Moderate-to-Severe Traumatic Brain Injury in Children: Complications and Rehabilitation Strategies.

Traumatic brain injury (TBI) is the leading cause of death in children in the United States. Each year 37,200 children sustain a severe TBI, with up to 1.3 million life-years potentially adversely affected. Severe pediatric TBI is associated with significant mortality and morbidity. Of the children who survive their injury, more than 50% experience unfavorable outcomes 6 months after the injury. Although TBI-associated death rates decreased between 1997-2007, disabilities for TBI survivors continue to have both a direct and indirect impact on the economic and human integrity of our society. The degree of disability varies with the severity and mechanism of the injury, but a realm of physical and emotional deficits may be evident for years after the injury occurs. This article describes the pathophysiology of moderate to severe TBI, its associated complications, and opportunities to improve patient outcomes through use of acute management and rehabilitation strategies. To address the many challenges for TBI survivors and their families, including significant financial and emotional burdens, a collaborative effort is necessary to help affected children transition seamlessly from acute care through long-term rehabilitation.

A critical change in a day in the life of intensive care nurses: rising to the e-challenge of an integrated clinical information system.

Critical care nurses in a large academic, tertiary care trauma center have adapted to a major system change since the implementation of a fully integrated Computerized Provider Order Entry (CPOE) system, an automated process of order entry. Working in a rapidly changing environment, clinicians are accustomed to viewing real-time discrete data and then using that data to provide safe, effective, and efficient intensive care to critically ill patients. This article describes how the implementation of the CPOE system from a major healthcare software vendor has changed the life of critical care nurses and the perceptions of the experience 1 year after the new technology was initiated. Through experience sharing, perhaps others may gain knowledge to ease their transition to CPOE.

Decreasing unplanned extubations: utilization of the Penn State Children's Hospital Sedation Algorithm.

OBJECTIVE: To determine whether institution of a standardized algorithm of goal-directed sedation impacted the incidence of unplanned extubations in critically ill pediatric patients. DESIGN: Prospective, observational study with historical controls. SETTING: Pediatric intensive care unit (PICU) in a tertiary care university-based children's hospital. PATIENTS: All mechanically ventilated children admitted to the PICU during a 10-yr period. INTERVENTIONS: After examining the data pertaining to unplanned extubations, the Penn State Children's Hospital Sedation Algorithm (PSCHSA) was instituted as an absolute requirement for all mechanically ventilated children. Physician orders for the goal sedation level and the appropriate medications to achieve that goal were obligatory for every ventilated patient. Data were then collected for 5 yrs after institution of the PSCHSA. MEASUREMENTS AND MAIN RESULTS: Before utilization of the PSCHSA, unplanned extubation rates ranged between 0.44 and 0.63 per 100 intubated patient days. In the 4 yrs after mandatory use of the PSCHSA for management of all ventilated patients, unplanned extubation rates were between 0 and 0.19 per 100 intubated patient days, demonstrating a significant decrease (p<.001). Throughout the entire study period, no changes were made in the model of patient care that would alter the rate of unplanned extubations. Despite a higher percentage of PICU patients that were intubated, length of stay in the PICU did not increase, suggesting that oversedation did not led to increased ventilator days. CONCLUSIONS: Utilization of the PSCHSA resulted in a decreased number of unplanned extubations without increasing the length of PICU stay. Implementation of the PSCHSA is needed in other PICUs to validate these findings.