Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. AO was implemented across 14 pediatric intensive care units as a quality improvement intervention during 2016-2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO was as follows: 5 L/min for infants (< 1 year), 10 L/min for young children (1-7 years), and 15 L/min for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Of 6549 TIs during the study period, 2554 (39.0%) occurred during the pre-implementation phase and 3995 (61.0%) during post-implementation phase. AO utilization increased from 23 to 68%, p < 0.001. AO was utilized less often when intubating infants, those with a primary cardiac diagnosis or difficult airway features, and patient intubated due to respiratory or neurological failure or shock. Conversely, AO was used more often in TIs done for procedures and those assisted by video laryngoscopy. AO utilization was associated with a lower incidence of adverse TIAEs (AO 10.5% vs. without AO 13.5%, p < 0.001), aOR 0.75 (95% CI 0.58-0.98, p = 0.03) after adjusting for site clustering (primary analysis). However, after further adjusting for patient and provider characteristics (secondary analysis), AO utilization was not independently associated with the occurrence of adverse TIAEs: aOR 0.90, 95% CI 0.72-1.12, p = 0.33 and the occurrence of hypoxemia was not different: AO 14.2% versus without AO 15.2%, p = 0.43. While AO use was associated with a lower occurrence of adverse TIAEs in children who required TI in the pediatric ICU after accounting for site-level clustering, this result may be explained by differences in patient, provider, and practice factors. Trial Registration Trial not registered.
Objective: To investigate the incidence, implicating factors and outcome of acute renal failure after cardiopulmonary bypass in patients admitted to a paediatric intensive care unit. Design: Prospective observational pilot study. Setting: A 14 bed paediatric intensive care unit in a university affiliated, tertiary care referral children's hospital. Patients: One hundred and one children (less than sixteen years of age) admitted to the Pediatric Intensive Care Unit following cardiopulmonary bypass between June 2003 and May 2004. Interventions: None Measurements and Main Results: PRISM-III score was calculated on admission. Baseline admission urea (mmol/L) and creatinine (μmol/L) serum levels and highest urea and creatinine levels were measured. Urine output (mL/kg/hour) and frusemide dose (mg/kg/day) were also noted. A baseline inotrope score was calculated on admission and the highest inotrope score was noted based on maximum infused doses of inotrope in the first 36 hours. The surgical procedure was used to determine a Jenkins score. Eleven (11%) children developed acute renal injury (doubling of creatinine), one child (1%) developed acute renal failure (tripling of creatinine) and one child died (1%). No child required dialysis for acute renal failure and none developed chronic renal impairment. Low cardiac output was the only significant risk factor identified for developing acute renal injury or failure. Conclusions: Acute renal injury is common and occurred in 11% of our children following congenital cardiac surgery, but acute renal failure requiring dialysis is uncommon.
To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart disease, is a predictor of myocardial dysfunction and low cardiac output syndrome (LCOS).Prospective, observational study.Paediatric intensive care unit in a tertiary care academic children's hospital, 1 June 2003 to 12 May 2004.99 consecutive eligible children who underwent a variety of surgical procedures for congenital heart disease, using cardiopulmonary bypass. All patients were cared for by a consistent perioperative care team.Measurement of TnI preoperatively, and at 0, 4, 8, 12, 24 and 36 hours after ICU admission.Patient demographics and outcome (as median and 25th-75th percentile) were as follows: age, 23.9 (4.6- 65.9) months; cardiopulmonary bypass time, 135 (98-178) minutes; aortic cross-clamp time, 65 (28-85) minutes; preoperative TnI level, 0.02 (0.01-0.03) ng/mL; 4h TnI, 10.6 (3.0-23.4) ng/mL; highest 24 h TnI, 11.7 (3.9-29.5) ng/mL; time to discontinuation of inotropes, 43.9 (18.7-92.9) hours; maximal inotrope score, 10.0 (5.0-16.3); time to extubation, 42.4 (19.8-137.5) hours; and time to ICU discharge 91.8 (45.7-169.7) hours. Twenty-three patients developed LCOS. A 4h TnI level > 13 ng/mL predicted LCOS with a sensitivity of 0.78 (95% CI, 0.56-0.93), and a specificity of 0.72 (95% CI, 0.61-0.82). The area under the receiver operating characteristic curve for TnI as a predictor of LCOS was 0.75 (95% CI, 0.63-0.88). TnI was the only predictive variable associated with LCOS in multivariate logistic regression analysis, with an odds ratio of 1.45 (95% CI, 1.05-2.01) for developing LCOS with each 10 ng/mL increase in 4h TnI. Linear regression analysis showed TnI to be significantly correlated with increased time to discontinuation of inotropes, maximal inotrope administration, time to extubation, and time to ICU discharge.Measurement of early postoperative levels of TnI may aid in the early identification of children who will develop LCOS.
Objective: The objectives of our study were to determine the incidence of catheter-associated blood stream infection (CA-BSI) pre- and postintroduction of our CA-BSI bundle. Design: Retrospective chart review for 2004 and prospective descriptive study for 2005. Setting: A tertiary referral, university affiliated, medical-surgical pediatric intensive care unit with 22 beds and approximately 1100 admissions per year. Patients: All patients who were admitted to our unit who had any documented CA-BSI according to the Centre for Disease Control criteria between January 2004 and December 2005. Interventions: Education and institution of a bundle for decreasing CA-BSI. The CA-BSI bundle was adapted for pediatrics and included components for catheter insertion and ongoing catheter maintenance. Measurements and Main Results: Cases of CA-BSI were collected and rates per 1000 line days and per 1000 admissions were calculated pre institution of bundle (January to September 2004), during institution (October 2004 to May 2005) and postinstitution (June 2005 to December 2005). Infection rates per 1000 line days decreased from pre 8.8 (17/1934; 95% confidence interval [CI], 5.2-14) to during 1.8 (3/1665; 95% CI, 0.4-5.3) and post 2.2 (3/1367; 55% CI, 0.4-6.4). Decreases per 1000 admissions were also seen: pre 18.3 (17/928; 95% CI, 10.7-29), during 4.3 (3/691; 95% CI, 0.9-12.3) and post 5.1 (3/583; 95% CI, 1-15). Conclusion: Strategies aimed at reducing CA-BSI appear to be effective.
Aims & Objectives: Background: We practice liberal oxygenation target however evidence suggests that conservative oxygenation target at best is more beneficial than liberal oxygenation and at worst, shows no harm1,2. Helmerhorst has shown feasibility and safety in implementing conservative oxygenation target in an ICU population3. Aim: To increase the adherence to SPO₂ target of 92% as lower limit for oxygen titration from 0% to 50% among non-cardiac, non-pulmonary hypertensive invasively ventilated children of all age groups (0 to 17 years) admitted between February to March 2024 Methods: Appropriate approval obtained from the department's Quality improvement unit. Stakeholder meeting held to review the change idea and its implementation and arrived at a pragmatic oxygenation target based on audit, existing evidence while balancing competing factors (e.g. alarm fatigue). Next stage will include unit wide education and feedback until the aim is achieved Results: Compliance with ordering SPO2 target limits on the electronic health record Compliance of bedside staff with ordered SPO2 limits by titrating oxygen accordingly Conclusions: It is expected that the unit would become compliant with the units newly adopted oxygenation practice in keeping with the PALICC-2 20234 recommendations and in line with new evidence that shows no harm signal for conservative oxygenation target in ventilated children in the PICU. Impact Statement To reduce the potential harmful effects of iatrogenic hyperoxia in the unit Keywords: Quality Improvement, Oxygenation, SP02
Examining how policy affects the human rights of people with disabilities, this topical Handbook presents diverse empirical experiences of disability policy and identifies the changes that are necessary to achieve social justice.
We compared saturations from a paediatric central venous oximetry catheter with co-oximetry values with changes in drug infusions, intravascular blood volume and hypoxia in an animal model. Piglets (large white) were anaesthetised, intubated and mechanically ventilated. PediaSat oximetry catheters were placed in the superior vena cava via jugular vein cut-down and in the inferior vena cava percutaneously via the femoral vein. A carotid arterial catheter was placed via cut-down for blood sampling and pressure monitoring. Anaesthesia was maintained with continuous thiopentone and supplemental morphine. Haemodynamics (heart rate, mean arterial blood, central venous pressure), fibreoptic ScvO2 (ScvO2-inferior) from inferior vena cava, fibreoptic ScvO2 (ScvO2-superior) from superior vena cava and blood gas oximetry (ScvO2-co-ox) were measured simultaneously at predetermined intervals during increasing adrenaline and sodium nitroprusside infusions and during increasing hypoxia and hypovolaemia. There was good agreement of both superior vena cava and inferior vena cava ScvO2 catheters with co-oximetry during adrenaline and sodium nitroprusside infusions. During the hypoxia study there was good agreement between the co-oximeter to ScvO2-superior catheter but poor agreement with to the inferior vena cava catheter samples. In the hypovolaemic phase of the experiment there was good agreement between the measured co-oximetry value and ScvO2-superior catheter until the mean blood pressure reached 43 mmHg. The oximetry catheter is capable of identifying changes in ScvO2 under physiological conditions usually encountered in clinical medicine but was less accurate at the extremes of physiology and when placed in the inferior vena cava catheter especially during hypovolaemia and hypoxia.
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