of rapid testing in a children's hospital on time to organism identification and antibiotic use in the setting of an established antimicrobial stewardship program. METHODS: We conducted a retrospective study over three consecutive time periods (spanning January 2013-August 2015) as our hospital sequentially introduced two rapid testing methods for positive blood cultures. An antimicrobial stewardship program was active throughout the study. In the baseline period, no rapid diagnostic methods were routinely utilized. In the second period (PNAFISH), a fluorescent in situ hybridization test was implemented for gram-positive organisms and in the third a rapid multiplex PCR (rmPCR) test was employed. For children with positive blood cultures, time to organism identification use and duration of select antimicrobial therapies were compared between periods. RESULTS: Positive blood cultures were analyzed. Median overall time to organism identification was 23, 11, and 0 h in the baseline, PNAFISH, and rmPCR periods, respectively (p < 0.001 for both PNAFISH and rmPCR vs. baseline). For gram-negative organisms, only rmPCR performed significantly faster than baseline (p < 0.001). The duration of vancomycin use for coagulase-negative staphylococci was shorter in both the PNAFISH and rmPCR periods (mean 31 h in the baseline period, 12 and 14 h in the PNAFISH and rmPCR periods, respectively). For MSSA bacteremia, use of vancomycin was significantly decreased only in the rmPCR period (32% of patients vs. 64 and 72% in the baseline and PNAFISH periods; mean duration of 9 h vs. 30 and 26 h). There was no difference in use or duration of broad-spectrum gram-negative therapy across the three time periods. CONCLUSION: Rapid diagnostic testing for children with positive blood cultures results in faster time to identification and can influence antibiotic prescribing in the setting of active antimicrobial stewardship particularly for gram-positive pathogens. FUNDING: Merck.

Correlation of weight-based i.v. immune globulin doses with changes in serum immunoglobulin G levels.

PURPOSE: Correlations between the i.v. immune globulin (IVIG) dose and the change in serum immunoglobulin G (IgG) concentration with three methods of weight-based dosing were investigated. METHODS: A retrospective medical records review was conducted to identify patients in a multicenter healthcare system who received IVIG over a 10-year period and had serum IgG measurements within two days before and two days after the date of IVIG administration. For each of the 11 adults and 7 adolescents identified, the relationship between the weight-based dose of IVIG (determined using actual body weight [BW], adjusted BW, or ideal BW [IBW]) and the resulting change in serum IgG was evaluated. Correlation coefficients and corresponding p values for the three dosing methods were calculated and compared. RESULTS: Among adult patients, the correlation of IVIG dose and postdose change in serum IgG was strongest with dosing by IBW (correlation coefficient [r], 0.83 [p < 0.05] versus r values of 0.73 and 0.70 for dosing by adjusted BW or actual BW, respectively [p = 0.05 for both]); the corresponding r values in adolescent patients were 0.99, 0.99, and 0.95, respectively (p < 0.005 for all). There were no statistically significant differences between the r values calculated for the three weight-based dosing methods in either adults or adolescents. CONCLUSION: In adult patients, the correlation between the dose of IVIG and the change in IgG level was strongest when doses were calculated using IBW; comparable degrees of correlation were observed with the three evaluated methods of weight-based dosing in the adolescent population.