Outcome of paediatric intensive care survivors

The development of paediatric intensive care has contributed to the improved survival of critically ill children. Physical and psychological sequelae and consequences for quality of life (QoL) in survivors might be significant, as has been determined in adult intensive care unit (ICU) survivors. Awareness of sequelae due to the original illness and its treatment may result in changes in treatment and support during and after the acute phase. To determine the current knowledge on physical and psychological sequelae and the quality of life in survivors of paediatric intensive care, we undertook a computerised comprehensive search of online databases for studies reporting sequelae in survivors of paediatric intensive care. Studies reporting sequelae in paediatric survivors of cardiothoracic surgery and trauma were excluded, as were studies reporting only mortality. All other studies reporting aspects of physical and psychological sequelae were analysed. Twenty-seven studies consisting of 3,444 survivors met the selection criteria. Distinct physical and psychological sequelae in patients have been determined and seemed to interfere with quality of life. Psychological sequelae in parents seem to be common. Small numbers, methodological limitations and quantitative and qualitative heterogeneity hamper the interpretation of data. We conclude that paediatric intensive care survivors and their parents have physical and psychological sequelae affecting quality of life. Further well-designed prospective studies evaluating sequelae of the original illness and its treatment are warranted.     

Clinical performance of the new glucometer in the nursery and neonatal intensive care unit

Background: Performance of point‐of‐care (POC) glucometers in newborns have been unsatisfactory in low glucose concentration range and the effects of different hematocrit levels on glucose measurements have also demonstrated in currently used POC glucometers. Methods: The aim of this study was to evaluate the performance of the new glucometer (Nova‐Statstrip^®; Nova Biomedical, Waltham, MA, USA) compared to the reference method. Venous blood specimens of neonates were collected and tested by the two glucometers. Standard reference was performed using the hexokinase method within 10 min of blood collection. Hematocrit and total serum bilirubin measurements were performed simultaneously. Results: One hundred and fifty‐one blood specimens were collected and measured by the reference method with plasma glucose concentrations ranging from 12 to 371 mg/dL. Twenty‐one specimens had plasma glucose concentrations <45 mg/dL. At plasma glucose concentrations less than 75 mg/dL, the Statstrip^® achieved 93% in the tests for discrepancy < 15 mg/dL. At a glucose concentration more than 75 mg/dL, 97% of the Statstrip^® readings were within 20% of the reference values. The mean difference (±2SD) of the Statstrip^® was 2.8 (?14.1, 19.7) mg/dL. At a hypoglycemic level (<45 mg/dL), it showed a sensitivity of 95.2%. No significant interference of hematocrit or total serum bilirubin was found on the mean bias of the Statstrip^®. Conclusion: The new glucometer (Nova‐Statstrip^®) could be used for point‐of‐care blood glucose measurement in neonates as it showed a narrow margin of error and had no hematocrit or bilirubin interference.     

No resuscitation orders and withdrawal of therapy in French paediatric intensive care units

Objective: To determine the incidence of different modes of death in French paediatric intensive care units and to compare patients' characteristics, including a severity of illness score (Paediatric Risk of Mortality: PRISM score) and prior health status (Paediatric Overall Performance Category scale), according to the mode of death. Design: A 4-month prospective cohort study. Setting: Nine French multidisciplinary paediatric intensive care units. Patients: All patients who died in PICUs, except premature babies. Main results: Among 712 admissions, 13% patients died. Brain death was declared in 20%, failure of cardiopulmonary resuscitation occurred in 26%, do-not-resuscitate status was identified in 27%, and withdrawal of supportive therapy was noted in 27%. The PRISM score and the baseline Paediatric Overall Performance Category were not different between the four groups. Brain-dead patients were older than those in whom a do-not-resuscitate order and withdrawal of therapy were made (median age 81 vs 7 and 4 months). Conclusions: Decisions to limit or to withdraw supportive care were made for a majority of patients dying in French paediatric intensive care units. Chronic health evaluation and severity of illness index are not sufficient to describe dead-patient populations.     

Characteristics and outcome of long-stay patients in a paediatric intensive care unit: a case-control study

Aim: To identify differences in baseline characteristics and outcome between long-stay and other patients admitted to a paediatric intensive care unit with the same diagnosis. Methods: Over a period of 6 y, data of paediatric intensive care unit patients with a length of stay of 30 or more days (long-stay patients) and aged 1 to 18 y were retrospectively collected. Long-stay patients were matched with the next patient who was admitted to the paediatric intensive care unit with the same diagnosis. Evaluated characteristics on admission included: age, sex, presence of chronic morbidity, functional status, Pediatric Risk of Mortality score, presence of multiple organ system failure and complications during admission. Outcome (survival and functional status) was assessed 2.5 to 8.5 y after admission. Results: Of 19 long-stay patients identified, 15 could be matched with a control patient admitted with the same diagnosis. No significant difference in baseline characteristics was found between long-stay patients and the matched controls. The mean number of complications per long-stay patient was 2.9, compared to 1.2 per control patient (p = 0.02). Infection accounted for half of the complications. Mortality rate in long-stay patients was not higher than in the matched controls (36.8 vs 26.7%, p = 0.54). Paediatric intensive care unit stay did not change functional status in either long-stay patients or controls.

Conclusion: Long-stay patients in the paediatric intensive care unit had more complications, but baseline characteristics, mortality and functional outcome were not different from a control group admitted with the same diagnosis.     

The association between maternal country of birth and neonatal intensive care unit outcomes

Background

Immigration is increasingly common worldwide and its impact on neonatal intensive care unit outcomes is uncertain.

Aims

To determine the outcomes of children of immigrant mothers admitted to NICUs in New South Wales (NSW), Australia, between 2000 and 2006.

Study design

Record linkage study of routinely collected state-based health databases.

Subjects

Infants of Australian-born (9813, 81.9%) and overseas born mothers (2166, 18.1%).

Outcome measures

NICU and childhood outcomes to a maximum 5 years of age.

Results

Immigrant mothers came from 122 countries, 897 (44%) from high income regions. Australian born mothers were more likely to be teenaged (Odds Ratio, 95% confidence interval: 3.07, 2.21–4.26), use drugs (3.55, 2.49–5.06) and suffer an antepartum hemorrhage (1.29, 1.14–1.48). They were less likely to have gestational diabetes (0.45, 0.38–0.54), fetal distress (0.75, 0.66–0.85) and intrauterine growth restriction (0.80, 0.67–0.93). Their infants were more likely to be admitted to the NICU for prematurity but less likely to have low 5 min Apgar scores (0.81, 0.69–0.93) or a congenital abnormality (0.79, 0.70–0.90). Infants of Middle-Eastern mothers had the lowest hospital survival rate (88.5%). Children of immigrant Asian mothers were least likely to be rehospitalized after NICU discharge (1.66, 1.27–2.17).

Conclusions

NICU outcomes are affected by maternal country of birth even within the same ethnic group. Further study regarding the impact of paternal race and immigration status and duration of residency will provide data for the changing cultural environment of global perinatal care.     

Skin‐to‐skin care in neonatal intensive care units in the Nordic countries: a survey of attitudes and practices

Aim: To investigate the application of skin‐to‐skin care (SSC) in the Nordic countries, the existence of guidelines for SSC and the attitudes of neonatal staff towards SSC. Methods: One questionnaire was distributed at unit level and one at staff level in all Nordic neonatal intensive care units (n = 109). Results: The unit questionnaire was answered by 95 (87%) units and the staff questionnaire by 1446 staff members (72%). All units offered SSC to various degrees, but guidelines only existed at 47% of them. Units in Denmark, Norway and Sweden seemed to use SSC earlier, longer and in more medically complicated situations than units in Finland and Iceland. Seventy‐seven per cent of the units had private rooms where parents and infants could stay together, still the physical environment of the units limited the use of SSC. Medical risks were considered the main barrier for further implementation of SSC, while general development and early interaction were the most frequently mentioned benefits. Conclusion: Skin‐to‐skin care is implemented in all Nordic neonatal units, but offered to various degrees, to various populations and to varying extents. Danish, Norwegian and Swedish units are offering SSC more extensively than units in Finland and Iceland.     

Incidents and errors in neonatal intensive care: a review of the literature

OBJECTIVES: To examine the characteristics of incident reporting systems in neonatal intensive care units (NICUs) in relation to type, aetiology, outcome and preventability of incidents. METHODS: Systematic review. Search strategy: Medline, Embase, Cochrane Library. Included: relevant systematic reviews, randomised controlled trials, observational studies and qualitative research. Excluded: non-systematic reviews, expert opinions, case reports and letters. PARTICIPANTS: hospital units supplying neonatal intensive care. INTERVENTION: none. Outcome: characteristics of incident reporting systems; type, aetiology, outcome and preventability of incidents. RESULTS: No relevant systematic reviews or randomised controlled trials were found. Eight prospective and two retrospective studies were included. Overall, medication incidents were most frequently reported. Available data in the NICU showed that the total error rate was much higher in studies using voluntary reporting than in a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. When a system approach was used, many contributing factors were identified. Information about the impact of system changes on patient safety was scarce. CONCLUSIONS: Multi-institutional, voluntary, non-punitive, system based incident reporting is likely to generate valuable information on type, aetiology, outcome and preventability of incidents in the NICU. However, the beneficial effects of incident reporting systems and consecutive system changes on patient safety are difficult to assess from the available evidence and therefore remain to be investigated.     

Health-related quality of life in paediatric patients with inflammatory bowel disease related to disease activity

Aim: Impaired health‐related quality of life (HRQoL) and an increased risk of psychosocial problems may encounter children and adolescents with inflammatory bowel disease (IBD). Generic HRQoL questionnaires, 15D designed for subjects over 16 years of age, 16D for adolescents aged 12–15 and 17D for younger children, allow comparison to healthy peers and have not been used in children with IBD before. Further, in paediatric IBD patients, HRQoL has not been related to disease activity. We evaluated the applicability of 15D, 16D and 17D questionnaires in the paediatric IBD population and examined how HRQoL is influenced by changes in clinical activity of IBD. Methods: The study subjects recruited at their scheduled, routine appointment in the outpatient clinic of the children's hospital completed the HRQoL questionnaire at baseline and again after 3–5 months. Disease activity was estimated by a three‐level scale. The HRQoL of the study population was compared with that of the age‐standardised general population. Results: Fifty‐five children, aged 7–19 years, were recruited. The HRQoL scores strongly correlated with the activity of the disease (P < 0.001). The two oldest age groups with IBD had lower HRQoL scores than age‐standardised peers (P= 0.001/0.04). There was no gender difference in HRQoL scores. Conclusions: IBD has a considerable impact on the HRQoL of children and adolescents. The generic HRQoL instruments used appeared to be promising tools for examining HRQoL in paediatric IBD patients in different age groups, but larger studies to establish their usefulness in the follow‐up of young patients are still warranted.     

Regional variation in ICU care for pediatric patients with asthma

OBJECTIVE: To determine adherence to guidelines for severe asthma care and evaluate regional variability in practice among pediatric intensive care units (PICU). STUDY DESIGN: A retrospective cohort study of children treated for asthma in a PICU during 2000 to 2003. We utilized the Pediatric Health Information System (PHIS) database to identify patients and determine use of asthma therapies when patients did not improve with standard therapy (inhaled beta-agonists and systemic corticosteroids). RESULTS: Of 7125 children studied, 59% received inhaled anticholinergic medications. Use of other therapies included systemic beta-agonists (n = 1841 [26%]), magnesium sulfate (n = 1521 [21%]), methylxanthines (n = 426 [6%]), inhaled helium-oxygen gas mixture (heliox) (n = 740 [10%]), and endotracheal intubation with ventilation (n=1024 [14%]). Use of therapies varied by census region. Over half the patients (n = 524) who received ventilation did so for < or = 1 day. Adjusted for severity of illness, use of mechanical ventilation varied significantly by census division; however, much of the variation was among children ventilated for < or = 1 day. CONCLUSION: Adherence to national guidelines for use of inhaled anticholinergics among critically ill children is low, and marked variation in use of invasive ventilation exists. More explicit guidelines regarding indications for invasive ventilation may improve asthma care.